March 2021: The Injectables Issue by Aesthetics & CCR

D IL N Y PR YO UT A BE A IN BE ES 16 H C P. N

VOLUME 8/ISSUE 4 - MARCH 2021

Hydrate from within for up to 12 months*1,2 with injectable HA microdroplets 1. Gubanova El et al. J Drugs Dermatol 2015;14, 288-298. 2. Gubanova El et al. Poster presented at IMCAS 2015. *with retreatment at 6 months

UKI-RES-2100004

Date of preparation: Feb 2021

Infraorbital Hollows CPD

Dr Jane Moon reviews the literature on the anatomy of under-eye hollows

Lip Trends and Treatments International practitioners discuss latest developments and techniques

Dealing with Patient Anxiety Dr Hannah Davies advises on treating patients suffering with health anxiety

Considering Branding Colours

Russell Turner shares tips on choosing a scheme for your clinic

Contents • March 2021 06 News The latest product and industry news 16 Beyond Beauty

Introducing our new magazine for consumers and patients

18 News Special: Dropping the Filter

Aesthetics explores recent ASA guidelines on social media filters

CLINICAL PRACTICE 21 Special Feature: Treating the Lips

Three international practitioners discuss the latest trends and techniques

News Special: Dropping the Filter Page 18

26 CPD: Infraorbital Hollows

Dr Jane Moon reviews literature on the anatomy of under-eye hollows

31 Treating the Deep Pyriform Space

Dr Varna Kugan explores the benefits of addressing the deep pyriform space

34 Managing Health Anxiety

Dr Hannah Davies advises on how to manage health anxious patients

36 Advertorial: Restylane Skin Boosters

Celebrating 25 years of Restylane

39 Addressing Filler Complications

Dr Hannah Ranjbar discusses managing patients with complications from other clinics

42 Advertorial: Perioral Rejuvenation using BELOTERO®

Dr Simon and Dr Emma Ravichandran share a patient journey

46 Case Study: Male Nasolabial Folds

Dr Armand Abraham details his technique for the male mid-face

50 Understanding the Science Behind Melasma

Dr Firas Al Niaimi and Dr Faisal Ali outline why melasma occurs

53 Case Study: Treating the Neck

Nurse prescriber Elaine Williams rejuvenates a female neck

57 Exploring Thyroid Disease & The Eye

Three practitioners explore common changes associated with thyroid disease

60 Advertorial: Galderma

Celebrating 40 years of leadership and innovation

61 Abstracts A round-up and summary of useful clinical papers

IN PRACTICE 62 Choosing Colours for Clinic Branding Branding professional Russell Turner looks into the impact of colour 64 Building Good Customer Service

Communications director Tim Morris on enhancing patient experiences

66 Understanding CPD

Dr Kalpna Pindolia explores continuing professional development

69 In The Life Of Alison Telfer

The clinic owner and nurse prescriber discusses balancing work and home life

70 The Last Word: Dermal Fillers Mr Ali Juma debates whether the term is fit for purpose NEXT MONTH IN FOCUS: BODY • Post-Pregnancy • Wound Healing • Breastlifting

Clinical Contributors Dr Jane Moon works in the maxillofacial department at St Richard’s Hospital and has attained a Diploma in Primary Dental Care covering oral surgery, oral medicine and research. She is a member of the Royal College of Surgeons. Dr Varna Kugan is a JCCP-registered aesthetic practitioner with more than five years’ experience. He is the clinical director at PICO Clinics in London, Milan and Shanghai and has a special interest in treating Asian patients. Dr Hannah Davies has a Bachelor of Medicine and Bachelor of Surgery, as well as a first-class degree in Biomedical Science from the University College London, where she was recognised on the Dean’s list for her achievements. Dr Hannah Ranjbar graduated from Keele University in 2018. She has trained in foundation and advanced dermal fillers and toxin. Dr Ranjbar runs her own clinic in Haywards Heath called L1P Aesthetics. Dr Armand Abraham is the founder and medical director of Face Lab Aesthetics based in London, where he specialises in treatments for men. Dr Abraham Graduated from Qasr Al Aini School of Medicine, Cairo University in 2012. Dr Firas Al-Niaimi is an award-winning consultant dermatologist, as well as Mohs and laser surgeon. Dr Al-Niaimi has participated in more than 200 publications and his own book on preparation for dermatology specialist examination. Dr Faisal Ali is a multiple award-winning consultant dermatologist, dermatological surgeon and specialist advisor to the CQC. Dr Ali completed his clinical medicine degree at the University of Oxford. He is currently based in Manchester and London. Elaine Williams is an aesthetic nurse prescriber and founder of EOS Aesthetics in Ascot, Berkshire. She has worked in aesthetics for more than 10 years, practising in Liverpool and Harley Street. Williams is a member of the British Association of Cosmetic Nurses. Miss Jennifer Doyle has Bachelor in Medicine and a Bachelor of Surgery with distinction, as well as a Master’s in Medical Sciences from the University of Oxford. Miss Doyle currently works as an NHS registrar in ophthalmology, as well as running Oxford Aesthetics. 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 Adriana Kovacova is a consultant ophthalmologist and oculoplastic surgeon. She is a surgical instructor at the Royal College of Ophthalmologists and specialises in eyelid reconstruction.

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Editor’s letter Whether you’re a beginner or an advanced practitioner, injectable procedures will more than likely form the backbone of your aesthetic clinic. That’s why this month is dedicated to exploring a range of treatments that are delivered with a needle or a cannula. Chloé Gronow We’re all aware of the demand for lip Editor & Content enhancement here in the UK, but have you Manager thought about how it may differ abroad? @chloe_aestheticseditor We explore trends and techniques from an international perspectives on p.21 – it really is a great read! February saw the release of new guidelines on the use of filters in social media marketing imagery. The Advertising Standards Authority stated that filters should be avoided if they are likely to exaggerate the effect of the product or service being promoted. This got us thinking, how many practitioners have used filters in their marketing? And what impact has this had on prospective patients? We spoke to a nurse and a doctor for their views on p.18, and would love to hear from you too – drop us a message via editorial@aestheticsjournal.com.

I’m delighted to confirm that Beyond Beauty – our new magazine for patients and consumers – will be out in April. It’s been a labour of love over the past few months for the team and I; we’ve poured our energy into making the first issue as comprehensive yet fun as possible, so fingers crossed you’ll love it just as much as we do! Full Member subscribers to the journal, along with anyone who is listed as a medical professional within our database, will have received a Beyond Beauty poster with this issue. You can display this in your clinic window to encourage your patients to subscribe in time to get their first copy free. To give you a taster of what your patients will learn, you’ll also get a free copy of the magazine with your April issue! As loyal subscribers to the journal, we hope that you trust us to deliver only evidence-based information in our magazine too. Our ultimate goal is to enable consumers to make safe and ethical decisions in aesthetics and cosmetic surgery, so we would love your support as we start this journey… You can read more about what to expect from Beyond Beauty and how it will benefit you on p.16.

Clinical Advisory Board

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

WE WANT TO HEAR FROM YOU!

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

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

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

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

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

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

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

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

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

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

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

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Body sculpting

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

#Congress Dr Raul Cetto @drcetto A big thank you to @jeddadermofficial for inviting me to be part of the 15th #jeddaderm congress. I thoroughly enjoyed these last three days of sharing experiences with colleagues from all around the world @teoxanemena #Teoxane #Television Dr Vincent Wong @drvincentwong Filmed something amazing for national TV today. Can’t wait for you all to see it!! #documentary #aesthetics #Education BCAM @britishcollegeofaestheticmed Great to see all trustees at today’s BCAM board meeting – some positive decisions made during our 20th anniversary year! #aestheticmedicine #anniversary #trustees

Global pharmaceutical company Allergan Aesthetics has launched its first body contouring system in more than 10 years. The next generation cryolipolysis device called CoolSculpting Elite has been redesigned and re-engineered for an improved patient and practitioner experience. The new CoolSculpting Elite has seven new compact and lightweight applicators and an improved cooling distribution to treat a greater percentage of targeted tissue, allowing practitioners to conduct twice the number of treatments in the same amount of time, according to the company. Maria Pierides, director of body contouring at Allergan Aesthetics, said, “Body contouring has evolved and as category creators, so have we. We have also listened to our customers and considered every detail of the new system to give every practice and their patients an improved experience.” Dr Tracy Mountford, aesthetic practitioner at The Cosmetic Skin Clinic, commented, “This newly evolved technology holds great potential in enhancing both our patients’ needs and the benefits in our practice. The improvements to the system and the ability to work with dual applicators on one patient means you can freeze fat in half the time – enabling us to offer a better and more efficient treatment experience to even more of our patients.” PLLA

#Hyaluronidase Dr Lee Walker @leewalker_academy Great discussion on hyaluronidase with my dear friend and colleague @gillian__ed.aesthetic. Superb interaction on our closed Facebook group complications collaborative!! #Filler Dr Raj Acquilla @rajacquilla Back to doing what I do best! LIVE injection shows. I’m planning a webinar with the global lip queen @juliehornelips Watch this space for updates!

Allergan releases CoolSculpting Elite

New body filler launches Pharmaceutical company Sinclair Pharma has launched a new biostimulating dermal filler for the body. There are two products in the range, Lanluma V for the face and hands, along with Lanluma X for the rest of the body, such as thighs, buttocks and arms. The company explains that Lanluma is made from poly-l-lactic acid (PLLA) and is designed to stimulate collagenesis to help restore the skin’s inner structure and improve shape, enhance the fullness of different areas of the body, and help with the reduction in the appearance of cellulite. The filler is only available for doctors and plastic surgeons to administer. Chris Spooner, CEO of manufacturer Sinclair Pharma, said, “Lanluma pushes injectable body sculpting to the next level, generating aesthetic results which speak for themselves. This highly efficacious PLLA product has been formulated to address the needs of the physician with bigger sizing, easier reconstitution and convenient storage.”

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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Consumer education

Beyond Beauty to launch next month A new magazine that aims to educate patients and consumers about aesthetic medicine and cosmetic surgery will be released in April. Created by the Aesthetics team, Beyond Beauty will include articles that explain the science behind procedures in layman’s terms, while advising how to choose a safe and ethical practitioner. It will also feature exciting patient interviews and case studies that demonstrate realistic yet fantastic results, product innovations and treatment reviews. Editor and content manager Chloé Gronow said, “We are so proud to finally launch our new publication that will debunk myths and misconceptions in aesthetics and cosmetic surgery. Mainstream media is dominated by negative botched-job stories, so it’s imperative that we use our platform to enhance consumers’ knowledge of the life-changing treatments that are available, build their trust by breaking down the science behind how they can be used safely, and promote positivity in the specialty as a whole. We invite all practitioners to join us on this journey and encourage their patients to subscribe!” All journal subscribers who are signed up as a Full Member or listed as a medical professional in the Aesthetics database will have received a poster with this issue that you can display in your clinic window to advertise the magazine to your patients. They will need to subscribe by March 15 to get their first copy free. You will also be sent a free copy of Beyond Beauty with your April journal to give you a taster of what consumers can expect. To find out more about Beyond Beauty, turn to p.16. Dermal filler

Restylane Defyne approved for chin augmentation Global pharmaceutical company Galderma has received approval from the US Food and Drug Administration (FDA) for the use of Restylane Defyne for chin augmentation. Restylane Defyne is a hyaluronic acid dermal filler that was first approved in 2016 by the FDA for mid-to-deep injection into the facial tissue for the correction of moderate to severe deep facial wrinkles and folds. Alisa Lask, general manager and vice president of the US aesthetics business at Galderma, said, “This marks Galderma’s eighth FDA aesthetics approval in five years, illustrating our long-term commitment to advancing aesthetics through new innovation. The chin is the foundational anchor of the face that brings the rest of your features into balance. Consumers can now address the chin with a non-surgical, safe option from a brand that uses cutting-edge XpresHAn technology to shape and produce long-lasting results.”

Vital Statistics More than a quarter of people surveyed noticed an influencer/celebrity marketing post in the previous month, 49% of whom felt that the posts did not represent the person making the endorsement (Econsultancy, 2021)

51% of 962 UK consumers have used some form of nutrition app (Mintel, 2021)

40% of 1,012 Americans said by the end of 2021 they would like to feel more conﬁdent in their own skin (Gelesis, 2021)

75% of the 931 women who opted for no breast reconstruction after a mastectomy were satisfied with the results, but almost 25% said their decision to go flat was not supported by their surgeons (Annals of Surgical Oncology, 2021)

78% of 3,157 nurses said they felt supported by their employer during the pandemic; however only 34% said they felt supported by their colleagues (Queens Nursing Institute, 2021)

50% of 533 women said that they have treatments without understanding what is being done to their skin (Etre Vous, 2020)

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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Technology

Cynosure launches new RF applicator

JOIN T H E VIRTUA L CEREM O NY

Education

UCL introduces Master’s of Surgery qualification University College London (UCL) has become the first global academic institution to offer a Master’s of Surgery (MS) in Aesthetics and Minimallyinvasive Aesthetics, supported by The British Association of Aesthetic Plastic Surgeons (BAAPS). Launching in September 2021, the new programme includes two courses – one for doctors, dentists, nurses and pharmacists, and the other designed for surgeons. BAAPS explains that many of its council members, including consultant plastic surgeon professor Afshin Mosahebi and past presidents Mr Rajiv Grover and Mr Paul Harris, have been involved in developing content and running the modules. BAAPS president Miss Mary O’Brien will be the external examiner. Professor Mosahebi commented, “As this sector of medicine is outside of the NHS in the UK, its governance and standards of care have been the focus of much debate over recent years. In an attempt to put some rigour into this area, BAAPS advises patients to ensure that their surgeon or practitioner is fully licensed and accredited, and they are in full support of the UCL programme.”

Laser manufacturer Cynosure has introduced a wrappable radiofrequency (RF) applicator as the latest addition to its TempSure 300 watt platform. According to the company, the FlexSure treatment uses peel-and-stick single-use applicators and aims to deliver deep tissue heating to multiple body parts, including the abdomen, back, arms, buttocks, thighs and above the knees. Todd Tillemans, CEO of Cynosure, said the company is committed to driving innovation forward and delivering best-in-class technology. He commented, “FlexSure not only meets our growing base of consumer needs, but practitioner needs as well, helping them to maximise both time with each patient and resources to remain productive and profitable. Created with these considerations and insight we’ve gleaned from a several recent global market research studies, the FlexSure device is the ideal product for practices to integrate as its single-use, disposable applicators help meet the needs expressed by consumers for hands-free, more hygienic treatment options.” Feminine health

New non-surgical labiaplasty method released Aesthetic distributor Novus Medical has introduced a new treatment protocol for nonsurgical labiaplasty using its APTOS threads. According to the company, the Intimate Thread Lifting Method can be used for various indications, such as: postpartum changes in the vagina and perineum, hormonal changes in the skin and mucosa, increasing aesthetic appeal, ptosis and loss of shape of the labia majora, lipodystrophy, pelvic floor muscle weakness, sexual dysfunction and more. Consultant plastic surgeon Mr Paul Banwell, key opinion leader for the company, commented, “I am truly delighted to be working alongside Novus Medical as we introduce APTOS labiaplasty to the industry in the UK. We can reshape the labia with very little downtime and effectively no pain during treatment, offering a very real alternative to the gold standard that is surgery for those who want to avoid going under the knife. APTOS threads couldn’t have launched at a better time to enable practitioners to offer effective, clinicallybacked treatment options for their patients.” Novus Medical explains that this treatment can only be offered by CQC-registered doctors, and practitioners must receive official training from the company. Radiofrequency

Dr Tapan Patel to host RF microneedling webinar Aesthetic technology manufacturer Cutera will hold an exclusive webinar on the Aesthetics website hosted by aesthetic practitioner Dr Tapan Patel. The webinar will discuss radiofrequency microneedling, and Dr Patel will explore its clinical benefits in improving skin texture and appearance. He will also evaluate the key features he looks for in a device in order to achieve optimum skin rejuvenation treatment results. The webinar will take place on March 15 at 12pm GMT, and practitioners can register for free on the Aesthetics website.

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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Conference & Awards

Aesthetics Awards goes virtual Following the postponement of the Aesthetics Conference and Exhibition (ACE) until March 11 and 12, 2022, the Aesthetics Awards will now be taking place virtually on May 28. Easyfairs, the company behind ACE and the Aesthetics Awards, has made this decision in close consultation with the aesthetics industry, and in consideration of the Government’s implementation of ongoing measures to maintain social distancing. Chloé Gronow, editor and content manager at Aesthetics, commented, “Holding the Aesthetics Awards virtually this coming May will enable us to celebrate the achievements of our fantastic industry and give our finalists the recognition they deserve, as well as providing an opportunity for some long-warranted lightheartedness and fun after an incredibly challenging year.” She continued, “We’re so proud of the aesthetics community for the support, time and dedication they have given to the fight against COVID-19. While so many of our readers and attendees are still doing so much to support the NHS, although we have all the safety measures in place to run a secure event, it felt only right to postpone ACE to 2022 when the vaccine will have been rolled out fully, the wider community will be safe and people will have had the opportunity to get their aesthetics businesses back on track after dedicating so much to the cause against the virus.” The virtual Awards ceremony will be free to attend and details on how to register will be released soon. Collagen

Allergan to produce dermal filler using plant-derived human collagen Global pharmaceutical company Allergan Aesthetics, an AbbVie company, has entered into an exclusive development and commercialisation agreement with regenerative medicine company CollPlant to use its plant-derived recombinant human collagen. Allergan explains that the collagen (rhCollagen) will be used in combination with its proprietary technologies, for the production and commercialisation of dermal and soft tissue fillers. Yehiel Tal, chief executive officer of CollPlant, commented, “We are very pleased to formalise this collaboration with Allergan Aesthetics, the worldwide leader in dermal and soft tissue fillers. We believe that combining technologies from Allergan Aesthetics and CollPlant will create a paradigm shift in the medical aesthetics field. CollPlant’s rhCollagen is non-immunogenic and non-allergenic, and offers better tissue regeneration performance over animal-derived collagen which is currently used in medical aesthetics. This agreement further validates CollPlant’s technology as the gold standard collagen for regenerative and aesthetic medicine. We look forward to a highly productive partnership.”

Developing your Content Marketing

Photographer Hannah McClune’s monthly tips on how to strengthen your business through branding Content marketing involves creating engaging copy, images or video to share with your audience. Consider ways you can provide valuable information that will educate, entertain and/or build a relationship with your ideal customers. Generally, the higher value the content, the more people will see it. A manageable approach to organising your content is by creating a content calendar. This is a way to map out all the social posts, blogs, emails and other pieces of information you want to share.

How to plan your content: 1. Theme: decide on your key messages over a given time period. 2. Format: choose the type of content, whether that is a photo, video, infographic or blog – a mix of all formats will usually work best throughout your campaign. 3. Platform: pick the channel(s) it will be shared. For example, some types of content will be more suitable for Instagram, while others could work better in an email newsletter. 4. Repurpose content: drip content out in different formats and on various platforms to remind your audience of those key messages. Please do email if you’d like to have a chat about how I can support you with image content and develop a content calendar with you: hello@visiblebyhannah.com

This column is written and supported by Hannah McClune, owner of brand photography company Visible by Hannah www.visiblebyhannah.com

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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

FEBRUARY’S IN FOCUS February’s In Focus theme ‘Trends in Complications’ kicked off with BACN Vice Chair Sharon King speaking with Professor Ewa Skrzypek in the second of the BACN’s In Conversation With digital series. Discussing implications in regards to COVID-19, and complications involving soft tissue inflammation, Sharon and Professor Skrzypek offered interesting insights into the challenges that medical practitioners will face in 2021 and beyond. The event was a warm up for the digital webinar also focusing on the theme of complications. Sharon led a roundtable discussion with BACN Management Committee members Linda Mather and Rachel Goddard, and BACN Honorary Member and aesthetic medico-legal expert witness Liz Bardolph, sparking lively debate and advice for BACN members. BACN members who missed out are encouraged to watch the recording which can be found in the member’s area of the BACN website. Finishing the month, BACN Honorary Member and Regional Leader for East Anglia Lou Sommereux led the peer review and social. The new format of BACN events has enabled members to engage with their membership each and every month to prevent isolation at this difficult time.

COMING UP IN MARCH This month the BACN will be working directly with Church Pharmacy for the theme ‘All Things Temples’. Lou Sommereux will be speaking with Dr Vikram Swaminathan via Instagram Live on Tuesday March 16 at 6pm. Dr Swaminathan has been working in surgical and aesthetic specialties for more than 10 years. Having discovered his passion for non-surgical aesthetic rejuvenation, he went on to work for many of the national cosmetic chains and training providers, before providing aesthetic services through his own clinics. BACN members also have exclusive access to March’s digital webinar on Tuesday March 23 discussing Temples, Brows & Lateral Orbital Lifting using YVOIRE® with Dr Andrew Greenwood and nurse Yvette Newman. As before, members will be encouraged to send their questions to BACN Events Manager Tara Glover at tglover@bacn.org.uk. This column is written and supported by the BACN

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Dermal filler

New HA filler launches in the UK Aesthetic distribution company Circa Skin has introduced the dermal filler Kysense to its portfolio. According to the company, Kysense is a cross-linked hyaluronic acid dermal filler without lidocaine/lignocaine, manufactured by Swiss-based Kylane Laboratoires. The range includes four product choices to treat all areas of the face: Volume, Define, Precise and Extreme. The filler has been CE approved by the British Standards Institution, the national standards body of the UK, under a class 111 classification. The CE clinical mark study was conducted by aesthetic practitioner Dr Kate Goldie as well as five international doctors, and it observed 50 participants with 110 treated injection areas. It was observed that there was an aesthetic improvement in 95% of injected sites one month after treatment. Six and 12 months after injection, respectively, 93% and 81% of subjects still had an improvement, according to the assessor. Claire Williams, CEO of Circa Skin, commented, “Kysense represents an exciting innovation and a step forward in what clinical practitioners can offer their patients and we are thrilled to be launching this advancement in HA technology. In addition, we are revolutionising the business aspect for our customers, with the launch of an educational digital platform and subscription service to support our clinicians in maximising their clinical and commercial returns.” The filler is only available to medical professionals. Cleanser

mesoestetic releases new cleansing solutions Pharmaceutical company mesoestetic has launched five new cleansing solutions designed with bio-balancing, antioxidant and anti-pollution action. The company explains that the classic hydramilk product is designed for in-clinic professional treatments, and effectively removes makeup and impurities, provides intense hydration and respects the skin’s physiological balance. The hydratonic is a facial tonic formulated using the combination of rose water with panthenol, designed to moisturise the skin. The pure renewal mask is white clay formulated using salicylic acid, mandelic acid and sodium lepargilate, aiming to provide a comedolytic, refining, antibacterial, and anti-blemish action. Its formula also has biodegradable cellulose particles, for a modulable mechanical exfoliating action that helps unclog and refine pores, according to the company. mesoestetic explains that the anti-stress mask is designed to target signs of sensitive or damaged skin, including reddening, irritation and feeling of tightness. The key ingredients of the mask are rhodosorus marinus extract and saffron flower. The hydravital mask aims to help moisture levels in dry, dehydrated and/or devitalised skin, formulated using argan oil, omega 3 and 6, and panthenol.

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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Charity

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Training

Facing the World receives international accreditation

The Royal College of Surgeons has awarded international accreditation to facial differences charity, Facing the World. The charity, which is supported by Aesthetics Media, funds operations for children with facial differences in Vietnam, and the accreditation was given to the charity’s partner hospitals, the Viet-Duc University Hospital and the 108 Military Central Hospital. A spokesperson from Facing the World commented, “We believe this accreditation will have a ripple effect through other hospitals within Vietnam, which will further aid our vision to have a world where children born with craniofacial differences can access the specialist intervention they so desperately need.” You can donate to Facing the World through the Aesthetics Just Giving page and learn more on p.44. Lasers

BMLA announces 2021 virtual conference The British Medical Laser Association’s 2021 Virtual Conference will take place on May 6 and 7, in association with the European Laser Association. Confirmed speakers at the event include laser clinical nurse specialist Natalie Allen, independent laser and radiation protection adviser Stan Bachelor, practitioner and laser trainer Kerry Belba, and clinical director of Lynton Lasers, Dr Sam Hills. BMLA president, Dr Vishal Madan, commented, “We are really excited about transitioning to a virtual, fully digital event, and are confident it will provide an exciting and interactive experience for delegates and sponsors alike. I look forward to the future with hope and in positive light, and welcome you all to the BMLA 2021 Virtual Conference in association with the European Laser Association. Despite all the odds, the show must go on!”

Acquisition Aesthetics launches masterclass in non-surgical rhinoplasty Aesthetic training provider Acquisition Aesthetics is launching the Non-Surgical Rhinoplasty Masterclass with aesthetic practitioner and trainer Dr Yusra Al-Mukhtar. The company explains that the CPD-approved course is dedicated to the understanding and practical applications of non-surgical rhinoplasty through a two day in-person event, coupled with learning videos and online modules. Dr Priyanka Chadha, director of Acquisition Aesthetics, commented, “We’re delighted to still be establishing this course after the tough year we’ve all had. We’ve seen such a phenomenal demand for this training, even during the pandemic, and we’re so fortunate to have our good friend and esteemed colleague on the faculty and leading this course. This is such a delicate procedure involving complex anatomy; scrupulous training is paramount to safety, and learning from a professional with such extensive, specialised experience in the field is simply invaluable.” Hydration

Skinbetter Science introduces male skincare product Skincare brand Skinbetter Science has launched the Solo Hydrating Defense for men, designed to provide antioxidant protection. The company explains that the product is formulated using nelumbo nucifera flower extract for oil control, ceramide blend for hydration, and sea whip extract to soothe and calm the skin. According to Skinbetter Science, the product was also created to help mens’ skin after shaving, as it can cause skin irritation, redness and may leave it dry and flaky. Vikki Baker, marketing manager of distributor AestheticSource, commented, “The new Skinbetter Science Solo Hydrating Defense for men is a complete skincare solution in one product. It combines hydration (and doubles up as a post-shave skin treatment), antioxidant protection, sebum control as well as UV, blue-light and infrared protection to provide fast, immediate results in a range of skin tones and types.”

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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#whycuteraUK Cutera UK. Head Office 42 Kingston Space Ltd, Molly Millars Lane, Wokingham RG412PQ 01462 419 937 | info.uk@cutera.com | cutera.co.uk

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Alexandra Tretiakova, general manager of UK and Ireland for Galderma Why is 2021 an important year? This year, we’re celebrating Galderma’s 40th anniversary and will be announcing a series of new initiatives, product launches and clinical support programmes, as part of our ongoing commitment to drive innovation, support and skills within the industry. It is also Restylane’s 25th anniversary – so lots of important milestones to celebrate! COVID and lockdowns have hit clinics hard – how is Galderma supporting practitioners? We’re delighted to be launching the Galderma Aesthetic Injector Network (GAIN) clinical training and mentor support initiative. GAIN is a network focusing on technical training and complication management support through webinars, face-toface sessions and private online groups. We’ve launched a business transformation webinar to help practitioners evaluate and improve their clinic – from branding and social media, to front of house. We are also running commercial offers on the Restylane and SkinBooster portfolios to help clinics get back up quickly once lockdown lifts. Sculptra is relaunching this year – what’s new? The Sculptra treatment protocols have been updated with new guidance to maximise patient results and minimise complications and will be rolled out by UK KOLs among experienced aesthetic professionals. The new rollout will be supported by the GAIN programme, alongside increased consumer PR and marketing to raise patient awareness of this innovative treatment option. What will be the next evolution in toxins? Consumers are demanding more from toxin treatments – they want faster onset of effects and many practitioners want easier formulations and better tools for treatment. How will Galderma shape the industry this year? We are actively bringing new solutions to the market, whilst continuing to drive excellence within our existing portfolio. We see our role as a partnership witth practitioners – not only focusing on new products, but upskilling them with the tools, support and training to help them achieve success. For more information and to register for the Sculptra GAIN programme contact katie.bennett@galderma.com This column is written and supported by

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Skincare

Medik8 launches overnight peel Skincare brand Medik8 has released an at-home 10% glycolic acid peel called Sleep Glycolic. According to the company, the product is formulated using glycolic acid, glycerine and Korean clover extract and is suitable for normal skin types, including blemish-prone skin, oily skin types, uneven textured skins and those prone to visible hyperpigmentation. Daniel Isaacs, director of research at Medik8, commented, “In Sleep Glycolic we have optimised our free, active acid content by lowering our pH to 3.5 to achieve a free active acid value of 10%. This gives us a truly powerful glycolic acid formula. Crystal encapsulation and bi-weekly usage helps us to control this power, reducing irritation from the formula to maintain a healthy skin barrier.” Industry

The JCCP requests feedback on new regulation plan The Joint Council for Cosmetic Practitioners (JCCP) has created a draft 10-point plan that aims to create a strategy that can be used to inform and address issues relating to regulation, patient safety, education and training. Created with input from Government, practitioners, regulators, professional bodies, associations, pharmaceutical companies and insurance providers, the plan identifies key policy areas where significant changes are required. Professor David Sines, executive chair of the JCCP, said, “The JCCP believes there is a strong willingness for the sector to come together, debate its priorities for action and to present a united and committed approach to Government and regulators. In order to do this, we must be able to agree on the issues to be addressed and contribute resources and expertise to delivering this plan to the key decision makers.” The 10-point plan will be available on the JCCP website soon and stakeholders are invited to submit responses by June 1. These can be sent to admin@jccp.org.uk. Inclusivity

Transform Hospital Group gains LGBTQ+ certification Independent healthcare provider Transform Hospital Group has been granted the Pride 365 Certification for its commitment to LGBTQ+ inclusion across its network of UK clinics. The Pride 365 Certification measures inclusion in the workplace, customer care quality and marketing. Companies must first score a minimum baseline performance and then publicly commit to a path of incremental improvement year on year. As part of its pledge, Transform Hospital Group explains that it has committed to being supportive of LGBTQ+ inclusion on a daily basis, and will demonstrate this by working with UK transgender charity Sparkle. Tony Veverka, CEO of Transform Hospital Group, said, “We’re absolutely thrilled to have our commitment to LGBTQ+ inclusion rubber-stamped with Pride 365 Certification. We want to position ourselves as a healthcare brand that is leading the way, creating real change and setting the standard for others in our field, and the Pride 365 Certification recognises the efforts we have made, and continue to make in achieving these goals.”

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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Digital

Allergan Spark releases new on-demand content Spark by Allergan Aesthetics has introduced a new expert series to its on-demand webinar service, in collaboration with training provider Harley Academy. The series features talks from aesthetic practitioner Dr Tapan Patel on Juvéderm in the mid-face and his full-face approach. There are also webinars by independent nurse prescriber Alison Telfer on Juvéderm in the perioral region, aesthetic practitioner Dr Rupert Critchley on Juvéderm in the lower face, and independent nurse prescriber Linda Mather on dermal filler complications management. Each episode in the series is hosted by Harley Academy founder Dr Tristian Mehta and aesthetic practitioner Dr Emily McGregor. John Campbell, Allergan sales manager, commented, “Following the previous success last year, it is inspiring to be able to launch our second webinar series in collaboration with Harley Academy to the aesthetic and Spark community. We are looking forward to providing these free webinars for healthcare professionals to plan, learn and prepare during the lockdown, to emerge, feeling more confident, inspired, and educated ready for the future.” Weight

Ozempic shown to be effective for sustained weight loss New clinical data has indicated that Ozempic (semaglutide), a glucagon-like peptide-1 (GLP-1) receptor agonist manufactured by pharmaceutical company Novo Nordisk, is effective for sustained weight loss. The product has previously been used to treat diabetes. Published in The New England Journal of Medicine, the Semaglutide Treatment Effect in People with Obesity (STEP) 1 study shows the results from 1,961 patients with a BMI of 30 or above, without diabetes. In a double-blind trial over 68 weeks, patients received once-weekly injections of either subcutaneous semaglutide (2.4mg) or a placebo, plus lifestyle intervention. Data at the end of the trial period showed a mean weight loss from baseline of 15.3kg in the semaglutide group, compared to only a 2.6kg weight loss in the placebo group. Overall, 83% of patients lost 5% or more of their body weight, compared to 23% of the placebo arm. Public relations

Kendrick PR launches new marketing toolkit Communications consultancy Kendrick PR has created a new clinic marketing toolkit for aesthetic practitioners to download. The company explains that the toolkit has been created to help new and emerging brands, as well as businesses who want to revise their PR and marketing strategies. The kit includes webinars, presentation decks, marketing guidance, how-to instructions and exercise sheets. Julia Kendrick, CEO of Kendrick PR, commented, “Start-ups rarely have the expertise or capital to engage a proper branding agency to support that all-important brand building and differentiation stage. This toolkit puts our years of expertise and hands-on experience at your disposal to help you build your own powerful brand identity.”

News in Brief Merz launches Facebook page Global pharmaceutical company Merz Aesthetics has launched an official Facebook page. The company explains that the platform will announce new and upcoming events, as well as the latest clinic support material. The page will also publish the most recent articles that Merz Innovation Partners have written and tips on social media and business support. Merz Aesthetics marketing manager for the UK and Ireland, Louise Miller, said, “We are really excited about this launch as Facebook allows us to create more informational content and advertise our products and events to a wider audience.” Cutera recruits practice managers Aesthetic technology manufacturer Cutera has invested in new practice development managers to work directly with its customers on an ongoing basis. Tim Taylor, country manager at Cutera UK, commented, “We understand exactly the type of support UK aesthetic professionals require when investing in new technology. We know that our level of post-purchase support and customer service has to match the clinical capabilities of our world-leading aesthetic devices. This is why we are delighted to announce further investment into our practice development team.” Dr Vyas launches new scheme Aesthetic practitioner Dr Amiee Vyas is relaunching the Ultimate Aesthetics Mentorship Programme, taking place on March 18. Dr Vyas had previously held the programme in January. The eightweek scheme is personally overseen by Dr Vyas and mentees will have the opportunity to create a tailored combination of topics including practical support for individual cases, evidencebased protocols which can be customised on a case-by-case basis, injectable skills, cosmetic dermatology skills, and business development. New eczema book launches Consultant dermatologist Dr Amélie Seghers has released a practical guide on how to manage dry, itchy and inflamed skin. Dr Seghers explains that ECZEMA How to Ditch the Itch will help educate patients on how to identify eczema triggers. The book explores soap use, showers, scratching, mosquitos, friction, teething, microbiome, clothing, and sunscreen. Dr Seghers commented, “I have written ECZEMA How to Ditch the Itch to equip patients with everything I wish they knew about eczema.”

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

Special Focus Beyond Beauty

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Introducing Beyond Beauty What your patients can expect from our new magazine dedicated to aesthetics and cosmetic surgery

Trout pouts, pillow faces and botched jobs tend to fill mainstream media’s coverage of our specialty. This is so frustrating when we know the subtle yet life-changing results that can be achieved when aesthetic treatments are performed well. In addition, social media is generally dominated by young influencers’ accounts of treatment, which can leave the older generation wondering whether aesthetics is right for them and hesitant to talk openly about their experiences. We want to change this. Our new magazine, Beyond Beauty, has three key aims. These are to: • Enhance Knowledge • Build Trust • Promote Positivity In each issue – released quarterly – we’ll be highlighting real-life stories from patients of all genders, ages and skin colours, so EVERYONE can learn about how aesthetic treatments and cosmetic surgery can help them. We’ll breakdown the science and remove all the fluff to educate consumers on what’s available and how to choose a trustworthy practitioner in this dangerously unregulated market.

Bringing the magazine to life! In 2022, we’ll host Beyond Beauty Live – inviting consumers to meet the brands and practitioners all in one place. With so many procedures and devices being launched each year, this two-day event will empower consumers to finalise the all-important decision of choosing the right treatment for them through educational content and speaking to brands directly.

How will this help you? Readers will close Beyond Beauty feeling well-informed and inspired to talk confidently about their aesthetic choices. For you, this will mean more loyal patients and word-of-mouth referrals, as the hush-hush nature of the specialty begins to change. In the future, there will also be the opportunity to retail Beyond Beauty from your clinics. You’ll simply purchase copies in bulk at a discounted rate, before selling the magazine at a profitable RRP from your reception desk and website!

What to expect from our first issue… • • • • •

A myth-buster masterclass to put an end to common misinformation Dermal filler definitions – an explanation of the benefits and risks of filler Reviews of some of the leading cleansers on the market Advice on recognising body dysmorphic disorder in friends Top tips for men to follow a simple skincare routine

PLUS… An exclusive interview with one of the most well-known and respected beauty journalists in the UK, and so much more!

Aesthetics | March 2021

This one-stop-shop will lead on patient safety, uniting key associations and practitioners to steer patient and consumer knowledge of the specialty. All subscribers are encouraged to invite their patients to attend!

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“As loyal journal subscribers, we hope you have come to trust in us to deliver the very latest unbiased information to support your continued professional development

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and understanding of medical aesthetics. Now we want to do the same for your patients. We invite you to support this new concept to showcase the very best of aesthetic

Special Focus Beyond Beauty

medicine to consumers and ensure they make safe, informed choices. Beyond Beauty will offer a unique and valuable tool for you to engage with new and existing patients!”

Chloé Gronow Editor & Content Manager

So, how do you get your hands on a copy for you patients? Tell them to visit www.beyondbeautylive.com by March 15 to get their first copy FREE! You can display the poster received with this journal in your clinic window to further encourage them. We’ll also: • Send all medical professional and Full Member journal subscribers a HTML email that you can forward to your patients for them to subscribe • Share Instagram posts on @aestheticsjournaluk and @beyondbeauty_mag that you can repost with subscription instructions All medical professional and Full Member subscribers will also receive a free copy of Beyond Beauty with their April journal to get a taster of what patients can expect! Supported by…

Contact hello@beyondbeautylive.com via email if you have any questions or would like to know more!

TELL YOUR PATIENTS

Consumers’ go-to magazine for the very latest trends and expert advice in skincare, cosmetic surgery, injectables, face and body treatments

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Aesthetics | March 2021

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with unrealistic expectations. She comments, “It’s extremely common for filtered photos to be used as a reference when patients are outlining their aesthetic goals. On average, I’d say I have at least one patient every two days who shows me a filtered image and asks why the person in this image looks so amazing. They want to know how they can look the same. It’s sad because these edited posts are something that people are exposed to every time they open their phones. It’s these unattainable standards of beauty which cause damage to our patients’ self-image and self-esteem.” While Instagram and Snapchat filters are typically seen as being something used by the ‘Gen Z’ generation, Scott thinks that older patients are affected by them the most. She notes, “While younger patients are exposed to these images more, I think they’re also more aware that everything is filtered. For example, a lot of younger people have their own editing apps. However, older individuals aren’t as used to it and are less likely to pick up when something has been altered. I think it gives older women the idea that they shouldn’t show signs of ageing, and they then strive to look 30 forever!”

Dropping the Filter Aesthetics explores recent guidelines warning against the use of social media filters in advertising Filters used on social media are overlays which can be placed over photos during or post-production, and can achieve various effects, such as exaggerated features or simply altering the colour of the image.1 Specific beauty filters are often used on apps such as Instagram and Snapchat to enhance a person’s physical appearance. Whether it be to smooth the skin, enlarge the lips or slim the face, these filters are regularly used by individuals, as well as companies, to help market their products and services. Last month, the Advertising Standards Authority (ASA) banned two social media posts that used filters to promote tanning products. According to the ASA, the filters exaggerated the effect of the tanning products and the ads were therefore deemed to be misleading.1 Following this, the ASA released guidance stating that influencers and companies promoting products that are directly relevant to what is being advertised should avoid applying filters to photos or videos which are likely to exaggerate the effect of the product/service. In terms of before and after imagery, the ASA reminded marketers that these images are treated as objective claims, just the same as written claims, meaning any ‘after’ image should be representative of what consumers can genuinely obtain from the product. Ads which break these rules will be taken down and prohibited from appearing again.2 With social media being such a big part of marketing in the aesthetics specialty, we spoke to aesthetic nurse Julie Scott and aesthetic practitioner Dr Amiee Vyas, to find out how filters can impact aesthetic patients and their expectations.

How to consult patients wanting the filtered look

Scott notes that when patients present to her wanting to mirror social media images posted by Instagram influencers or companies, she ensures to discourage them from treatment. She advises, “In our industry, practitioners need to be careful not to just follow what the patient tells them. It’s about doing what’s right for the patient, and if they have a distorted view of themselves due to social media, we need to try and rectify that rather than just doing whatever procedures they want.” Scott recommends practitioners are honest and tell patients when you think a procedure is unnecessary. She says, “I tell my patients when they might be going too far, and remind them they’re beautiful as they are. By pointing out to them that Instagram isn’t reality and by saying no, we also build patient trust.” Scott adds, “Filters can also potentially contribute to someone developing body dysmorphic disorder, so practitioners need to look

“We need to show our following that not everybody is born looking like this ‘filter ideal’, and that if you want those results, it takes time and a lot of work” Julie Scott, nurse prescriber

The issues filters cause Dr Vyas says that the main issue with influencers and companies using filters in their marketing is that patients will present for treatment

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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out for this and refer them to relevant help if necessary.” Dr Vyas also adopts a holistic approach when consulting patients. She comments, “One thing I always ask my patients during the initial consultation is how confident they feel in their skin. After doing this for a while, I noticed that the ones who spend more time on social media are the ones who always rate their confidence lower because they are comparing themselves to unrealistic images.” To help rectify this, Dr Vyas often provides her patients with mindset work alongside a treatment plan. She says, “I’ll also recommend the patient takes some time for themselves each day, doing things such as meditation, exercise, a bath, dancing to music – anything that can help them clear their minds away from their phones. When it comes to our review, I always find that the patients who have followed this advice are in a better place.”

Responsible marketing to patients Dr Vyas says that working with influencers poses challenges when it comes to responsible marketing as they are often so attuned to using filters. She explains, “I won’t be affiliated with anyone who promotes my work using edited images. Once, I had an influencer ask me if she could edit her before and after image before I put it onto my Instagram page, and this made me consider my ethical standards and values as a doctor. I decided not to post her results at all, because I never want to put anything out to my followers that isn’t real. I make sure that the people I do work with only post unedited and natural content, to reflect the authenticity of my practice, and this is agreed with the influencer beforehand. Of course, if it’s a silly filter adding snowflakes to a video or something it’s fine, but anything that changes the appearance of the skin is a huge no-no for me.” Scott adds that she believes the industry needs to focus on educating patients that the filters used online are unrealistic, and has been doing Instagram Lives with her patients to discuss their personal journeys and aesthetic concerns. She comments, “We need to show our following that not everybody is born looking like this ‘filter ideal’, and that if you want those results, it takes time and a lot of work. It also may not be achievable for everyone! Showing real people with unfiltered faces gives viewers something to relate to, and helps them realise that they’re not the only person in the world who has insecurities. I aim to show people that not everyone has naturally perfect skin – and that’s okay!” Dr Vyas advises other practitioners to ensure that their marketing is always authentic, so as not to contribute to a problem which can negatively impact their patients. She notes, “With the ASA now addressing the use of filters, I hope that people will become more aware of what’s reality and what isn’t. This will lead to patients seeking practitioners who show realistic results and are honest with their audiences. Dropping filters is something that protects our patients’ mental health, and it’s their wellbeing that we should always put first.” REFERENCES 1. ASA, 2021, The Misuse of social media beauty filters, <https://www.asa.org.uk/news/the-misuse-of-social-media-beauty-filters-when-advertising-cosmetic-products.html> 2. ASA, 2021, Cosmetic and the use of production techniques, <https://www.asa.org.uk/advice-online/cosmetics-the-use-of-production-techniques.html>

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

A NATURAL LOOK IS

AN EXACT SCIENCE

Patients today want a filler that naturally integrates into their tissue, so that they can retain their identity and express their emotions with confidence1.

BELOTERO® Balance is indicated for the correction of moderate lines, such as: nasolabial folds, glabellar and perioral lines so patients can feel empowered with natural-looking results2.

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merz-aesthetics.co.uk

BALANCE References 1 Prager W et al. J Drugs Dermatol. 2017; 16(4): 351-357 2 Micheels P et al. J Clin Aesth Derm. 2015; 8(3): 28-34 3 Kerscher M et al. Clin Cosm Inv Dermatol. 2017;10:239-247

M-BEL-UKI-0938 Date of Preparation January 2021

@merzaesthetics.uki Merz Aesthetics UK & Ireland

Merz Pharma UK Ltd, 2 Ground Floor Suite B, Breakspear Park, Breakspear Way, Hemel Hempstead, Hertfordshire HP2 4TZ MERZ AESTHETICS is a registered trademark of Merz Pharma GmbH & Co. KGaA.

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

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done because they didn’t want to end up with an overdone, trout pout look. There is still this fear to some extent, but with more recognition and awareness about the aesthetics industry, older women are beginning to realise that they can subtly add volume in the lips to create a more youthful appearance. So, instead of classifying lip augmentation solely as an enhancement, this treatment is now also associated with rejuvenation goals. This has led to a big growth in patients who are seeking natural results. Of course, in some countries it is actually a sign of wealth to have big lips and lots of filler, so I don’t expect to see these cultures have the same shift to natural results any time soon.” As well as a shift to the natural, Horne and Dr Hart have seen the Russian lip trend growing in popularity over the last year. This involves creating a very high ‘Russian doll’ pout, as it tends to lift the lip rather than add volume. However, the trend has proven to be controversial. Horne comments, “The process involves Aesthetics speaks to three international practitioners using the tenting technique by placing tiny droplets of filler, injected vertically into the about the latest trends and developments, as well as lip. The problem with Russian lips is that the practitioner seems to try to achieve as much their techniques for augmenting the lips height as possible, and in many results the Regardless of country or patient demographic, lip augmentation upper lip is practically touching the nose. Although there can be some continues to be a popular aesthetic treatment. Annual statistics results which look good, I think most of them are way too extreme. I’ve published by the American Society of Plastic Surgeons indicated actually seen videos of patients screaming while getting this treatment that dermal filler lip treatments are on a steady rise, with 2,160,578 done because the practitioners are digging so hard and pushing the lip augmentations performed by its members in 2019, making it the needle so deep to get the desired result!” second most common non-invasive procedure after botulinum toxin Dr Hart notes that younger patients are more likely to opt for this look, injections.1 However, the ways that patients want their lips to look is whereas older patients are leaning towards the natural trend outlined changing and techniques are constantly evolving. above. She comments, “In New Zealand, the younger crowd are going for trends like the Russian lips because it mirrors the Instagram In this feature, Aesthetics gains an international perspective to lip filter look, which is popular right now. However, I find that other ages augmentation and speaks to three leading practitioners and key are after something more subtle. We also have a lot of people who opinion leaders who are based abroad. Swiss aesthetic nurse Julie want their procedures reversed because they originally went too big Horne, dutch dermatologist Dr Jonathon Kadouch and New Zealand and are now after more natural results.” aesthetic practitioner Dr Sarah Hart share their preferred approach to treating the lip area, and discuss the best ways to market the results. When asked whether she thinks the Russian lip trend will be here to stay, Horne believes it’s likely to lose its popularity soon. She states, “I Developing patient trends think it will be the same with many other trends, and it will disappear eventually! I can’t see it still being popular in a few years’ time. On All three practitioners have noticed a shift in what patients are the other hand, a trend that I’ve seen emerging which seems to requesting; for example, it’s now becoming more common for have some longevity is patients asking for a really crisp, sharp, lip people to seek subtle changes rather than dramatic results. Horne, border. People are after a really good frame. There’s also been a comments, “Trends have definitely shifted in the last few years, with rise in patients looking for us to treat their M-shaped lips, which was people wanting a much more natural look, which is something I fully challenging at first. However, now I’ve experimented and made my support. Aesthetics isn’t about a one size fits all approach. Every own technique they’re something that I do the most of!” patient or person has different needs, and we can’t treat everyone the same. It’s all about a proper assessment and creating balance Differing practitioner techniques and harmony, rather than going as big as you can go!” Dr Kadouch agrees. He notes, “It used to only be young females With recent debate on the preference of cannulas or needles for getting lip filler, and there was a popularity of getting overfilled lips. aesthetic injections,2 Dr Kadouch has seen a rise in the use of This meant that most older women were afraid to get their lips cannulas. He believes it is a better instrument for administering

Treating the Lips

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

Takeover We’ll be talking all things temples with the BACN  Tuesday 16th March  6pm In Conversation with Dr Vikram Swaminathan  Instagram Live @BACNurses

 Tuesday 23rd March  6pm In Focus Live Webinar discussing Temples, Brows & Lateral Orbital Lifting using YVOIRE® with Dr Andrew Greenwood and Yvette Newman, RN.

FIND OUT

MORE HERE

Exclusively available at

www.ChurchPharmacy.co.uk/YVOIRE

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Before

After

Figure 1: A 40-year-old patient before and after 1ml of Restylane Kysse. Images provided by Julie Horne.

professional camera and then look at them with the patient. You can get yourself into trouble if you just jump into doing a procedure without thinking it through – you need a plan. I use a blue background for my images because the skin has no blue tones in it, so it acts as a green screen. This means I can edit the background to any colour I want.” Dr Hart uses the photo as a tool to help her throughout her procedure. She comments, “Something that helps me is to keep looking at the patient’s before photo while I’m treating them. This is because the numbing cream can cause swelling or bruising, so the photo serves as a way to remind myself what the original is!” In regards to her preferred method of injection, Dr Hart also uses needles because she uses a harder filler to create more defined lips. She notes, “I use the vertical tenting technique a lot but I won’t do it all the way along the lip like the Russian technique, I just use it in particular areas where I want more aversion. I also avoid directly treating in the vermilion border, because I find that just going near it enhances it enough. Doing this can also stop migration up towards the nose; that’s when lips can start to look artificial and you lose that crisp definition.”

Product selection dermal filler into the lips. He comments, “I always use a cannula for lip augmentation. In my opinion, it’s an easier and less traumatic technique. Something that is changing is that practitioners used to use very thin cannulas, but it’s become more apparent that they can still puncture a vessel and cause a vascular occlusion. I would advise practitioners use a 25 or 22 gauge cannula, rather than a 27 gauge, for better safety. What I like to do is to make a small entry point just next to the corner of the mouth, and from that point I can access the body of the lip up to halfway. I can also access the submucosa space and retrogradely deposit a small amount of filler.” He continues, “One thing I will say about the technique I use is that you have to do it with a little pace. You can’t do it very slowly because the lips will swell, making it harder to be accurate. I don’t want to advocate quick and careless treatments though, so you need to learn how to pick up the pace without becoming careless. If you aren’t an experienced injector, I wouldn’t risk doing it this way.” Dr Kadouch also uses bone structures to create lifting. He notes, “In other injectable procedures, we put volume on top of the bone structure as its support helps to lift the overlying tissue. What a lot of practitioners don’t realise is that, although being a soft structure, the oral mucosa can be used in the same way. So, in terms of lip augmentation, the patient benefits from putting filler on top of the lip mucosa, pushing the lips up and outwards. It’s all about injecting other areas to help enhance the lip.” Horne takes a different approach, advocating the use of needles to create a sharper frame. She comments, “I love to have a thin, delicate and crisp border to make it defined. My favourite technique is to have an increased height in the medial third of the lip, and then let the height fade out laterally. It’s a look that suits many faces, even square or round. I find that building too much volume lateral to the lip can make a patient look wide and square, which can make women look more masculine.” Horne also notes that she rarely injects a full syringe into the lips. She says, “I normally inject only 0.7-0.8ml of product. If we need to build on them then I will do several treatments over time to make the results more subtle and prevent filler migration.” For successful treatment, Dr Hart believes it all begins with photo analysis. “I always make sure that I do a really detailed assessment prior to treatment. I take photos of the lips at all angles using a

In terms of product selection, Galderma KOL Horne prefers to use Restylane Kysse, Restylane Defyne or Restylane Classic for the lips. She comments, “I started in aesthetics with the Restylane portfolio and I’ve studied the products very well. I know they are of excellent quality and how they all behave in different tissues, which allows me to get great results. One thing that I like about this range is that the fillers aren’t hydrophilic, meaning they don’t attract or hold a lot of water. When fillers do this, it creates a puffier look and, in my experience, can also change the colour of the lips.” As an Allergan Aesthetics faculty member, Dr Hart’s main filler of choice is Juvéderm Ultra. She comments, “I use a lot of Juvéderm Ultra throughout my treatments because I prefer a harder filler for restructuring and shaping the lips. With softer filler you can’t change the proportions of the lips as much, and so that is something I think is only good to use when you want to add some volume. I do actually use Belotero Balance as well because it blends the lip line very well. The reason that I mainly use Ultra is because I don’t think anything Before

After

Figure 2: A 45-year-old patient who has had 3ml of Juvéderm Ultra over the past two years. Images provided by Dr Sarah Hart.

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else gives you that rounded look in the lower lip, and you can really mimic the natural elements of the lip more than you can with anything else.” Merz Aesthetics trainer Dr Kadouch uses two products when treating the lip. He comments, “I usually use Belotero Intense (or Belotero Shape) for the body of the lip to create structure and volume and for the vermilion border I use Belotero Balance (or Belotero Contour) which is uniquely suited to the most superficial injections required to treat this indication.” Before

types of lips and are different ages. As well as Instagram, I also have a Facebook page. I find that Facebook tends to drive more people to my website, because on Instagram people tend to look at the photos and not the captions.” Rather than using images to market himself, Dr Kadouch relies on word of mouth. He says, “also I don’t implement discounts or use prices to attract patients – I would rather have less patients than have ones who aren’t interested in quality. So for me, it’s all about listening to my patients and taking time with them. From there, word will spread.”

The future of lip augmentation

After

Figure 3: Before and after images of a 46-year-old female, treated with Belotero Lips Shape. Images provided by Dr Jonathan Kadouch.

Tips for marketing lip treatments While practitioners might achieve great lip augmentation results in clinics, many struggle to find the right ways to market themselves. Horne’s before and after photos have gained her great popularity on Instagram, now amassing 120,000 followers. She believes that this is not only down to good results, but also her presentation. She comments, “The reason I like to use before and after pictures is because patients can see photos which remind them of their own lips, letting them know that whatever they start out with, good results can be possible. Of course, you also need to ensure that patients know results may vary from person to person, so as to manage expectations. It’s up to each of us how we choose to present our artwork and personally I prefer not to post images of lips that have severe swelling, bruising or blood. When I take the photos, I often apply Oxygenetix medical grade foundation around the mouth area and put a medical ointment on the lips for protection and comfort.” Although some criticise the use of ointment as being deceptive, Horne responds, “Having this medical ointment in the picture doesn’t alter the result, it just makes the image look clearer and more aesthetically pleasing. In the future I will be putting medical ointment on for the before images too, so that the photos remain consistent.” Dr Hart also uses before and after images, but she believes you should take care in making sure that the images reflect the ethos of your clinic. She comments, “You need to be very specific about what your marketing aesthetic is, so that you attract the right people. If you show big lips, you’ll attract patients who want big lips. Personally, I like to show a variety of patients on my Instagram, who all have different

On how lip augmentation techniques may continue to develop, Dr Kadouch believes that the use of ultrasound will become an important part of injectable treatments, something which is already very common practice in the Netherlands.3 He comments, “Practitioners can use ultrasound to scan the lips and see if there’s been any filler in the lips before, as well as how much filler is left, or to see if there is any deviation from the normal structure. The last thing that any injector wants to do is create a vascular problem, so in doubt I always use ultrasound to avoid or treat complications, as well as using ultrasound-assisted injections. The industry is always changing and adapting, so we’ll hopefully see a rise in safer and subtler techniques.” Dr Hart believes that the industry will see developments in techniques for hard-to-treat lips. She comments, “I do think we’ll see a lot of resurgence of old techniques – take the Russian lip for example, the tenting technique has been around forever but people are acting like it’s brand new! However, there are also a lot of new techniques that I think will emerge for more difficult lips, such as for ones that are sun damaged. These in particular are tough to treat because the structure has collapsed and there are a lot of lip lines.” She adds, “Recently I learnt a new technique from my colleague Dr Ellen Selkon, which involves using a mixture of filler, anaesthesia and botulinum toxin, and you place a flurry in the lips. It really helps to improve the skin quality. I think we’ll see these sorts of innovative techniques start to grow when they gain more notoriety.” Horne believes that the future will also see a shift in how practitioners treat different ethnicities. She comments, “People are starting to recognise that we can’t treat every lip the exact same, and that it’s all about balance and harmony with the rest of the face. The previous trend has always been to have this ‘golden ratio’, where the upper lip is 1:3 and the bottom is 2:3. But this is only for Caucasian faces! If we look at different ethnicities around the world, they don’t have the same measurements. African patients for example suit 1:1, so we need to treat them accordingly. I’m trying to make people more aware that it isn’t all about this golden ratio, and I hope that diversity in treatment styles will continue to gain more awareness in the coming years.” REFERENCES 1. ASPS, 2020, 2019 Plastic Surgery Statistics <https://www.plasticsurgery.org/documents/News/ Statistics/2019/cosmetic-procedure-trends-2019.pdf> 2. Holly Carver, 2021, Cannulas vs. Needles , Aesthetics journal. <https://aestheticsjournal.com/feature/ cannulas-vs-needles> 3. Shannon Kilgariff, 2020, Utilising Ultrasound in Aesthetics , Aesthetics journal. <https:// aestheticsjournal.com/feature/utilising-ultrasound-in-aesthetics>

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Treating Infraorbital Hollows Dr Jane Moon reviews the literature on the anatomy contributing to the under-eye hollows and explores injection techniques using HA dermal fillers The infraorbital hollow refers to the curvilinear depression under the eyes and comprises the tear trough (TT), nasojugal fold and palpebromalar groove. The TT is the medial portion of the infraorbital hollow. It is defined as the depression formed in the medial lower eyelid, lateral to the lacrimal crest and limited in its inferior aspect by the inferior orbital rim, ending in a virtual vertical line projected from the pupillary axis.1 The infraorbital hollow is the upper limit of the mid-face, and there are many anatomical factors that contribute to its formation (Figure 1). The infraorbital hollows are considered to be one of the most challenging areas to treat due to variable patient factors. It is vital for clinicians to understand the anatomy, patient suitability and appropriate technique for successful treatment. This ensures precise placement of dermal filler for better outcomes, reducing the risk of complications and maximising patient satisfaction.

Intraorbital fat

Orbital septum Orbicularis retaining ligament Malar bag

Malar fat pad

Palpebral portion of orbicularis oculi muscle

Tear trough

Nasojugal groove Orbital portion of orbicularis oculi muscle Levator labii superioris alaeque nasi (LLSAN)

Figure 1: Anatomy of the infraorbital hollow.5

The anatomical structures involved Different theories of infraorbital ageing in the literature The periorbital region is a complex area with ligaments, fat compartments, muscles, vascularisation and lymphatics. All facial tissues play a role in facial ageing, including the interplay between the skin, muscle, fat, and bone. There are many different theories regarding the causes of the infraorbital hollow. These are summarised below:2 • Herniation of the intraorbital fat3 as the integrity of the orbital septum diminishes with age.4 TT deformity accentuates and allows fat to herniate through the lax palpebral orbicularis.5 • Age-related descent of malar fat pad resulting in orbital rim prominence.3 • Atrophy of the bone, skin and subcutaneous fat in the suborbital region, making TT more visible with age.6,7,8 • The presence of the orbital retaining ligament and TT ligament.9,10 • The gap between the orbicularis oculi muscle and levator labii superioris alaeque nasi (LLSAN) muscles.3,11 • The lack of suborbicularis oculi fat (SOOF) pad in the TT.7,8 • The thin lower lid skin compared to increased skin thickness towards the cheeks, at the medial canthus to mid pupillary line.12 • Other skin presentations such as hyperpigmentation and actinic changes contributing to the appearance of hollows.4 There is a void of high-level evidence; thus current literature is subjective. Many anatomical research papers lack a large or representative sample number, only representing a narrow racial bracket, with a limited age range. This often creates bias, along with an unrepresentative and unreliable data sample. This will be discussed further in the study limitations section.

The infraorbital hollow is a multifactorial phenomenon involving the skin, muscle laxity, ptosis of tissues with fat and bone volumetric changes. For the purpose of this article, we will focus on the muscle and ligaments, fat and skeletal changes (Figure 2). Muscles and ligaments Haddock et al. performed anatomic dissections of 12 fresh cadavers (six heads) examining the lower eyelid and midfacial regions, identifying the two planes (superficial and deep) that contributed to the TT and lid-cheek junction.7 In the superficial plane, the TT corresponds with the junction between the palpebral and orbital portions of the orbicularis oculi muscle. In this area, changes to the skin texture and thickness,12 absence of subcutaneous fat and pigmentation is sometimes present.13,14 In the deep plane, the orbicularis retaining ligament separates the TT from the lid-cheek junction, which is responsible for forming the palpebromalar groove.7 The orbicularis retaining ligament is an osteocutaneous ligament that originates from the periosteum of the orbital rim, traverse the orbicularis oculi muscle and inserts into the skin of the lid-cheek junction.15 The orbicularis retaining ligament continues superficially to separate the palpebral and orbital portions of the orbicularis oculi muscle.16 A study that dissected and histologically evaluated 48 hemifaces confirmed the presence of the TT ligament between the palpebral and orbital portion of the orbicularis oculi, and it was shown to originate from the maxilla.9,17,18 This tight muscle attachment with its scant subcutaneous tissue in the palpebral portion would emphasise the volume loss during its contraction.13 At the midpupillary line, it continues laterally as the orbicularis retaining ligament.17 This ligament may also increase in laxity, allowing inferior displacement of the lower lid.19

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Intraorbital fat Bone

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The SOOF is located behind the orbicularis oculi muscle and is divided into medial and lateral portions. The medial SOOF extends from the medial limbus to the external canthus, while the lateral SOOF runs from the external canthus to the temporal fat compartment. The upper and lower limit of SOOF is defined by the orbicularis retaining ligament and zygomatic cutaneous ligament respectively. The SOOF is further divided into vertical components by the malar septum, which originates in the periosteum of the orbital rim, which crosses the orbicularis oculi muscles and attaches to the skin.22 The malar septum is clinically relevant for the depth of filler placement in treating the infraorbital hollows, which will be discussed further.

Saggital cut

Thin skin

Palpebral portion of orbicularis oculi muscle

Orbicularis retaining ligament

Scant subcutaneous fat

SOOF Malar fat pad

Malar mound

Orbital portion of orbicularis oculi muscle Zygomatic cutaneous ligament

Bone The skeleton is the framework on which the soft tissue drapes over. Studies have shown an increase in the orbital aperture with age, which leads to the appearance of the aged eye (Figure 3).23,24 In a study by Mendelson and Wong,23 the superomedial and inferolateral aspects of the orbit were shown to have the greatest tendency to resorb. This contributes to the periorbital ageing, such as increased prominence of malar fat pad, elevation of medial brow and lengthening of the lid cheek junction.23 The lower orbit recession may result in the lag of the lower lid, with the descent of the lid cheek junction and a deepening of the infraorbital hollow, as surplus tissue piles up against the orbicularis origin along the medial rim.24 Rebuilding the areas of lost skeletal support is a method for restoring volume and can facilitate the repositioning of the soft tissue.

Figure 2: Sagittal section of the infraorbital hollow and its associated structures. Images adapted from Yongwoo.33

Fat Haddock et al. concluded that the lid cheek junction becomes more obvious due to the overlying malar fat below.7 The superior border of the malar fat is in line with the TT deformity. Haddock et al., however, studied only six fresh cadavers (three female, three male), 50 years or more of age. Due to this small sample size and the lack of ethnic diversity and age range, this cross-sectional study may not be representative of the wider population. The age range of the sample is particularly relevant, as shown in the study by Yang et al., which concluded that the superior border of the malar fat pad in elderly specimens was located caudally when compared to younger specimens.10 In addition, there was reduced thickness and volume of malar fat pads in the elderly specimens. The overall result was that TT deformity was more evident in the elderly specimens. The authors hypothesised that if the malar fat pad in young individuals were thin, the shape of the orbicularis oculi muscle would be more visible, which explains the presence of TT deformity in some young individuals.10 The infraorbital hollows may accentuate as the orbital fat above protrudes due to orbital septum weakening,20 mid-face volume atrophy9 and malar fat pad descent.10,20 In particular, the hollowing becomes more noticeable as the transition between the SOOF and deep medial cheek fat (DMCF) becomes more prominent due to atrophy-related to ageing.21

Anatomy considerations for filler treatment It is essential for clinicians to have in-depth knowledge of the relevant anatomy when treating the infraorbital hollows. The main arteries to consider are the infraorbital artery, angular artery and zygomaticofacial artery. The infraorbital foramen is usually located medial to the pupillary line and approximately 1cm below the infraorbital rim. The angular artery, a branch of the facial artery, runs along the medial canthus and anastomoses with the supratrochlear and supraorbital arteries.24 The zygomaticofacial artery and nerve arise from the Figure 3: Changes in the facial skeleton with ageing. Arrows indicate the areas of the facial skeleton susceptible to resorption with ageing. The size of the arrow correlates with the amount of resorption. Image adapted from Mendelson and Wong 2012.23

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foramen on the vertical line of the outer margin of the lateral orbital rim at about 0.5-1cm below the horizontal line of the lateral canthus and pass along the inferior border of the SOOF.25 Other than the consequences of vascular occlusion, an infraorbital haematoma can increase pressure on soft tissue and may trigger a lymphatic insufficiency and malar lymph-oedema. An embolism in the angular artery could have rare but catastrophic consequences; if it occludes the ophthalmic artery or central retinal artery, it can lead to blindness.26 In addition to periorbital vascularity and nerves, the lymphatics must be considered when treating the infraorbital hollows. Newberry et al. explained the anatomical basis of malar oedema.27 The superior and inferior portions of SOOF are divided by the malar septum. The interdigitation of the malar septum with the fibrous septa creates an impermeable barrier from the orbital rim to the skin overlying the cheek.21,22 If the filler is placed anterior or superficial to malar septum, due to its impermeability, it can compress the superficially-located lymphatic vessels and cause chronic lymphoedema due to lymphatic insufficiency.21,22,27 Hence it is advisable to perform deep injections to avoid lymph drainage impairment.1

Adopting safer techniques Given the diversity of anatomical explanations, it is not surprising that there are numerous variations and often conflicting surgical and injectables techniques performed for the treatment of infraorbital hollows. Many articles explore specific non-surgical techniques.1,5,21,28 Most importantly, the clinician should focus on adopting techniques that are as atraumatic as possible. With age, DMCF and SOOF atrophies, resulting in a greater transition between the orbital fat compartment and cheek fat compartments.26 Especially in patients that present with negative or neutral vectors, restoring the mid-face can be highly beneficial. Deep fat rejuvenation can reduce the transition between the lower eyelid and cheek fat compartment.26 This approach can potentially reduce the overall amount of filler required in the infraorbital region; an area that is considered high risk for lymphoedema.21 The SOOF is an ideal bed for HA placement in the treatment of infraorbital hollows, especially at its highest part along the orbicularis retaining ligament.1 The SOOF can be reached using a cannula or a needle, but it is important for the clinician to use the appropriate technique and location to ensure minimal trauma. Techniques that involve deep injection into SOOF are recommended by advancing the cannula or needle onto the supraperiosteal plane.1,28 Small aliquots of dermal filler can be placed along the infraorbital hollows to prevent the compression of lymphatics, haematoma, surface irregularities and nodule formation.26 Any nodules in this region are more visible and palpable as the skin over the lower eyelid is particularly thin. Fillers in the TT should preferably be placed below the malar septum to avoid chronic lymphoedema due to compression of the superficial lymphatic vessels.27 The cause of frequent oedema in this area can be explained by the exceptional lymphatic drainage of the SOOF.29 Haddock et al. recommend techniques for treating TT deformity according to the anatomical dissections.7 The article does not advise superficial HA deposition at the plane of the orbital and malar fat boundary, which corresponds to the anatomical plane of TT deformity. Restoring this boundary would require superficial placement of HA, which can risk contour irregularities due to its particularly thin skin.7 Many articles advise HA placement in the

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A study that dissected and histologically evaluated 48 hemifaces confirmed the presence of the TT ligament between the palpebral and orbital portion of the orbicularis oculi deep, submuscular plane to indirectly affect the TT deformity.1,7,8,30 HA can be injected along the infraorbital hollow, deep to the orbicularis oculi muscle. However, Haddock’s cadaver studies have shown the attachment of orbicularis oculi muscles at TT to very tightly adhere to bone; therefore, HA is likely to be deposited intramuscularly than the intended supraperiosteal plane at the innermost aspect of the tear troughs.7,8 Patient selection and thorough history taking are vital, as patients prone to malar oedema, or those with pre-existing malar bags or festoons are at increased risk of lymphoedema, hence treatment is best avoided.5 Patients with excessive intraorbital fat herniation must be considered for other modes of treatment such as surgery, as the ability of the dermal fillers to disguise the excessive fat herniation is limited and could result in poor aesthetic outcome.5 Using a wide gauge cannula with a slow injection can reduce the risk of intravascular injection and embolism.31 The use of an appropriate resorbable dermal filler with low cross-linking, low molecular weight, and low G prime may reduce the risk of the Tyndall effect and surface irregularities.32 It is preferable to use a filler with low elasticity (G’), as they offer less resistance to applied force with reduced extrusion and tissue stretching. The greater the elasticity, the higher the risk of lymphatics compression.29 It is also important to avoid over massaging to avoid displacing the filler superficially.

Study limitations The challenges of cadaveric studies are that there are limitations posed by the generally small study sample size. In addition, the preparation of the cadaveric specimens varies, which can affect the tissue structures. There are different methods of cadaveric sample preservation, which may further alter or distort the anatomy. Even if histological studies are included, they are dependent on the preparation of the sample and the various dyes used for detecting the tissue layers.10 The authors state that they could not obtain accurate measurements because of unstable reference objects. In addition, due to the transposition of tissue during the fabrication of histologic sections, authors faced difficulties in identifying and accurately measuring the original position of the malar fat pads.10 It is also difficult to quantify the complex three-dimensional

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changes of the ageing anatomy when two-dimensional measurements are used, as is the case in most published cadaver studies. It must be acknowledged that cadaveric tissues are very different from live human tissues. The ideal study would be a large linear study to show the ageing changes in the same living individuals.

Conclusion Despite limitations, the anatomical cadaver studies are nonetheless valuable in providing three-dimensional, visual information to help educate clinicians on techniques to reduce complications and promote treatment success. Atraumatic, slow injection speed using the correct HA product in small amounts supraperiosteally are advocated by authors when treating the infraorbital hollows. Correct patient selection and thorough assessment of the surrounding anatomy is vital. The infraorbital hollows are not localised to the tear troughs alone and the changes to its surrounding tissues lead to its characteristic features. After all, the infraorbital region is a continuum of the midface and it is equivocally prone to age-related changes involving the bone, fat, muscle, ligaments and skin. Understanding the ageing process of the face and the associated complex anatomy contributing to infraorbital hollowing is essential for a successful outcome and minimising the risk of complications.

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

Possible Answers a. b. c. d.

Orbital ligament Orbicularis retaining ligament Masseteric cutaneous ligament Zygomatic cutaneous ligament

a. b. c. d.

Orbicularis retaining ligament Orbital rim Palpebral portion of orbicularis oculi Zygomatic cutaneous ligament

3. What is the typical

a. b. c. d.

SOOF hypertrophy Contraction of orbital septum Descent of lid cheek junction Skin hyperpigmentation

4. Which muscle is

a. b. c. d.

Orbicularis oculi Zygomaticus major Levator labii superioris alaeque nasi Orbicularis retaining ligament

5. What are 3 main

a. b. c. d.

Infraorbital, angular and zygomaticotemporal Infraorbital, angular and zygomaticofacial Supraorbital and supratrochlear Angular, supraorbital, lateral nasal

Which ligament is present at the lid-cheek junction?

2. What is the lower limit of the SOOF?

feature of periorbital ageing?

tightly adhered to the maxilla in the (true) tear troughs?

arteries to consider during the injection of the under-eye hollows?

Answers: 1. b, 2. d, 3. c, 4. a, 5. b

Dr Jane Moon is a dental surgeon and aesthetic practitioner. She works at Dr Yusra Clinic, Thérapie and Harland & Dear and previously worked in the maxillofacial department at St Richard’s Hospital. Dr Moon has a Diploma in Primary Dental Care covering oral surgery, oral medicine and research. She has also completed a Diploma in Aesthetic Injectable Therapies and is a member of the Royal College of Surgeons. Dr Moon is passionate about patient safety and education and is an injectables trainer at Facial Aesthetic Courses. Qual: BDS, PG Dip, MFDS, RCSEd REFERENCES 1. Anido Javier, Fernández Jose Manuel, Genol Ignacio, Ribé Natalia, Sevilla Gema Perez, ‘Recommendations for the treatment of tear trough deformity with cross-linked hyaluronic acid filler,’ J Cosmet Dermatol. 2021;20:6–17. 2. Lee Ji Hyun, Hong Gi Woong. ‘Definitions of groove and hollowness of the infraorbital region and clinical treatment using soft-tissue filler,’ Arch Plast Surg 2018;45:214-221. 3. Barton FE Jr, Ha R, Awada M, ‘Fat extrusion and septal reset in patients with the tear trough triad: A critical appraisal’. Plast Reconstr Surg. 2004;113:2115-2121discussion 2122. 4. Jiang J, Wang X, Chen R, Xia X, Sun S, Hu K. Tear trough deformity: different types of anatomy and treatment options. Postepy Dermatol Alergol. 2016;33(4):303-308. 5. Stutman Ross, Codner Mark, ‘Tear Trough Deformity: Review of Anatomy and Treatment Options,’ Aesthetic Surgery Journal, Volume 32, Issue 4, May 2012, Pages 426–440 6. Flowers RS. The tear trough deformity and its correction. Presented at the Annual Meeting of the California Society of Plastic Surgeons; 1970; Monterey, USA. 7. Haddock NT, Saadeh PB, Boutros S, Thorne CH. ‘The tear trough and lid/cheek junction: anatomy and implications for surgical correction’. Plast Reconstr Surg 2009;123:1332-40. 8. Hwang SH, Hwang K, Jin S, Kim DJ. ‘Location and nature of retro-orbicularis oculi fat and suborbicularis oculi fat’. J Craniofac Surg. 2007;18:387-390. 9. Wong CH, Hsieh MK, Mendelson B. ‘The tear trough ligament: anatomical basis for the tear trough deformity’. Plast Reconstr Surg 2012;129:1392-402. 10. Yang C, Zhang P, Xing X. ‘Tear trough and palpebromalar groove in young versus elderly adults: a sectional anatomy study’. Plast Reconstr Surg 2013;132:796-808. 11. Loeb R. ‘Naso-jugal groove leveling with fat tissue’. Clin Plast Surg 1993;20:393-400. 12. Lambros VS. ‘Hyaluronic acid injections for correction of the tear trough deformity’. Plast Reconstr Surg2007;120(6S):74S-80S. 13. Hirmand H. ‘Anatomy and nonsurgical correction of the tear trough deformity’. Plast Reconstr Surg. 2010 Feb;125(2):699-708. 14. Roberts WE. ‘Periorbital hyperpigmentation: Review of Etiology, Medical Evaluation and Aesthetic Treatment’. Journal of drugs and dermatology. April 2015 Vol 13 472. 15. Alghoul Mohammed, Codner Mark, ‘Retaining Ligaments of the Face: Review of Anatomy and Clinical Applications’, Aesthetic Surgery Journal, Volume 33, Issue 6, August 2013, Pages 769–782. 16. Muzaffar AR, Mendelson BC, Adams WP. ‘Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus’. Plast Reconstr Surg 2002;110(3):873-884. 17. Alghoul Mohammed, ‘Blepharoplasty: Anatomy, Planning, Techniques, and Safety’, AestheSurgery Journal, Vol 39 (1) 2019, 10-28. 18. Mendelson BC Muzaffar AR Adams WP. ‘Surgical anatomy of the midcheek and malar mounds’. Plast Reconstr Surg2002;110(3):885-896. 19. Nassimizadeh Abdul, Nassimizadeh Mohammed and Ahmed Shahzada. One-point tear trough correction. THE PMFA Journal Vol7 Issue 1 Oct/Nov 2019 <https://www.thepmfajournal.com/features/ post/one-point-tear-trough-correction> 20. Heffelfinger Ryan, Blackwell Keith, Rawnsley Jeffrey, ‘A Simplified Approach to Midface Aging’, ARCH FACIAL PLAST SURG/VOL 9, JAN/FEB 2007, 48-55. 21. Guisantes Eva, Beut Javier. ‘Periorbital anatomy: avoiding complications with tear trough fillers’. Aesthetic Medicine Volume 21, Number 31, 73-78. 22. Pessa JE, Garza JR. ‘The malar septum: the anatomic basis of malar mounds and malar edema’. Aesthet Surg J. 1997; 17(1):11-7. 23. Mendelson Bryan and Wong Chin-Ho, ‘Changes in the Facial Skeleton With Aging: Implications and Clinical Applications in Facial Rejuvenation’, Aesthetic Plastic Surgery, 36(2012), 753-760. 24. Kahn DM, Shaw RB Jr. ‘Aging of the bony orbit: a three-dimensional computed tomographic study’. Aesthet Surg J. 2008 May-Jun;28(3):258-64. 25. Kumar S, Durairaj Kesavi, ‘Incidence and location of Zygomaticofacial foramen in adult human skulls’ International Journal of Medical Research & Health Sciences 3 (2014) 80. 26. Pascali M, Quarato D, Pagnoni M, Carinci F. ‘Tear Trough Deformity: Study of Filling Procedures for Its Correction’. J Craniofac Surg. 2017 Nov;28(8):2012-2015. 27. Newberry Ian, Mccrary Hilary, Thomas Regan, Cerrati Eric, ‘Updated Management of Malar Edema, Mounds, and Festoons: A Systematic Review’, Aesthetic Surgery Journal, Volume 40, Issue 3, March 2020, Pages 246–258. 28. Sharad J. Dermal Fillers for the Treatment of Tear Trough Deformity: A Review of Anatomy, Treatment Techniques, and their Outcomes. J Cutan Aesthet Surg. 2012;5(4):229-238. 29. Casabona Gabriela et al, ‘How to best utilize the line of ligaments and the surface volume coefficient in facial soft tissue filler injections’ Journal of Cosmetic Dermatology, 2019;00: [01/02/21] 1–9. 30. Griepentrog Gregory J, Lemke Bradley N, Burkat Cat N, Rose John, Lucarelli Mark, Anatomical Position of Hyaluronic Acid Gel Following Injection to the Infraorbital Hollows, Opthalmic Plastic and Reconstructive Surgery. 29(1):35-39,Feb 2013. 31. Walker L, King M ‘Visual Loss Secondary to Cosmetic Filler Injection’ J Clin Aesthet Dermatol 11(5) (2018) p53–55. 32. Huber-Vorländer Jürgen et al, ‘Correction of tear trough deformity with a cohesive polydensified matrix hyaluronic acid: a case series’, Clin Cosmet Investig Dermatol, 8 (2015); 307–312. 33. Yongwoo, L ‘Essential Facial Anatomy for Petit Surgery, D&PS, 2015. <http://idnps.com/basics/essential-facial-anatomy-for-petit-surgery/6-1-mid-face-indian-bands/>

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Presenting ageing complaints

Treating the Deep Pyriform Space Dr Varna Kugan explores the benefits and challenges of treating the deep pyriform space for mid-face volumisation The perialar region is notoriously known for being a high-risk zone with regards to soft tissue augmentation. The deep pyriform space is a relatively overlooked treatment area and was only well-described in detail a few years ago.1 In 2008, Rohrich et al. termed a space medial and deep to the deep medial fat compartment as ‘Ristow’s space’.2 In 2016, Surek et al. described the anatomical boundaries of this space in more detail and proposed a name change to the deep pyriform space for anatomical continuity with other named potential spaces in the face, such as the prezygomatic and premaxillary spaces.1 In this article, I will share my own experience and injection technique for volumising the deep pyriform space and will explore the anatomy, presenting complaints, injection strategy and challenges posed when treating the space.

Anatomical considerations The deep pyriform space is an inverted triangular-shaped space bound inferomedially by the depressor septi nasi, the soft tissue insertions on the bony pyriform aperture and

The treatment indication for volumising the deep pyriform space is due to having a depression or hollowing in the perialar region caused by maxillary bone retrusion.1 In addition, this bony retrusion also contributes to the formation of nasolabial folds.6,7 We know that maxillary retrusion is part of the ageing process and bony changes invariably have an impact on overlying soft tissues.6,8 This is compounded by soft tissue ageing itself such as hypertrophy of the superficial nasolabial fat compartment.9 I will also point out that in my practice, where I treat a significant number of East Asian patients, I perform many deep pyriform space volumisation treatments in much younger patients. This is due to the inherent structural bony differences of the demographic when compared to Caucasians. In general, the maxillary bone is more retruded in East Asians and perialar recession, associated with early nasolabial folds, is a common presentation in this group of patients, as early as in their 20s.10 I describe the differences between the aesthetic ideals of Asian vs. Caucasian patients in my previous article published in the Aesthetics journal.11 Not only can volumising the deep pyriform fossa improve perialar recession and nasolabial folds, it can also enhance the three-dimensional profile of the mid-face.10

post-orbicularis oris fat. It is bound laterally and superficially by the deep medial cheek fat and lip elevators.1 Pneumatisation of this space in cadaveric studies has demonstrated Injection technique a cephalic extension to the level of the tear I prefer to use a hyaluronic acid filler with a trough ligament.1 high G prime for two main reasons. The first The angular artery courses lateral and being that this offers the best lift capacity superficial to the deep pyriform space to help volumise the overlying tissues; within a septum, between the space and secondly, it ensures the product will stay the deep medial cheek fat at this level.1,3 in place which is important as this region is This is an important consideration when highly dynamic. deciding on the injection depth as we I prefer to use a needle over a cannula as I want to be in a deep plane to avoid the want to be able to place an accurate bolus angular artery. The infraorbital foramen lies directly onto the bone, which I feel is better superolateral to the angular artery in this achieved with a needle. I approach the skin region and, in 57% of cases, the infraorbital with the needle from lateral to medial so that artery shares the same supplying territory I am perpendicular to the nasolabial line. or anastomoses with the angular artery. This Blue triangle = Alar fossa is compared to the other Yellow arrow = The direction of injection 45%, which show no Orange dot = Bolus of product Horizontal dotted line = The widest connection to the angular point of the nasal alar Other dotted line = The nasolabial line artery in 284 cases.4 Practitioners should be aware that there are variations in vasculature especially with the branches of the facial artery, but this is beyond Figure 1: Injection technique for treating the deep pyriform space the scope of this article.5

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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Before

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The product is injected very slowly as a bolus and I always ensure I am deep onto the bony pyriform aperture to avoid the angular artery, which is superficial to the deep pyriform space.1 You will be able to see the gradual volumisation of the region as you are injecting. In addition, whilst you are injecting you should observe the whole face for any signs of vascular occlusion such as pain, blanching and delayed capillary refill time.14 It is highly advisable to use no more than 0.3ml of a high G prime filler on each side to reduce the risk of vascular compression (Figure 2).

After

Figure 2: 23-year-old female patient before and immediately after volumisation of the deep pyriform space using 0.3ml of Juvéderm Ultra Plus on each side.

Alternatively, you can aim in the direction of the contralateral oral commissure for guidance. I ensure the bevel is facing down and angle the needle as low as possible (ideally 10 degrees). A study in 2019 showed that injecting at an angle of 10 degrees with the bevel down reduces uncontrolled product distribution into superficial fascial layers. The study also mentions that using a 30 gauge needle helps in reducing spread, but that the angle of injection seems to have a greater influence on precision than it does needle size.12 My preference is to use a 27 gauge needle, however, as I find it easier to inject a high G prime filler as the extrusion force needed is lower. I like to pull the nasolabial fat superolaterally with my non-injecting hand before I enter with the needle. Once I am happy that I am on the bone I free my non-injecting hand and proceed to aspirate before injecting. There is debate regarding aspiration as a safety manoeuvre especially due to false negative results.12,13 Whilst there is no conclusive study on whether to aspirate or not, even in the pyriform fossa, for such a precarious treatment zone I personally feel the need to aspirate. This may change over time and will depend on an evidence-based approach.

Treatment challenges In my opinion, I think the biggest challenge in treating the deep pyriform space is ensuring accurate product placement without uncontrolled product spread. I have noticed that I do not get the same level of volumisation and therefore optimal aesthetic outcome if the needle is not touching the bone before I inject. It can be difficult to hit the bone if you are approaching from a very low angle of injection as I suggested above, but I believe this comes with practice and confidence. If your product is injected too superiorly then there is a higher risk of compression or occlusion of the infraorbital artery.4,15 If your product is injected too low (inferior to the nasal alar) then there is a chance that it may be deposited in the alveolar mucosa. To avoid these two scenarios, I ensure that the end of my needle is parallel with the widest point of the nasal alar. After treating the deep pyriform space, there may be a residual nasolabial fold and you can treat this accordingly to optimise the aesthetic outcome for mid-face rejuvenation (Figure 3).

Conclusion

After

Figure 3: 55-year-old female patient before and immediately after volumisation of the deep pyriform space using 0.3ml of Restylane Lyft on each side. The medial cheek and deep medial fat compartment were also volumised using a cannula technique for optimal outcome.

safety and confidence when treating this area. There are various injection techniques for treating the space but, in my experience, the technique I have described has yielded a high level of patient satisfaction and safety profile. I will also stress that treatment of this space is just one aspect that contributes to optimal aesthetic mid-face rejuvenation and it is important to take into consideration other mid-facial regions such as the medial and lateral cheeks. Ultimately, I believe it is highly advantageous for aesthetic practitioners to appreciate that this space exists and, if treated correctly, can demonstrate excellent aesthetic outcomes. Dr Varna Kugan is a JCCPregistered 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. Qual: MUDr (MD)

Whilst the deep pyriform space is a fairly recently described anatomic space, its significance as an important target for midface volumisation is unquestionable. One should appreciate the latest publications on the regional anatomy to ensure maximum

Top tips for treatment success Always consider the deep pyriform space when volumising the mid-face Treat in the deep plane to minimise risk of vascular occlusion Use a high G prime hyaluronic acid filler Pulling nasolabial fold superolaterally before injecting may help move the facial artery away from the treatment area • Injection angle should be as low as possible with bevel down • Ensure needle is touching the bone before injecting • Minimise uncontrolled product spread • • • •

Before

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Managing Health Anxiety Dr Hannah Davies describes the increasingly common condition ‘health anxiety’ “I am pleased to say Mrs X, that your clinical examination is normal. There is no sign of infection, there is good blood flow to the area, and there is no sign of allergy. Your chin filler looks perfect and is healing nicely.” Mrs X had been examined on four consecutive days and given endless reassurance, not to mention prescriptions for corticosteroids, antibiotics, anti-histamines and analgesia, yet she was convinced there was a catastrophic problem with the dermal filler I had administered her. This highlights the crux of the problem – despite how much Mrs X tries to absorb my reassurance and guidance, and how much she wants to stop worrying, she cannot. Mrs X suffers with health anxiety, and she is not alone. This was my first experience of managing a patient with health anxiety within the realms of aesthetics, which was something I had not been fully prepared for. Upon reflection, I have acknowledged and digested the invaluable lessons it has taught me, all of which have provided the impetus for this article. Unsurprisingly, given the paucity of evidence on health anxiety in the general population, the awareness of it amongst aesthetic practitioners is lacking, and yet failure to recognise this condition may lead to psychological, physical and economical stresses for both patient and clinician.

What is health anxiety? Health anxiety is a relatively new notion which shares overlap with both anxiety disorders (e.g. fear, hypervigilance to bodily symptoms, and avoidance) and obsessivecompulsive disorders (OCD), for example, preoccupation, rumination and repetitive behaviours.1,2 Health anxiety is largely similar to hypochondriasis; however, it differs in that somatic symptoms are not necessarily present.2,3,4 A more accurate description lies in the International Classification of Diseases (ICD)-11 categorisation, which describes it as a ‘hypervigilance to and a catastrophic misinterpretation of bodily signs and symptoms, including normal or commonplace sensations’.2,3 The ICD-11 classification also goes onto describe how the individual’s preoccupation and fear of serious illness leads to behaviours such as: information seeking, reassurance seeking and avoidance.1,3 Health anxiety is becoming increasingly common, however there is no official data on the prevalence of it in the general population.5 One Australian study comprising 8,841 participants found that it affected almost 6% of people.6 A more recent study performed at Imperial College London, comprising 28,991 participants, suggested health anxiety affected almost 20% of individuals.7

Relevance to aesthetics The health anxious individual will return home after an aesthetic treatment and

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ruminate on the possible complications such as infection, hypersensitivity reactions, or vascular occlusion. They may misinterpret normal clinical signs and symptoms, for example bruising and swelling, as indicators of serious disease or plug their harmless symptoms into a search engine which leads them to a disproportionately high number of highly unlikely explanations, including lifethreatening disease. In turn, this will lead to a heightened state of anxiety and they will start to fear grave complications resulting from their treatment. It is abundantly clear that they will experience great emotional distress from their symptoms. In my experience, the result is an unremitting cycle of telephone/video/face-to-face consults, reassurance seeking, investigations and potentially unnecessary treatments, all of which fuel the anxiety further. Both health anxiety and cyberchondria culminate in excessive reassurance-seeking behaviour, which is comparable to obsessivecompulsive checking behaviour seen in OCD.8 This behaviour can be persistent, extensive and debilitating for both the patient and practitioner, particularly given that the reassurance is usually poorly absorbed or only short-lived. In my experience, failure to recognise health anxiety can lead to a heavy investment in your time and money, over-treatment, and undue worry. Moreover, given the lack of evidence, the treatment outcomes in those with health anxiety are not defined. However, it can be expected that these patients are likely to be dissatisfied with their treatment because their aesthetic results are overshadowed by anxiety. This is comparable to studies which have shown unsatisfactory outcomes following aesthetic surgery in those suffering with severe psychological disorders such as major depression.9 As clinicians we must remember, ‘first, do no harm’. Therefore, it may be in their best interests not to undergo aesthetic treatments.

How to spot health anxiety Whilst aesthetic practitioners are increasingly astute to spotting more common psychological disorders, such as the aforementioned BDD, they may be less experienced in recognising health anxiety. It can be adequately screened for during the consultation process using a validated questionnaire. Three of the most widely used and validated assessment platforms for health anxiety are:

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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• The Health Anxiety Inventory (HAI) • Illness Attitudes Scale (IAS) • Whiteley Index (WI) 10 All three screen screening tests have high negative predictive values (NPV), meaning you can have confidence the patient does not have health anxiety if they get a negative test result. They are all highly specific and sensitive tests.10 Whilst many argue that the HAI and IAS are superior to the WI based on their excellent psychometric properties, the WI is much shorter and therefore, more practical for use as a screening tool in an aesthetic clinic setting. The WI is composed of 14 questions and, in my experience, takes approximately 15 minutes to complete. The WI assessment includes questions such as: ‘Do you often worry about the possibility that you have got a serious illness?’ and ‘If a disease is brought to your attention (through the radio, television, newspapers or someone you know) do you worry about getting it yourself?’11 In comparison, the HAI and IAS are composed of 64 and 29 items, respectively, and are not practical for use in aesthetics. It is essential that every aesthetic consultation involves, in some format, screening for underlying mental health diagnoses. I strongly advocate the consultation process integrates, to some degree, a screen for underlying health anxiety. Cyberchondria, which has a positive correlation with health anxiety, can be detected using the validated Cyberchondria Severity Scale (CSS), or more simply screened for by asking patients to state how many hours they spend per day searching the internet for medical information.12,13

Management Effective management lies within the consultation and the ability to identify at-risk individuals. The relationship between health anxiety and aesthetic treatment outcomes has not been researched. As such, patients with this condition should be managed on a case-by-case basis. Following identification of existing, or susceptibility to, health anxiety it is imperative you explore this with your patient. From my experience as a GP registrar and an aesthetic practitioner, it is important to emphasise that proceeding with any treatments may cause them unnecessary worry, which may outweigh the benefits of having the procedure done. This can result in under-appreciation of the results and

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Pre-procedure

Diagnose

Identify those at high risk

2. Discuss

Discuss your concerns; offer alternatives; signpost them to their GP

3. Digest

Allow time for the patient to consider the options

Procedure:

4. Minimise treatments

Treat only one area at a time

5. Minimise volumes

Use only small amounts of filler or toxin at one time

Post-procedure

6. Aftercare

Provide detailed verbal written aftercare advice

7. Healing process

Explain the normal healing process in detail

8. To take away

Provide written information for their reference and your contact number for help/advice

Table 1: Dr Davies’ suggested management for health anxious patients

dissatisfaction. If you recognise that your patient has health anxiety, implore them to seek help from their GP. Randomised control trials have shown cognitive behavioural therapy (CBT) to be an effective treatment for health anxiety.1,15 Consider offering your patients lessinvasive alternatives to treat their aesthetic concerns such as medicalgrade skin products, chemical peels, or microneedling. Allow your patient time to go away and digest the information discussed. I would suggest a period of one to two weeks. If you deem your patient’s mental state stable and their anxiety not so severe to interfere with treatment or aftercare, then you may decide to proceed with treatment. In my experience, anxiety can be minimised post-procedure by adhering to a few simple rules. Firstly, educate your patient. In the initial consultation, explain the normal healing process, aftercare advice, and describe what is to be expected over the proceeding hours, days and weeks. Describe the signs and symptoms that would warrant urgent clinic review such as pain, pallor, or paraesthesia.16 It is useful to provide written information detailing the aforementioned as a source of accurate information for the patient to refer to once home. Given that up to 80% of verbal medical information provided by practitioners is immediately forgotten, written information is extremely important and helpful.17

aesthetic-naive patient. In my clinic this has been an effective way of minimising posttreatment anxiety. Furthermore, minimising the volume of dermal filler injected in one sitting can also reduce anxiety by reducing the occurrence and severity of local side effects such as erythema, bruising and oedema, all of which are signs that could be misconceived by the health anxious as indicators of severe illness and disease. It has been suggested that limiting injections of dermal filler to 0.1ml per injection site is safest practice.18 Imperatively, your patient must have access to help and support from your clinic should they become concerned after treatment. Dr Hannah Davies has a Bachelor of Medicine and Bachelor of Surgery, as well as a first-class degree in Biomedical Science from the University College London, where she was recognised on the Dean’s list for her achievements. She currently works as a GP registrar for the NHS as well as leading her private aesthetic clinic, Dr Davies Aesthetics. Qual: MBBS, BSc

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Secondly, I would recommend limiting the number of procedures performed per sitting to one treatment area, especially for the

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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• Deterioration of skin structure • Loss of elasticity • Fine lines and wrinkles Such changes in the skin’s appearance can affect patients’ confidence and self-esteem3 – particularly after the stresses of long-term lockdown and increased usage of Zoom and video calls. After months of disruption to clinic businesses, it’s understandable that practitioners are looking forward to springing back into action, and what better way than to boost the confidence and skin glow of patients after lockdown.

Dr Munir Somji, director of Dr Medispa “For the vast majority of our patients, radiance is high up the priority list for the most sought-after skin goals. As we age, natural radiance can fade and with it, confidence. Restylane Skinboosters provide the perfect solution for those that seek a natural glow from within; something that gives skin a long-lasting refresh without being too tell-tale. When you’re giving back skin confidence to your patient, the effect is more than just good skin, it’s a positive shift in self esteem.”

Restylane Skinboosters infuse a thin layer of micro droplets of hyaluronic acid beneath the skin surface, where it draws water and provides long-term deep hydration to provide a refreshed and radiant look that lasts. A course of three treatments around four weeks apart is recommended with a top-up or maintenance treatment at six months.

Key Benefits • Boost radiance through deep hydration and improved elasticity5-7 • The original HA-based injectable for improved skin quality8 • Favourable safety profile based on 17 years of clinical experience and over 5.5 million treatments worldwide8,9 • Long-lasting results that leave them glowing with confidence9,10

Aesthetics | March 2021

Available in two variants; Vital and Vital Light, Restylane Skinboosters nourish skin from within, using the ability of HA to restore the natural composition of the skin, boost hydration and improve elasticity,7,12,13 for overall skin quality improvement. Indications are varied and versatile giving practitioners the ability to treat imperfections in the face, neck, décolletage and hands. • Restylane Skinboosters Vital is the original formulation for face, hands, neck and décolletage • Restylane Skinboosters Vital Light is used for a more subtle effect when treating the neck and décolletage

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Before

After

Before

After

Before

After

Before

After

With 17 years of clinical evidence and practice, Galderma’s Restylane Skinboosters are your first port of call for delivering naturally glowing, radiant skin to your patients so they can feel good in their skin once again. Keep an eye on the Med-fx website for Restylane SkinBooster offers www.medfx.co.uk This advertorial was written and supplied by Galderma

Galderma | Empowering Beauty in all forms for 40 years Restylane Skinboosters and Galderma are trademarks owned by Galderma S.A. Date of Preparation: UKI-RES-2100005 DOP FEB 2021 REFERENCES 1. 2. 3. 4. 5.

Data on File (MA-39929) Finn et al. Dermatol CJ Surg 2003;29(5):450-455. The Emotional Impact of Skin Problems. Psychology Today. Sydney R. et al. Aesth Surg 2006 : 26 S4;1-2 Nikolis A and Enright KM. Clin Cosmet Investig Dermatol

6. 7. 8. 9.

2018;11:467-475. Williams S et al. J Cosmet Dermatol 2009;8(3):216-225. Gubanova E et al. J Drugs Dermatol 2015;14(3):288-295. Data on file (MA-33110). Data on file (MA-39929).

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10. 11. 12. 13.

Kerscher M et al. Dermatol Surg 2008;34(5):720-726. Wu Y et al. J Cosmet Dermatol 2020;19(7):1627-1635. Gubanova El et al. Poster presented at IMCAS 2015. Distante F et al. Dermatol Surg 2009;35(S1):389-93.

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advises one year for its Teosyal products.3 This has been done to ensure that if an adverse reaction was to occur, the brand of dermal filler that’s more likely to be the cause is easily identifiable. I then ask the patient to discuss what they feel the issue is. I think it’s important at this stage not to be vocal about your Dr Hannah Ranjbar discusses her approach to personal assessment before you listen. By treating patients who present with dermal filler first listening to the patient’s story, you fully complications from another practitioner understand their concerns from their eyes, which will help you to form your opinion It is well known that complications data is lacking in the aesthetic and give significant, detailed and specific advice according to their sector, but anecdotally there are reports that they are rising. If presented complaint/area of concern. a practitioner has been fortunate enough not to have been faced Once the treatment history and desired outcome is obtained, I always with an aesthetic correction, it’s likely they will at some point in the ask who their original practitioner/clinic was and advise they discuss future. With this comes the complex issue of addressing concerns their concerns with their original practitioner. I do this as I feel that from another injector’s work. each injector should have the ability and opportunity to rectify or In many circumstances consulting these patients can prove very address their patient’s concerns, and because it’s commonly stated on difficult, being conflicting and distressing for both the practitioner insurance policies that once remedial work is carried out, the patient and the patient. I have personally had many patients present to me then fully becomes yours. Of course, insurance policies are always from other clinics seeking my opinion on their outcomes. bespoke, so be sure to check with your own provider. In my experience, the most common complaint patients present At this point, the patient sometimes feels more at ease because they with is related to lip fillers and product migration. Migration of may have felt their previous injector was incompetent; but this is not dermal filler is where the product moves above or below a border always the case. By taking the time to discuss the ‘problem’, the where it is placed, causing, in some instances, a shadow outside of possible reasons why something has happened and talk though the lip border. The borders can become blurred and the vermilion what to do next, the patient is often much more confident and less border is no longer crisp. What was the philtrum and upper lip area anxious about going back to their original practitioner. is now one with the pink of the lip.1,2 In my experience, for those happy to return to their original Other unsatisfactory results I am often approached about are practitioner, I would estimate that around 60% of previous lumps, asymmetry, lack of change, too much change, unnatural practitioners will address the issue presented to them. However, results or even too natural; all of which are undesired in the eyes around 30% will unfortunately suggest the fault lies with the patient of that patient. Rarely do I get presented with a vascular occlusion and the remaining 10% ignore all forms of contact. It’s these 40% of (VO) case. patients that usually find their way back to me. This article aims to explore some of the challenges I have faced Alongside this, sometimes patients refuse to contact their previous and provide my tips for overcoming them. injector due to the lack of faith in their ability even if the practitioner has offered to address the concern. In most cases, they have already Initial consultations approached the previous practitioner and unfortunately the advice When approached about a complication or unsatisfactory results, the given and/or rectification plan was not to their liking, and they felt they questions I would initially ask the patient are: would still be left with their undesired result. On several occasions, I • When were you last injected and in what area? have also found that rather than being offered adequate rectification, • How many times has the area of concern been injected? where in some instances dissolving is required, further dermal filler is • What product/s have been used and how much was injected? offered ‘for free’. • What was your desired outcome? Once I have been made aware of the particular injector that had • What practitioner/clinic did the initial treatment? carried out treatment, I will usually check their credentials and see if they have the ability to rectify a particular issue. On rare occasions, I When the patient was injected is extremely important. Each brand have also found the previous practitioner is not competent to carry of dermal filler has a recommended timeline suggested before out corrections. This can be individuals who have not attended or had switching to a different brand. Teoxane, for example, strongly included in their training the use of hyaluronidase for instance, or are

Addressing Filler Complications

My experience Managing patients presenting from other practitioners has personally been an eye opener for me. I know first-hand how it feels to have treatment and for it to go terribly wrong. I had my own lips injected several years ago and unfortunately had an undesired outcome,

causing a deformed overall appearance. My injector was unreachable to assist or advise me with any options, which was scary and distressing to have no help. I ensure that I never allow any of my patients to feel this way by always supporting them through their treatment journey. I have written about my

experience and many patients have read this before they have attended clinic, which has actually helped me to gain their trust as they feel I can relate to their circumstance. I also gain trust by using relevant visual aids such as anatomical materials or videos to show them similar cases and manage their expectations.

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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not a prescriber or have a prescriber, which makes the process lengthy and complex for them to address. On these occasions, I would take the person on as my patient without advising they return to their original practitioner and improve their situation to the best of my abilities.

Treatment consultations If I decide to go ahead with treating the patient, I will always seek the medical history from the previous injector, where possible. I initially ask the patient to obtain this and typically, practitioners are accommodating. In instances where this is not possible, I personally send an email to the clinic asking for the information and include the patient in the email. If I am unable to acquire the information required, I collate as much evidence as possible, such as appointment confirmations, their previous before and after images with time stamps, and the previous practitioner’s possible product of choice, which can generally be found on their social media and/or website. I will then, as usual, undertake a full medical history of my own using the medical model (comprehensive consultation, assessment with diagnosis and treatment plan aiming to treat aesthetic, medical and psychological concerns) and initiate a minimum cooling-off period of at least four to six weeks if not an emergency. This allows the patient time to heal adequately and to overcome the emotional aspects, as well as come to terms with a potential treatment plan. I always ensure I ask what the patient has had done in the past and if all treatments were at the same clinic or various clinics. Unfortunately, many patients ‘clinic hop’ and are unsatisfied with every treatment they have had. Regrettably, with these particular patients, satisfaction is never gained, even with adequate consultation and management of expectations. Some of these patients may also have underlying Body Dysmorphic Disorder (BDD) that must be screened for and considered to cause ‘no harm’.4 The patient should be consented, with the risks of your treatment clearly explained, and I add on the consent form that they are aware that full resolution may not be achieved. They understand that I will get it as close to their desired outcome as possible, but they understand the difficulty when working to rectify, hence outcome is not a guarantee. Managing expectations is paramount and is advised by both the JCCP and CPSA in their ‘Guidance for Practitioners Who Provide Cosmetic Interventions’5 as well as recommended by the GMC in its guidance for doctors.6

Figure 1: Patient 1 images showing tissue necrosis after being injected with 1ml of dermal filler several days after treatment

contacted the practitioner a few hours later with her concerns, but was informed it was ‘simply an allergic reaction to the dental block’, and was advised to take antihistamines. A few days later, despite having immediate severe pain, discoloration and ulceration at the site of injection, the practitioner denied the patient a face-to-face review. Several days later, the tissue had become black (tissue necrosis) and parts of her lip were ‘falling off’. She had to self-manage at home with over-the-counter pain relief, massaging (as she felt the area had ‘a lump’) and watchful waiting. She had contacted her GP, seven days after, who misdiagnosed and prescribed treatment for impetigo, prescribing topical fusidic acid, and then flucloxacillin as second line. Although this may have not been the relevant treatment plan, indirectly with watchful waiting, massaging and pain management, her symptoms started to slowly ‘resolve’ to a more bearable state. To me, the images and description of the patient’s experience demonstrated an obvious VO and impending necrosis. Unfortunately, this was never suggested to her and she was never even consulted about complication risks or signs to look out for.7 This mismanagement caused great loss of lip tissue and scarring, leaving the indentation she presented with in the body of her bottom lip (Figure 2). Figure 2: Patient 1 showing resolution of tissue necrosis after watchful waiting, massaging and pain management, yet there is evident loss of tissue as a result of VO

Managing expectations Complications such as VOs, migration, lumps and asymmetry, can be challenging and time-consuming to rectify. However, I find cases where a patient ‘didn’t get what they asked for’ much more challenging. With the rise of social media and celebrity influencers, patients commonly show images of other people’s lips asking for that exact look. However, what they do not always understand is that results can vary from patient to patient and the exact same result is unachievable. If this isn’t addressed in the consultation, an avoidable complication could occur as the patient may not be happy with the result.

Case study – vascular occlusion

Figure 3: Patient 1 immediately before and after treatment at my clinic

A 48-year-old female presented to me a year following injection of 1ml of dermal filler to her lips at another clinic (Patient 1). She was concerned with scaring and unevenness she had been left with, which affected her physically and psychologically and had images to demonstrate the result (Figure 1). She said that immediately post injection she had unbearable pain but was told by her practitioner not to worry and that it was normal. She

Circumstances like this are very difficult to manage, as the patient had no trust in their previous practitioner and they were greatly against going back to them. I therefore decided to help and was able to add volume and definition to her lip to become close to her natural lip shape, however, I could not rectify her scars. In fact, I had to be very careful around the scared area as deep tissue scars can fix arteries

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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in place and make them easier to penetrate (Figure 3).1 I advised that microneedling and platelet-rich plasma treatment might help with her remaining evident scaring.

Case study – undesired aesthetic result A 26-year-old lady approached me 18 months after lip augmentation elsewhere because she was concerned about the lumps she had in the underside of her lips (Figure 4). These lumps were present two weeks after her treatment, but increased in size over the following months. She approached her previous injector, but was not offered a face-to-face consultation and was told to massage them to resolve. However, the lumps remained, and she was still refused a faceto-face consultation. The patient explained that initially the lumps were not something that were of great concern and she explained they were ‘bearable’. She finally came to see me as they had eventually become a topic of anxiety for her. Before

Before

the potential outcomes and managing her expectations. She did not want to be treated with hyaluronidase as she had watched many videos online; some showing extreme pain, tremendous swelling and bruising, causing her great anxiety. I advised that we could first try to manually remove/lance some of her larger lumps8 to see if the outcome was an aesthetically pleasing result she would be happy to ‘live with’ until she was ready to be treated with hyaluronidase. Some were very superficial so were easy to remove. I reviewed her again 14 days later. The lancing had improved the overall appearance by around 30%, which was expected and explained to her prior to treatment. We had another consultation and again discussed her options. At this point I had built her confidence, not only in me as her practitioner but also in her ability to visualise and accept the journey required to get her to where she wanted her lips to be. We finally treated her lips with hyaluronidase, and refilled once the lips had healed over a further 14 days. The Patient was much less nervous in her dissolving session due to the results she had seen up until this point and the trust we had built between patient and clinician. She was happy with the results post treatment; she was able to close her lips with no protrusion of lumps; her borders were defined and there was no migration or blurred borders/philtrum (Figure 4).

Take special care with managing these patients The aesthetic specialty is thriving and with that we can assume there will be increased complications presented to us from other practitioners. We as medical professionals should learn to address these concerns in a manner that is holistic in its approach. If a patient presents from another clinic, I believe practitioners should take care in the consultation and encourage them to return to their treating practitioner. If this is not possible, as with many cases I have seen, we should clearly give them the options available and allow them to reflect on the information given.

After

Figure 4: A 26-year-old female patient who presented 18 months after dermal filler treatment at another clinic with extensive lumps in the oral mucosa. The large lumps were lanced, and she was treated with hyaluronidase and retreated with filler.

The patient had been told that her lips were normal when to me they clearly weren’t; so in the consultation I detailed what is generally accepted as ‘normal’ and ‘not normal’ in the perioral region. Upon examination, I observed numerous lumps in the body of the lip and within the oral mucosa. The larger lumps had caused incompetent lips where the interlabial gap was visible on resting. As well as this, she had severe migration above her vermillion border and her philtrum was distorted. I initially advised the patient to approach her previous injector, however she refused as she had already tried on several occasions and was turned away and made to feel as if ‘she was bothering the practitioner’. Given her anxiety, and how sensitive she was with any discussion regarding her lips, I came up with a treatment plan to suit her. Her main concern was the fear of going back to her natural lip, but with an added deformed appearance. She required in-depth discussions with what each stage of treatment set out to achieve and the timeline of results, highlighting

Dr Hannah Ranjbar graduated from Keele University in 2018. She has trained in foundation and advanced dermal fillers and toxin, as well as attending lip filler masterclasses. Dr Ranjbar has trained in mid and lower face dermal fillers with Harley Street Institute. She has an interest in cosmetic/plastic surgery and is working towards a surgical career. Dr Ranjbar runs her own clinic in Haywards Heath called L1P Aesthetics. Qual: BSc, MBChB with Honors REFERENCES 1. Jordan, David R., and Bazil Stoica, “Filler Migration”, Ophthalmic Plastic And Reconstructive Surgery, 31 (2015), p257-262 2. Lemperle, Gottfried, Peter P. Rullan, and Nelly Gauthier-Hazan, “Avoiding And Treating Dermal Filler Complications”, Plastic And Reconstructive Surgery, 118 (2006), p92S-107S <https://pubmed.ncbi. nlm.nih.gov/16936549/> 3. Are Teosyal Dermal Fillers compatible with other fillers? | Teoxane Laboratories, Teoxane.Com, 2020 <https://www.teoxane.com/en/are-teosyalr-dermal-fillers-compatible-other-fillers> 4. Saade, D. S., M. B. de Castro Maymone, and N. A. Vashi. 2018. ‘The Ethics of the Cosmetic Consult: Performing Procedures on the Body Dysmorphic Patient’, International Journal of Women’s Dermatology, 4.3: 185–87 5. JCCP, Guidance For Practitioners Who Provide Cosmetic Interventions, Jccp.Org.Uk, 2020 <https:// www.jccp.org.uk/ckfinder/userfiles/files/JCCP&CPSA%20Code%20of%20Practice(2).pdf> 6. Guidance For Doctors Who Offer Cosmetic Interventions’, Gmc-Uk.Org, 2020 <https://www.gmcuk.org/ethical-guidance/ethical-guidance-for-doctors/cosmetic-interventions> 7. Souza Felix Bravo B, Klotz De Almeida Balassiano L, Roos Mariano Da Rocha C et al. ‘Delayedtype necrosis after soft-tissue augmentation with hyaluronic Acid’. J Clin Aesthetic Dermatology. 2015;8(12):42–47. 8. Saade DS, de Castro Maymone MB, Vashi NA. The ethics of the cosmetic consult: Performing procedures on the body dysmorphic patient. Int J Womens Dermatol. 2018;4(3):185-187. Published 2018 Jun 6.

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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Perioral Rejuvenation Dr Simon and Dr Emma Ravichandran share a case study of using BELOTERO® in multiple tissue planes to deliver natural-looking dynamic results Aesthetic medicine is evolving rapidly owing to a better understanding of facial anatomy, senescence and product rheology. In this case study we will share with you our current approach to perioral rejuvenation. We have developed this approach through our experience of treating patients within our Clinetix chain of clinics, as well as from our global teaching and training. For the first time ever we offer you a video of the entire treatment journey of this patient via the QR code in this article. Ashley’s complaint is that her lower face looks old, she has smokers’ lines although she has never smoked and her lips are thin. She has a history of 10 years of sunbed use, is currently on a topical programme of AHAs and retinol, and has previously had toxins and dermal fillers. Her anticipated outcome is a rejuvenation of her perioral area. Our diagnosis for Ashley is that she has skin changes due to chronic sun exposure, senescent changes greater than expected with age and a mild class 2 skeletal base with a retrognathic chin. Our plan is to use dermal fillers to augment her chin and reduce the appearance of her class 2 skeletal base, reposition nasolabial and sublabial tissues, volumise the body of lips, and restructure the dermal integrity of the vermillion border, nasolabial line and perioral rhytids.

Assessment: resting and animation While senescence is unavoidable, genetics and environmental factors also play an important role in the presentation of signs of ageing by our patients. We should listen to the patient’s concerns and anticipated outcomes; however we should also have a systematic approach to assessing the face and each subunit of the face, in this case the perioral region. Ashley shows loss of volume in the nasolabial folds, body of the lips, oral commissures, sublabial areas, marionette areas, prejowl sulcus, 42

mental crease and chin. Her chin is slightly retrognathic and there is mild asymmetry of the upper lip. On animation we see loss of integrity of the vermilion border and perioral rhytids.

Chin Treatment of Ashley’s chin will improve the projection of her lower face, effecting her profile, jawline, the dimpling of her skin and her whole perioral area. Whilst the ideal width of her chin should be equal to her intra-cantal distance, subtle differences to the tapering or curvature of the chin can be made depending on the volume and pattern injected. We used a three bolus technique, a superior 0.4ml bolus of BELOTERO® Volume1 on the Pogonion (most anterior point) of the chin and two inferior boluses 1cm each lateral to the Gnathion (most inferior point) of the anterior chin. A 27G unprimed needle is advanced until bone is contacted, an aspiration is performed and the boluses slowly injected. BELOTERO® Volume1 is the product of choice because of its cohesive lifting capacity.

Pre-jowl, marionette and mental crease Correction of prejowl hollowing may be considered part of the anterior jawline treatment. It is important to replace the volume in this area and to transition between the lower lateral face and the chin. Step 1 2 small boluses of BELOTERO® Volume1 are placed along the inferior margin of the mandible in the prejowl hollow. A 27G unprimed needle penetrates the skin until contact with bone is made. After a negative aspiration, 0.2mls of BELOTERO® Volume1 are deposited. The needle is moved 0.5cm anterior and a second bolus of 0.2mls is then deposited. Aesthetics | March 2021

Step 2 A 23G trochar needle makes an entry point for our primed 25G 1.5 inch cannula to enter into the subcutaneous fat. The cannula is advanced towards the oral commissure and a thread of 0.025mls of BELOTERO® Intense2 is laid down with a retrograde technique. The cannula is repositioned medially and inferiorly and multiple threads of BELOTERO® Intense2 are deposited next to one another to make a strong support network under the skin. The cannula can reach across to the midpoint of the mental crease. Several small strands of BELOTERO® Intense2 restructure the mental crease.

Sublabial support The descent of the oral commissures is multifactorial and results from a combination of loss of lift from the facial tissues above, and loss of support from the facial tissues below. Ashley shows early oral commissure decent. We replace support below by injecting a small 0.05ml bolus of BELOTERO® Intense2 below the oral commissure under the lower lip. A 27G 0.5 inch unprimed needle is placed through the dermis and into the subcutaneous fat. An aspiration is performed before the bolus is deposited.

Lips Natural rejuvenation of aged lips requires skill, using multiple products and treating multiple tissues on multiple planes. Step 1 For Ashley we begin with restructuring the vermillion border. We use BELOTERO® Balance3 for this indication because of its low viscosity and Cohesive Poly-densified Matrix (CPM) technology.4 A primed 30G needle is advanced along the vermillion boarder intradermally. The filler is placed with a slow retrograde technique. The subsequent injections are a needle length away from the last injection point. Small deposits of

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A total total ofof 6mls of BELOTERO® was used for this treatment. 2 Before After A of 6mls of BELOTERO® was used for treatment. , 3mls BELOTERO® Intense and 1ml 2mls BELOTEO® Volume BELOTERO® Balance . We have created a natural looking A total of 6mls of BELOTERO® was used for this treatment. 2mls BELOTERO® 1 of 6mls 2 BELOTERO® 3 A total of BELOTERO® was used for this treatment. , 3mls Intense and 1ml 2mls BELOTEO® Volume rejuvenation by replacing volume lost at each tissue plane with Volume, 3mls BELOTERO® Intense and 1ml of BELOTERO® Balance. We 1 2 2 and 1ml 3 1 , 3mls BELOTERO® Intense 2mls BELOTEO® 2 , 3mls BELOTERO® Intense andused 1ml for this 2mls BELOTEO® Volume of BELOTERO® Balance . We have created3 a11,natural looking 1 of 6mls 1Volume 22 33 A total of BELOTERO® was treatment. 3mls BELOTERO® Intense 1ml 2mls BELOTEO® Volume 2 and rejuvenation by replacing volume lost at each tissue plane with Volume, 3mls BELOTERO® Intense and 1ml of BELOTERO® Balance. We ,natural 3mls BELOTERO® Intense and 1ml 2mls BELOTEO® Volume BELOTERO® Balance .aaWe have created amatch natural looking 33.a of BELOTERO® BELOTERO® Balance We have created natural looking aof product that has rheological qualities the tissue have created natural looking rejuvenation by replacing volume lost at of Balance . We have created looking rejuvenation by replacing volume lost at each tissue plane with that 22 3 11 ,volume 3mls BELOTERO® Intense and 1ml 2mls BELOTEO® Volume of BELOTERO® Balance have created a natural looking 3. We a product that has rheological qualities that the tissue by replacing volume lost atthat each tissue plane with have created avolume natural rejuvenation by replacing volume lost at rejuvenation by replacing lost at each tissue plane with arejuvenation product qualities the tissue ofthat BELOTERO® Balance . match We have created amatch natural looking rejuvenation by replacing lost at each tissue plane with that ithas isrheological replacing, resulting in a smooth and untreated look each tissue plane with alooking product that has rheological qualities that match 33 match the tissue a product product that has rheological qualities that a that has rheological qualities that match thesmooth tissue that it iseach replacing, resulting in awith smooth and untreated look of BELOTERO® Balance . We have created a natural looking rejuvenation by replacing volume lost at each tissue plane with that it is replacing, resulting in a and untreated look tissue plane a product that has rheological qualities that match rejuvenation replacing volume lost atAt each tissue plane with a product that has rheological qualities that match the tissue both at rest and in dynamic her 2 week review, tissue that itby is resulting in a smooth and untreated look both that ititatis isthe replacing, resulting in aareplacing, smooth and untreated look that replacing, resulting in smooth and untreated look both rest and in dynamic movement. At her 2movement. week review, rejuvenation by replacing volume lost atAt each tissue plane a product that has rheological that match the tissue both rest and in dynamic her 2 week review, tissue that ither is replacing, resulting in atwo-week smooth and untreated look arest product that has rheological qualities that match the tissue that itat iswas replacing, resulting in aqualities and untreated lookwith both at atthe rest and in dynamic movement. At her her week review, both rest and in dynamic movement. At 22movement. week review, Ashley was delighted with treatment. Ashley delighted with her treatment. at and in dynamic movement. Atsmooth her review, Ashley wasboth a product that has rheological qualities that match the tissue that it is replacing, resulting in a smooth and untreated look Ashley at was delighted with her treatment. Ashley was delighted with her treatment. Ashley was delighted with her treatment. rest and in dynamic movement. At her two-week review, Ashley that itatisrest replacing, resulting movement. in a smoothAt and untreated look was both in dynamic her 2 week review, delighted withand her treatment. that it is replacing, resulting in a smooth and untreated look both at rest and in dynamic movement. At her 2 week review, delighted with her treatment. both at was rest delighted andhas in dynamic movement. Atmy her 2self weekconfidence, review, with her treatment. “The Ashley treatment really restored I love it!” both at rest and in dynamic movement. At her 2 week review, was delighted with her treatment. “The Ashley treatment has really restored my self confidence, I love it!” Ashley was delighted with her treatment. Ashley was delighted with her treatment. REGISTER NOW for our 2021Clinical Education Series Webinars at REGISTER NOW for our 2021Clinical Education Series Webinars at merzwebinars.com REGISTER NOW for our 2021Clinical Education Series Webinars at merzwebinars.com

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References 1 IFU BELOTERO® Volume References References 2 IFU BELOTERO® Intense 1 IFU BELOTERO® BELOTERO® Volume 1 3 IFU IFU BELOTERO® Volume Balance 2 IFU IFU BELOTERO® BELOTERO® Intense Intense 2 4 Tran C. et al., In vivo bio-integration of three hyaluronic acid fillers in IFU BELOTERO® BELOTERO® Balance Balance 33human IFU skin: a histological study – Dermatology, 2014, 228:47-54 4 Tran C. et al., In vivo bio-integration of of three three hyaluronic hyaluronic acid acid fillers fillers in in 4 Tran C. et al., In vivo bio-integration human skin: skin: aa histological histological study study –– Dermatology, Dermatology, 2014, 2014, 228:47-54 228:47-54 human

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

References 1References IFUThis BELOTERO® Volume advertorial was written and supplied by Merz Aesthetics References M-BEL-UKI-0982 Date of Preparation February 2021 2 BELOTERO® Intense IFUThis BELOTERO® Volume 11 IFU IFU BELOTERO® advertorial was written and supplied by Merz Aesthetics M-BEL-UKI-0982 Date of PreparationVolume February 2021 M-BEL-UKI-0982 Date of Preparation February 2021 32References IFU BELOTERO® Balance IFU BELOTERO® BELOTERO® Intense Intense 2 IFU 43References C. et al., In vivo bio-integration of three hyaluronic acid fillers in IFU BELOTERO® Balance 1Tran IFUBELOTERO® BELOTERO® Volume 3 IFU Balance References human histological study – Dermatology, 2014, 228:47-54 Tran C. skin: et al., al.,aIn In vivo bio-integration of three three hyaluronic hyaluronic acid fillers fillers in in 2 IFU BELOTERO® BELOTERO® Intense 441 Tran C. et vivo bio-integration of acid IFU Volume 1References IFU BELOTERO® BELOTERO® Volume References human skin: aa histological histological study –– Dermatology, Dermatology, 2014, 2014, 228:47-54 228:47-54 3 IFU Balance study human skin: 2 IFU BELOTERO® Intense 2 IFU BELOTERO® Intense 1 IFU BELOTERO® Volume 1 IFU BELOTERO® Volume 4 Tran C. et al., In vivo bio-integration of three hyaluronic acid fillers in 3 IFU BELOTERO® Balance 32 human IFU BELOTERO® Balance IFU BELOTERO® BELOTERO® Intense study – Dermatology, 2014, 228:47-54 2 IFU Intense 4 Tran C. skin: et al.,aInhistological vivo bio-integration of three hyaluronic acid fillers in 4 Tran C. et al., In vivo bio-integration of three hyaluronic acid fillers in IFU BELOTERO® BELOTERO® Balance 33 human IFU Balance M-BEL-UKI-0982 Date of Preparation February 20212014, 228:47-54 skin: a histological study – Dermatology, histological study – Dermatology, 2014, 228:47-54 Tran C. C. skin: et al., al.,aIn In vivo bio-integration bio-integration of three three hyaluronic hyaluronic acid fillers fillers in in 44 human Tran et vivo of acid M-BEL-UKI-0982 Date of Preparation February February 2021 2021 M-BEL-UKI-0982 Date of Preparation human skin: skin: aa histological histological study –– Dermatology, Dermatology, 2014, 228:47-54 228:47-54 human study 2014, M-BEL-UKI-0982 Date of Preparation February 2021 M-BEL-UKI-0982 Date of Preparation February 2021 M-BEL-UKI-0982 Date of Preparation February 2021 M-BEL-UKI-0982 Date Date of of Preparation Preparation February February 2021 2021 M-BEL-UKI-0982

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43 43

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Advertorial Facing The World

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Occurrence of facial differences It is estimated that 6%, or 7.9 million, annual global births result in serious defects and are of genetic or partially genetic cause. In Vietnam, however, the occurrence of severe facial defects is estimated to be between four and 10 times higher than in other neighbouring countries. This is believed by many to be as a result of exposure to Agent Orange, a chemical which was used in the Vietnam War. Thousands of children suffer from serious health conditions arising from their facial differences, which is why Facing the World has focused its efforts in the country. In addition, statistics suggest that 90-94% of all infants with serious birth defects are born in low-middle income countries (LMICs). The Lancet Commission on Global Surgery has called for global investment in surgical and anaesthetic care in LMICs, without which, it is estimated that between 2015-2030, the countries will have losses in economic productivity of US $12.3 trillion.

Aesthetics Media Supports Facing The World Help us raise funds for children born with facial differences

Help give these children a more positive future by supporting them today.

Community support For a second year, we’re asking the aesthetics community to join us in supporting Facing the World. This worthy charity raises desperately needed funds to treat children in Vietnam born with facial defects. Not only are these children suffering from psychological trauma associated with their facial deformity, but serious physical concerns too. The Facing the World charity was suggested to us by nurse prescriber and BACN member Sharon Gilshenan. She has a special affiliation with the charity after being born with a cleft lip, so understands the noteworthy work it is doing Sharon Gilshenan to help children who aren’t as lucky to receive the support she has had in the UK. 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 our 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 44

shunned by my community, as I was born with a bilateral cleft lip and palate and have had 25 operations. Yet 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.”

FURTHER READING Katrin Kandel, Vietnam Training Program, Facing the World <https://facingtheworld.net>

To donate to this special charity scan the QR Code or visit www.justgiving.com/fundraising/ aestheticsmedia

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Treatment The plan for this patient was to aim to conservatively restore the mid-face volume loss that was caused by downward migration of the malar cheek pads, which greatly contribute to the fold formation.1,2 I used a combined technique of needle and cannula, starting with a 27 gauge needle, direct onto periosteum of the zygomatic bone. I was able to remodel the cheeks and offer volume restoration using Stylage XL in a concentration of 21mg/g, which comprises cross-linked HA, with mannitol and lidocaine. I administered boluses of 0.5ml, 0.4ml, 0.3ml, respectively moving upwards and outwards, following the zygomatic bone close to the lower border and as inferiorly as possible.

Case Study: Treating Male Nasolabial Folds Dr Armand Abraham shares his technique for successful mid-face treatment in men Since I began practising aesthetics, I have built a loyal patient base, of whom approximately 70% are men. I have found that their usual treatment preferences are for jawline contouring and wrinkle-relaxing injections in the upper face, while also requesting regular treatments for general facial rejuvenation. In this article I outline the case of a 42-year-old male patient, who was a smoker, who presented to my clinic for the first time to discuss treatment options for his nasolabial folds, which were causing him significant concern. He had not undergone any aesthetic treatment previously and was particularly concerned with the risk of feminisation.

Assessment and consultation Upon assessment I noted that as well as his prominent nasolabial folds, the patient also had volume loss in the cheeks. While his cheeks could benefit from treatment, volumising this area presented a stronger risk of feminisation due to the fact he was bald. In my experience, the absence of a hairline can limit the approach and amount of filler used in cheeks. I then discussed some of the treatments which can contribute to mitigating the patient’s concerns, such as injectable dermal filler treatment, non-surgical skin tightening and microneedling, explaining that the first two are known as the best treatments for nasolabial folds.1 I also answered the concerns and questions of the patient, which related to the risk of feminisation, how effective the treatment would be, and the side effects and complications that could occur. To alleviate his concerns I explained that my treatment approach is more on the conservative side, tending to be more restorative and focused on correcting concerns rather than changing or compromising patients’ masculine features. I explained that I do this by ensuring appropriate product selection, while phasing treatments so that results are gradual and subtle. This of course also helps reduce the risk of side effects and complications. Together we decided that the most effective treatment for his nasolabial folds would be hyaluronic acid (HA) filler. I believe this was the best course of action because, in this patient’s case, he had nasolabial folds rather than creases, which had become deeper over time. In my experience, they are better targeted with HA filler to provide the cushioning support needed to push the fold up, while being able to shape it and massage it into place. Of course, being able to dissolve HA in case of an emergency or if the patient was not satisfied with the result was also of benefit.

I then moved to using a 25 gauge 40mm cannula to administer 0.4ml of the same product in a fanning technique, which extended the filler upwards and outwards close to the zygomatic arch in the deep dermis, while avoiding the creation of the sharp angle usually desired by female patients. This was followed by careful massage from observing the outline of cheeks from above the patient’s head and taking in consideration the skull outline visible on his forehead.

The patient’s concerns related to the risk of feminisation, how effective the treatment would be, and the side effects and complications that could occur

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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Before

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Immediately after

Before and immediately after HA dermal filler treatment to the cheeks and nasolabial folds using Stylage L and Stylage XL.

The second step involved an entry point 1cm below and lateral to the labial commissures using a 25 gauge 40mm cannula to administer Stylage L, a 24mg/g cross-linked HA with mannitol and lidocaine. I started in a bolus and a fanning manner in the upper third of the fold at the deep dermis level, before moving to a linear technique in the middle third of the fold, followed by a short fanning injection in the lower third at the level of the labial commissures, administering 1.3ml of filler on each side. Now returning to needle injection, I targeted the middle third of the fold, again using a cross-hatching deep and superficial technique to provide the support needed to lift the fold, without flattening, which was not desired in this patient. My final step was to gently massage the fold to avoid any bumps and lumps, again without flattening, to emphasise the scaffolding effect created for the middle third.

Potential side effects The most common side effects that could occur as a result of treatment includes bruising and redness on cheeks. The patient experienced a little bit of redness on his face which was managed with a cold compress. Inflammatory reactions such as oedema, erythema, redness, swelling, possibly combined with itching or pain when pressure is applied, can occur for several days in some cases. Haematomas, indurations or nodules may appear at the site of the injection. Very rare cases of bleaching of the injected area have been

reported. In addition, following injections of HA, rare cases of abscess, granuloma and some cases of necrosis or hypersensitivity have been observed.3 Patients should of course be informed of these risks in consultation and advised that if any of these adverse effect persist after their appointment, they must be reported to the treating practitioner. It is essential that practitioners are well-versed in complication prevention and management prior to treatment. It must be noted that in case of serious inherited predisposition to allergies, dermatological disease, problems with haemostasis or inflammatory disease, or if the precautions for use are not adhered to, the incidence of adverse effects may be increased.

Conclusion It is important to bear in mind that the cheeks should be targeted first when treating the nasolabial folds to maximise results. This should be done so in a very careful manner in men, especially bald men who, due to the lack of hairline, could look over feminised. Product choice is extremely important when it comes to treating nasolabial folds or creases, as different concentrations of cross-linked HA fillers will provide the appropriate results for each. I would recommend the use of a cannula when possible to minimise bruising, particularly in men who wish to remain discreet about undergoing facial aesthetic procedures. The appropriate use of a needle is useful too, as long as it will deliver better results for the patient. Dr Armand Abraham is the founder and medical director of Face Lab Aesthetics based in London, where he specialises in treatments for men. He graduated from Qasr Al Aini School of Medicine, Cairo University in 2012 and completed his aesthetics training in London. Dr Abraham has been working a medical advisor for a petroleum company, as well as an aesthetic practitioner, with special affinity to making the industry more inclusive of male patients. Qual: M.B.B.CH REFERENCES 1. Guyuron B, Michelow B. 1994. The nasolabial fold: A challenge, a solution. Plast Reconstr Surg, 93:522–532 <https://pubmed. ncbi.nlm.nih.gov/8115507/> 2. Brandt FS, Cazzaniga A. Hyaluronic acid gel fillers in the management of facial aging. Clinical Interventions in Aging. 2008 ;3(1):153-159. <https://europepmc.org/article/pmc/ pmc2544360> 3. Abduljabbar, Mohammed & Basendwh, Mohammad. (2016). Complications of hyaluronic acid fillers and their managements. Journal of Dermatology & Dermatologic Surgery. 20. <https:// www.researchgate.net/publication/304142906_Complications_ of_hyaluronic_acid_fillers_and_their_managements/citation/ download>

Post-procedure results As per usual HA injection aftercare, I advised the patient to avoid heat or extreme cold for 48 hours following treatment. Strenuous physical activity and massaging of the treated area should also be avoided for at least six hours. A follow-up consultation was scheduled for 14 days post procedure, in which we discussed the patient’s recovery. He had experienced mild bruising and some pain at the middle part of the folds, which was expected with the intensive cross-hatching injection points. The patient was satisfied with the results and pleased that we did not completely eradicate the appearance of the folds, which he feared would look too feminine. The patient was advised that the results would last 12-18 months.

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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It is in fact the mast cell that is increasingly recognised as being instrumental in the pathogenesis of melasma through a number of mechanisms. The mast cell secretes a substance called histamine, which has a direct melanin stimulatory effect through the H2 receptors, in addition to another secreted Dr Firas Al-Niaimi and Dr Faisal Ali outline why substance called tryptase that upregulates matrix (MMP)-9.6 This is partly responsible melasma occurs and how it can be approached metalloproteinase for the basement membrane damage, as well as the with treatments based on the current science upregulation of other MMPs and Granzyme-B, which are responsible for extracellular matrix degradation, Melasma is undoubtedly a ubiquitous condition presenting giving rise to the solar elastosis observed in the upper dermis in to many dermatologists. While the clinical diagnosis appears lesional melasma skin compared to uninvolved skin.2 Furthermore, the relatively unchallenging, satisfactory cure often evades patients mast cell increases the dermal vascularity through the mediation of and their practitioners. Let’s look at the image in Figure 1. Most VEGF and transforming growth factor beta-2 (TGF-beta2).7 readers will have little difficulty in making this diagnosis and The observed increased vascularity in many melasma cases (termed proposing a treatment plan. It could be considered insouciant angiogenic melasma) is responsible for the ongoing increased to approach this as simple ‘excess pigmentation’. In the last few hyperpigmentation through the secretion of certain factors, in years significant advances have been made in the understanding particular endothelin-1. These factors stimulate the melanocytes of melasma and its pathophysiology, which we endeavour to through activation of the melanogenesis process.2,7,8 summarise in this article. The role of the senescent fibroblasts is increasingly recognised through the secretion of melanogenic factors such as proteins, growth factors and, more importantly, stem cell factor (known as SCF) which directly activates c-kit, the ligand of the tyrosine kinase receptor responsible for melanogenesis in the melanocytes.4,6

Understanding the Science Behind Melasma

Translating this to clinical practice

Figure 1: Image demonstrates the presentation of melasma

Causes of melasma Let’s start from the upper part of the skin – the epidermis. In addition to the melanocytes which produce melanin through melanogenesis, there are keratinocytes and important receptors which play a role in the process of melasma.1 Keratinocytes produce a multiplicity of factors implicated in melasma, including vascular endothelial growth factors (VEGF), melanocyte stimulating hormone (MSH), and inducible nitric oxide synthase (iNOS). Moreover, there is greater understanding of the direct role of visible light (in particular the blue spectrum) on melanocyte stimulation and, as a consequence, melanogenesis particularly in the darker skin types.1 The next level from the epidermis deeper into the skin is the essential basement membrane which separates the epidermis from the dermis. Numerous histological studies have demonstrated damage and insufficiency in the basement membrane (particularly collagen type IV component), leading to ‘dropping’ of the melanin into the dermis only to be encapsulated later by macrophages, giving rise to the term melanophages.2,3 It is the defect in the basement membrane that is responsible for the term ‘dermal melasma’ commonly recounted in dermatology literature. Arriving at the dermis is where a number of important changes occur that are instrumental for the pathogenesis of melasma. These include senescent fibroblasts, solar elastosis, increased vascularity and the increased presence of a particular inflammatory cell; the mast cell.2,4,5

Indisputably, the melanocyte is the lynchpin in the pathophysiology of melasma through the production of melanin. The stimulatory effects on melanocytes are multifactorial and not limited to the ultraviolet rays. As explained earlier, the role of visible light is being increasingly recognised, as well as the stimulatory effects from the mast cells and endothelin from the dermal vasculature through endothelin-specific receptors on the melanocytes. In clinical practice, treatment and control of the vascular component (through vascular lasers and tranexamic acid) can lead to improvement in the melasma independent from direct melanocyte action.8-10 Notably, the effects of tranexamic acid extend beyond the inhibition of the vascular component and include the blockade of plasmin conversion to plasminogen, which in turn stimulates the production of prostaglandins (a powerful melanocyte stimulator) through the arachidonic acid metabolites. Plasmin is upregulated by ultraviolet exposure and is one pathway of many inhibited by the use of sunblock.7-10

It could be considered insouciant to approach this as simple ‘excess pigmentation’ Strengthening the basement membrane with topical treatments (niacinamide and retinol) or energy-based devices limits the melanin ‘drop’ from the basal layer to the dermis, thereby limiting the formation of melanophages. Similar benefits are derived from treating the upper dermal solar elastosis and senescent fibroblasts with analogous interventions.1-3,11

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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Summary Melasma is a common condition with varying degrees of severity and proclivity to recrudescence. Treatment has traditionally been preoccupied with ultraviolet radiation protection, along with melanin removal and inhibition. In recent years a greater and deeper understanding of the pathophysiology of melasma has delineated the roles of three crucial components; namely the mast cells, basement membrane, and vascular component. Whilst some or all components might be involved in varying degrees of severity, it is apparent that melasma is a complex interplay of the aforementioned factors, for which optimal control and treatment should be taken into consideration. The surge of popularity and efficacy of tranexamic acid in melasma is testimony to the increasingly recognised roles the mast cells, endothelin and plasmin activation play in this challenging condition to treat. Dr Faisal Ali is a multiple award-winning consultant dermatologist, dermatological surgeon and specialist advisor to the Care Quality Commission based in London and Manchester. After graduating with a double first and PhD from the University of Cambridge, Dr Ali completed his clinical medicine degree at the University of Oxford and subsequently trained in several world-renowned dermatology centres. Currently based in Manchester and London, he has published more than 160 scientific papers and articles, including in Nature, The Lancet, BMJ and New England Journal of Medicine. Qual: BA (Hons), BM BCh, MA, MRes, MRCP, MRCS, MRCP (Dermatology), FRCP, PhD

Dr Firas Al-Niaimi is an award-winning consultant dermatologist, as well as Mohs and laser surgeon based in London. He has published more than 200 publications, 10 book chapters and his own book on preparation for dermatology specialist examination. Dr Al-Niaimi is also a researcher at Aalborg University, Denmark, and is involved in clinical and translational research in the field of lasers and spectrophotometry. Qual: MD, MSc, MRCP, MRCP (Dermatology), EBDV REFERENCES 1. Bagherani N, Gianfaldoni S, Smoller BR. An overview on melasma. J Pigment Disord. 2015;2(10):218. 2. Gautam M, Patil S, Nadkarni N, Sandhu M, Godse K, Setia M. Histopathological comparison of lesional and perilesional skin in melasma: A cross-sectional analysis. Indian J Dermatol Venereol Leprol. 2019;85(4):367-373. 3. Kim NH, Choi SH, Lee TR, et al. Cadherin 11 Involved in Basement Membrane Damage and Dermal Changes in Melasma. Acta Derm Venereol. 2016;96:635-640. 4. Kim M, Kim SM, Kwon S, Park TJ, Kang HY. Senescent fibroblasts in melasma pathophysiology. Exp Dermatol. 2019;28(6):719-722. 5. Wang Y, Viennet C, Robin S, Berthon JY, He L, Humbert P. Precise role of dermal fibroblasts on melanocyte pigmentation. J Dermatol Sci. 2017;88(2):159-166. 6. Yuan XH, Jin ZH. Paracrine regulation of melanogenesis. Br J Dermatol. 2018;178(3):632-639. 7. Masub N, Nguyen JK, Austin E, Jagdeo J. The Vascular Component of Melasma: A Systematic Review of Laboratory, Diagnostic, and Therapeutic Evidence. Dermatol Surg. 2020;46(12):1642-1650. 8. Lee HC, Thng TG, Goh CL. Oral Tranexamic Acid in the Treatment of Melasma, J Am Acad Dermatol. 2016;75(2):385-92. 9. Searle T, Al-Niaimi F, Ali FR. Visible light and hyperpigmentation: the invisible culprit. Clin Exp Dermatol. 2020 Dec 19. 10. Forbat E, Al-Niaimi F, Ali FR. The emerging importance of tranexamic acid in dermatology. Clin Exp Dermatol. 2020;45(4):445-449. 11. Forbat E, Al-Niaimi F, Ali FR. Use of nicotinamide in dermatology. Clin Exp Dermatol. 2017;42(2):137144.

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Ageing of the neck A youthful neck is observed to be clearly defined, have good skin tone, a welldefined mandibular border, appropriate chin projection, and a well-defined cervicomental angle. From the frontal view, there is an absence of horizontal rhytids and no accumulation of submental fat.4-6 The contour and shape of the neck is an important aspect of medical aesthetics. The appearance of transverse neck lines and vertical neck bands are both a result of platysmal muscle hyperactivity, appearing with age as a result of both intrinsic and extrinsic ageing. Loss of soft tissue support often increases skin laxity, resulting in creases developing perpendicular to the muscle action direction. In turn, the less elastic platysma of an ageing neck attempts to provide the support resulting in active and over-taut muscles visible as bands, forming the pejorative, ‘turkey neck’ appearance.7 The patient’s neck had evidence of skin laxity, dehydration, platysmal bands and the transversal lines of her neck were starting to become more apparent. Whilst the patient Nurse prescriber Elaine Williams rejuvenates didn’t ruminate on her ageing neck, she was concerned about it and wanted it addressed. a female neck through biostimulation Her primary concern was the appearance Concerns and consultation of the skin on her neck, and she described her primary treatment This 52-year-old female is a regular patient, having facial aesthetic goal would be one of increasing hydration, which she felt would treatments for many years. Her treatment plan includes regular then be in keeping with her face. Setting realistic expectations with botulinum toxin treatments, bioremodelling, dermal fillers and the patient is always critical, and contributes to patient satisfaction.8 medical-grade skincare. She booked a consultation to explore Through the ageing process, the physiology of the skin undergoes a treatments for her neck. The patient described herself as perinumber of changes, leading eventually to chrono-ageing. Skin laxity is menopausal and felt that the loss of collagen and elastin she was a phenomena occurring early in the ageing process and is related to experiencing was becoming more obvious on her neck, partially as the loss of elastin and collagen. It’s also associated with alterations in a result of having focused her treatments on her face. This was the the extracellular matrix (ECM), particularly with a reduction of hyaluronic motivating factor for the consultation. acid (HA) concentration.9 Casabona et al. have supported this patient’s assertion, suggesting HA is a naturally-occurring component of the extracellular matrix; it is a that the availability of botulinum toxins and dermal fillers to address glycosaminoglycan (GAG) polymer, composed of alternately repeating the ageing process in the face may lead to a stark contrast with the units of D-glucuronic acid and N-acetyl-D-glucosamine.10,11 The largest neck and décolletage, revealing a person’s age and consequently amount of HA resides in the skin tissue; consequently, approximately becoming a significant aesthetic concern for many patients.1 50% of the total HA in the body is found in the skin.12 A full and comprehensive medical history, including mental health, social and economic factors was undertaken. I ensured that the Treatment options assessment documentation was contemporaneous and included Minimally-invasive procedures have revolutionised the treatment evidence of the treatment options available. The risks and potential paradigm in cosmetic medicine, resulting in innovative approaches to outcomes were also discussed and understood, including options for treatment, multi-modality approaches and increasing safety profiles treatment, ensuring the option of no treatment was raised. with good aesthetic outcomes for patients.13 From a legal standpoint, the landmark case of Montgomery vs. We discussed a number of potential non-surgical modalities to treat Lanarkshire Health Board in 2015 is of paramount importance when the patient’s concerns regarding her neck, with many offering the consenting a patient. This requires that reasonable care is taken opportunity to have a combined approach. Along with others, options to ensure that the patient is aware of any material risks involved in include neurotoxin, dermal fillers, skin boosters and energy-based the recommended treatment, and of any reasonable alternative or treatment. variant treatment.2 Practitioners have a duty to ensure the patient Profhilo was also considered for this patient. Unlike many other understands all aspects of the potential procedure, which should HAs, which are made from a polysaccharide and are either crossbe included in the documentation with signed consent forms and linked, non-cross-linked, mono phasic or biphasic gels, this product reproducible photographs.3 is stabilised through a thermal process and does not use chemical

Case Study: Treating the Neck

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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Action

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Rationale

Hand hygiene

Remove transient microorganisms from the hands

Safe storage of equipment

Prevent damage to the sterile equipment, preserve sterility of the equipment and prevent microbial contamination

Cleaning of the procedure trolley or tray

Reduce microbial contamination

Preparation of equipment

Prevent microbial contamination of sterile equipment

Personal protective equipment (PPE)

• Aprons provide protection from potential contamination from the healthcare professional’s (HCP’s) uniform and the procedure, while also protecting them from contamination • Non-sterile gloves provide protection for the HCP from contamination from blood and body fluids that may contaminate the hands • Sterile gloves protect key sites from potential microbial contamination from the HCP’s hands

Preparation of the environment

Reduce microbial contamination during the procedure

Preparation of the patient

Gain informed consent and reduce anxiety

Waste disposal

Prevent contamination of the environment, protect staff from needlestick injury

Documentation

Provide essential communication and meet your regulatory body’s professional standards

Figure 1: Principles of aseptic technique17

cross-linking. The product has unique characteristics such as high HA concentration (64mg/2ml), low viscosity, high manageability, optimal tissue diffusion and a low inflammatory response. It has also been evidenced to reduce skin laxity and increase elasticity and consistency of soft tissues.9 This product was of interest and suitable for the patient because it is indicated for treatment of the neck, using a specific technique – the Bio Aesthetic Points (BAP) neck technique – for remodeling and improvement of skin laxity of the malar and submalar area. Profhilo has two molecular weights, which protect each other from enzymatic degradation, prolonging the duration of effect, as when compared with traditional biostimulation.14 The patient’s face had also successfully been treated previously and she had been thrilled with the results.

Treatment The procedure was undertaken utilising an aseptic technique. The fundamental principle of an aseptic technique incorporates protecting key elements of the equipment in order that they remain free from micro-organisms, for example, the barrel of a sterile needle.15 These ‘key parts’ and ‘key sites’ are critical components of 5

any invasive procedure. If contamination occurs, this may result in the patient acquiring a preventable infection. Key parts are defined as equipment used in the procedure that come into direct or indirect contact with another key part or site. Key sites include insertion sites and puncture sites. Both key parts and key sites always need to be protected.16 Figure 1 provides the principles of aseptic technique. Preparation for treatment included: • Taking suitable photographs for progress documentation • Cleaning the treatment area • Re-consenting the patient verbally • Marking the treatment area (Figure 2) Profhilo is usually delivered via the BAP technique, at the level of deep dermis. This technique has been specifically designed for this product, aiming to minimise risks and maximise HA distribution, whilst reducing the number of intradermal injection points and treatment sessions required.18 The 10-point neck technique was developed in order to provide reproducible points of injection, to standardise these points irrespective of variations between patients and ensure that the injection points avoid potential injury to vital structures. In my experience, both techniques reduce pain, downtime and the number of treatment sessions, making it quick and non-invasive. This injection technique is recommended for all other areas, taking into the consideration the product’s high spreadability values.14,18-20 Using a 29 gauge needle and prefilled syringe, 2ml of Profhilo was administered following the 10 point neck BAP technique, with 0.2ml to each point. The patient tolerated it well, commenting that the neck was more comfortable than the face. The treatment took approximately 20 minutes.

Post procedure 3

Figure 2: Identifying the BAP injection sites

Following the procedure, I took photographs of the results and added them to the patient’s clinical records. I then re-cleansed the skin using Clinisept+, and applied Teoxane Post Procedure Soothing Aftercare Fluid, as well as Heliocare 360 Mineral Tolerance Fluid SPF 50. Immediately after the treatment, there were visible, small swellings, which is normal and the patient was advised that these would subside within 24 hours. I then outlined

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

the general aftercare advice of avoiding makeup, touching the area and not exercising for 12 hours, while emphasising the importance of using sun protection, before agreeing a date for the next treatment and review with the patient, which was four weeks later, in line with the protocol.18

Side effects/complications In my experience, Profhilo, when administered using the BAP technique, offers a good treatment option to restore vitality in ageing skin. Side effects are limited, with bruising and small wheals at the point of injection being most common,18 which I find usually dissipate within 24 hours. A post-treatment aftercare card with product label was given to the patient, with the normal advice to contact the clinic if she has any concerns, which she did not. Before

After

Figure 3: Pre-procedure markup and post-procedure results six weeks after initial treatment

Conclusion There is an increasing interest in treating the ageing neck with nonsurgical interventions. Treatment of the neck is pivotal in the overall rejuvenation approach and, in my experience, can really benefit patients. Of course, it is important to discuss all potential treatments with your patients to ensure you offer options that suit their individual requirements and budget. Elaine Williams is an aesthetic nurse prescriber and founder of EOS Aesthetics in Ascot, Berkshire. She has worked in aesthetics for more than 10 years, practising in Liverpool and Harley Street, and is a member of the British Association of Cosmetic Nurses. Qual: RMN, INP, BSc (Hons) PG Cert, PG Dip, MSc

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Exploring Thyroid Disease and the Eye Miss Jennifer Doyle, Mr Richard Scawn and Miss Adriana Kovacova explore the common cosmetic changes in the periocular area associated with thyroid disease that aesthetic practitioners should consider Thyroid disease is common with more than 12% of the US population developing a thyroid condition during their lifetime.1 In the UK, about 15% have clinically detectable goitres or thyroid nodules, and the lifetime risk of developing a thyroid nodule is around 5-10%.2 Eye problems can be the presenting feature of thyroid disease in 10-20% of patients before their thyroid function becomes abnormal.3 Around 60% of patients then develop eye problems within one year of onset of thyroid disease.4 Periocular changes secondary to thyroid disease can vary in character and be asymmetric. Patients may present, with or without a systemic thyroid diagnosis, to aesthetic clinics to look for solutions to the changes in their appearance. In this article we aim to educate aesthetic practitioners as to the nature of thyroid eye disease, the clinical signs they may notice in a patient with thyroid disease, how these patients are treated both with regards to their thyroid disease and as to the cosmetic treatment of the periocular changes.

Understanding thyroid eye disease Thyroid eye disease (TED) is an autoimmune disorder; whilst the pathogenesis is not completely understood, the presence of shared autoantigens between the thyroid and orbit is thought to explain why the disorder affects both tissues.3,5 The disease mainly affects women in their third to fifth decade of life.5 It is most commonly associated with Graves’ disease, which is an autoimmune disorder resulting in hyperthyroidism.6 It can cause distressing symptoms for many, with sight-threatening complications for a few.3 Altered appearance can be very upsetting for patients with TED and studies have shown that this can have a significant impact on their

quality of life.7-9 Extraocular muscles and orbital connective tissue become infiltrated with lymphocytes, causing the activation of cytokine pathways driving an inflammatory pathway, and resulting in swelling and oedema of the orbital tissues.3,5 The orbital fibroblasts have been shown to become activated and add to the increase in tissue volume by secreting excess glycosaminoglycans3 and differentiating into mature adipocytes, causing further expansion of the orbital adipose tissue.5 For the patient, this results in visible changes including swelling and redness of the eyelids and conjunctiva, widening of the palpebral fissure, proptosis of the globes, eyelid retraction and changes in the eyelid contour (e.g. temporal flare).4,5 Up to 20% of patients develop eye disease before their thyroid function becomes abnormal,3 so patients may present directly to aesthetic practitioners with periocular aesthetic concerns that they perceive as involutional. It is therefore important that aesthetic practitioners are aware of some of the common signs of TED which are not to be overlooked. Thyroid eye disease classically runs a course as described by Rundle in his eponymous curve (Figure 1).3,10 Rundle’s curve describes how the disease worsens during the dynamic phase, reaches a point of maximum severity and then gradually improves and reaches a plateau phase.11 This course tends to last 18 months on average before reaching the ‘burnt out’ phase.3 At this point, the disease is inactive but the patient is left with morphological changes to the tissues instigated by the active phase. Smoking is the risk factor most strongly linked to a prolonged disease course and more severe disease.12 Patients diagnosed with thyroid eye disease should be advised of this and supported in their smoking cessation efforts.

Severity

Plateau

Dynamic phase Inactive/burnt out phase

Time

Figure 1: Rundle’s curve2,10

Swelling and redness of the eyelids and conjunctiva Patients may present complaining of ‘puffy eyes’, seeking cosmetic procedures to help with this. This altered periocular appearance can be an early symptom of TED and may be misdiagnosed as allergic conjunctivitis, which also presents with periorbital swelling and redness of the conjunctiva.3 The presence of eyelid retraction, proptosis and/or restriction of eye movements should alert the clinician to the possibility of thyroid eye disease rather than other causes of periorbital oedema.12 Patients presenting with possible TED wanting cosmetic restoration of the

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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surgical or non-surgical rehabilitation for patients with thyroid eye disease is generally reserved for inactive disease and is carried out in the sequence of orbital decompression, followed by extraocular muscle surgery with eyelid procedures performed last.12 This is because each stage may have an impact on the next, and therefore are addressed in turn.12

Figure 2: Patient frontal and side view with periorbital oedema and swelling of the upper lid and brow region

periorbital swelling should be cautioned against early blepharoplasty or other cosmetic procedures to the periorbital area and investigated accordingly. TED can lead to lagophthalmos (the inability to close the eyelids completely). Any procedure which further reduces the lid tissue and, hence, increases this possibility, could result in severe lagophthalmos, corneal scarring and vision loss.13 This is particularly applicable in TED where eyelid retraction and proptosis are also contributing towards the possibility of lagophthalmos. Proptosis of the globes Proptosis (or exophthalmos) of the globes is the second most common sign of TED with 60% of TED patients exhibiting this sign.14 It is an anterior displacement of the globe (eyeball) and is caused by the oedema of the extraocular muscles and connective tissue. Proptosis occurs as the globe is displaced anteriorly by the oedematous extraocular muscles and orbital connective tissue.3 Widening of the palpebral fissure and eyelid retraction Patients develop a characteristic staring gaze,15 with upper eyelid retraction being the most common presenting sign of TED.16 Up to 90% of TED patients exhibit upper eyelid retraction.16 The cause is thought to be multifactorial, due to a combination of proptosis of the globes, increased sympathetic tone causing Müller’s muscle to elevate the upper lid, contraction of the levator muscle and scarring between the lacrimal gland and the levator muscle.14 Changes in the eyelid contour Patients may notice a change in the contour of their retracted upper eyelid. Lateral flare is an appearance that is almost pathognomonic for TED.17 It is specifically the scarring between the lacrimal gland and the levator muscle which gives rise to the lateral flare.18

Treatment of the cosmetic changes caused by TED The underlying thyroid disease should be treated under endocrinology or the patient’s general practitioner in order for them to achieve a euthyroid state.19 It is important to remember that

Surgical management The general principle with regards to surgical management of TED would be to reserve surgical treatment for patients in the burnt-out inactive stage of the disease, with a view to rehabilitate them.12 Intervening whilst the patient still has active TED is likely to result in the patient requiring further surgery in the future.12 The exception to this would include patients with sight-threatening TED requiring orbital decompression in order to avoid vision loss.19 As mentioned previously, the surgical sequence would generally be orbital decompression first (if required), followed by surgery to the extraocular muscles (if required), and then finishing with eyelid procedures last.12 This order is so that if changes are induced by a previous step, they can be corrected at the next procedure.12 With regards to addressing the cosmetic changes to the periocular area, procedures undertaken are generally performed to address altered eyelid position, and finally to address excess skin and eyelid fat left following the swelling and oedema to the periocular tissues that occurs during the active phase. The most common indication for lid surgery is upper eyelid retraction.19 Treatment aims to lower the upper eyelids to their previous position, and address asymmetry. This is achieved by weakening the muscles that lift the eyelid; the levator muscle and/or the Muller’s muscle.19 A similar procedure can be performed on the lower eyelids in order to reduce the amount of inferior scleral show, which can appear unnatural and give the patient a ‘staring’ gaze. This often involves recession of the lower lid retractors which can raise the lower lids by about 1mm.19 If further distance is required then a graft or spacer may be used by some surgeons.19 Addressing the excess skin and fat with a blepharoplasty is generally the final surgical procedure a TED patient will undergo.19 It is important that this is done with caution so as not to take too much skin that the patient cannot close their eyes fully.12 Patients with TED are more likely to have a negative vector orbit;20 where the anterior surface of the globe protrudes past the malar eminence. As ‘bulging eyes’ is often considered a poor aesthetic attribute, patients may seek correction of this.21 A negative vector is often considered a warning sign when considering a patient for lower lid blepharoplasty as the procedure can result in the globe appearing even more prominent.22 Non-surgical management Non-surgical treatments can also play a role in achieving some cosmetic rehabilitation. However, expectations need to managed carefully. It is important that before embarking on any non-surgical

Figure 3: Patient front and side view demonstrating proptosis and widening of the palpebral fissure with inferior scleral show

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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After decompression

After blepharoplasty

Figure 4: Patient demonstrating severe changes from thyroid eye disease. This patient has swelling and redness of the periorbital tissues and conjunctiva, proptosis of the globes, lid retraction, lateral flare and the characteristic staring gaze. After images show results following a surgical orbital decompression and then blepharoplasty.

treatments, aesthetic practitioners ensure that the patient has reached the burnt-out phase of the disease, and has had any surgical intervention required first by their specialist. Patients can develop deep glabellar furrows secondary to overaction of the accessory muscles for eyelid closure; the glabellar muscles corrugator supercilia and procerus.23 The resultant frown lines or glabellar furrows can be treated with botulinum toxin.23,24 Patients may also develop a tear trough deformity due to excess periorbital fat bags and mid-face descent leading to the appearance of periorbital hollows.21 This can potentially be ameliorated with a conservative lower lid blepharoplasty or with a hyaluronic acid (HA) filler injection into the tear trough area.24

Conclusion Thyroid eye disease can result in cosmetic and functional changes affecting the periorbital area that can be distressing to patients and affect their quality of life. The periorbital cosmetic changes may precede a diagnosis of endocrine abnormality, so patients may present via way of cosmetic clinics. It is important that aesthetic practitioners are familiar with the common cosmetic changes that occur with thyroid eye disease and are aware that these patients require referral to an endocrinologist for diagnosis and management of the underlying thyroid condition. Surgical treatments to achieve cosmetic rehabilitation are generally reserved for patients in the inactive phase of the disease to prevent the need for successive surgeries. Surgical options generally include procedures to address the altered eyelid position, and blepharoplasty to address the excess skin and fat that may be left following the swelling and oedema of the periorbital tissues. It is important to be conservative with surgical blepharoplasty in order to avoid lagophthalmos post-operatively. Non-surgical options such as botulinum toxin to treat the glabellar furrows that result from the recruitment of secondary muscles for eyelid closure can be used, as well as HA filler to the tear trough area. 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 is a Fellow of the Royal College of Ophthalmologists. Miss Doyle has completed the Level 7 in Injectables and is a lead trainer at Harley Academy. She currently works as an NHS registrar in ophthalmology, as well as leading her clinic, Oxford Aesthetics. Qual: BMBCh, MA(OXON), L7Cert, FRCOphth Mr Richard Scawn is a consultant ophthalmologist and oculoplastic surgeon in London and Buckinghamshire. He specialises in functional and aesthetic oculoplastics, including blepharoplasty, complex eyelid reconstruction and periocular skin cancer. He leads the oculoplastic service at Chelsea and Westminster NHS Trust. Privately he sees patients at The Portland, The Lister, Hospital of St John and St Elizabeth and The Chiltern. He offers an oculoplastic fellowship to train future generations of oculoplastic specialists. Qual: MBBS, BSc, FRCOphth

Miss Adriana Kovacova is an ophthalmologist and oculoplastic surgeon. She completed oculoplastic fellowships in Liverpool and Chelsea and Westminster in London. Miss Kovacova is a surgical instructor for the Royal College of Ophthalmologists and specialises in eyelid reconstructive and aesthetic surgery, as well as non-surgical facial rejuvenation. She leads the oculoplastic service at St Helens and Knowsley Teaching Hospitals NHS Trust and sees private patients by arrangement. Qual: MUDr (Medicinae Universae Doctor), FRCOphth REFERENCES 1. General Information. Press Room. American Thyroid Association, 2020. <https://www.thyroid. org/media-main/press-room/#:~:text=Prevalence%20and%20Impact%20of%20Thyroid,are%20 unaware%20of%20their%20condition> 2. NICE, Thyroid disease: assessment and management, 2019. <https://www.nice.org.uk/guidance/ ng145/chapter/Context> 3. Perros P. Neoh C. Dickinson J. Thyroid eye disease. BMJ, 2009;338:b560. 4. Holds JB, Buchanan AG. Graves orbitopathy. Focal Points: Clinical Modules for Ophthalmologists. Module 11. San Francisco: American Academy of Ophthalmology; 2010. 5. Weiler DL. Thyroid eye disease: a review. Clinical and Experimental Optometry 2017. Volume 100, Issue 1, Pg 20-25. 6. Frueh BR, Musch DC, Garber FW. Lid retraction and levator aponeurosis defects in Graves’ eye disease. Ophthalmic Surg. 1986 Apr; 17(4):216-20. 7. Estcourt S et al. The impact of thyroid eye disease upon patients’ wellbeing: a qualitative analysis. Clinical Endocrinology. Volume 68 Issue 4. 29th September 2007. 8. Bahmani-Kashkouli M, Pakdel F, Astaraki A, et al. Quality of life in patients with thyroid eye disease. J Ophthalmic Vis Res. 2009;4(3):164-168. 9. Coulter, I, Frewin, S, Krassas, G E, & Perros, P. (2007). Psychological implications of Graves’ orbitopathy, European Journal of Endocrinology eur j endocrinol, 157(2), 127-131. 10. Bartley GB. Rundle and His Curve. Arch Ophthalmol. 2011;129(3):356–358. 11. Rundle FF, Wilson CW. Development and course of exophthalmos and ophthalmoplegia in Graves’ disease with special reference to the effect of thyroidectomy. Clin Sci. 1945;5(3-4):177-194. 12. Stan MN, Garrity JA, Bahn RS. The evaluation and treatment of graves ophthalmopathy. Med Clin North Am 2012; 96: 311–328. 13. Oestreicher J & Mehta S. Complications of Blepharoplasty: Prevention and Management. Plastic Surgery International. 2012. Article ID 252368, 10 pages. 14. Bartley GB, Fatourechi V, Kadrmas EF, et al. Clinical features of Graves’ ophthalmopathy in an incidence cohort. Am J Ophthalmol. 1996;121(3):284-290. 15. Kuriyan AE, Phipps RP, Feldon SE. The eye and thyroid disease. Curr Opin Ophthalmol. 2008;19(6):499-506. 16. Liaboe CA, Clark TJ, Shriver EM, Carter KD. Thyroid Eye Disease: An Introductory Tutorial and Overview of Disease. EyeRounds.org. <https://webeye.ophth.uiowa.edu/eyeforum/tutorials/thyroideye-disease/2-clinical-presentation.htm> 17. Koornneef L. Eyelid and orbital fascial attachments and their clinical significance. Eye (Lond). 1988; 2 ( Pt 2)():130-4. 18. Dickinson AJ, Perros P. Controversies in the clinical evaluation of active thyroid-associated orbitopathy: use of a detailed protocol with comparative photographs for objective assessment. Clin Endocrinol (Oxf). 2001 Sep; 55(3):283-303. 19. Maheshwari R, Weis E. Thyroid associated orbitopathy. Indian J Ophthalmol. 2012;60(2):87-93. doi:10.4103/0301-4738.94048 20. Naik M.N. (2020) Periorbital Aesthetic Considerations in Thyroid Eye Disease. In: Rath S., Naik M. (eds) Surgery in Thyroid Eye Disease. Springer, Singapore. <Https://doi.org/10.1007/978-981-32-9220-8_17> 21. Mommaerts, Maurice. (2018). Definitive treatment of the negative vector orbit. Journal of CranioMaxillofacial Surgery. 46. 10.1016/j.jcms.2018.05.011. 22. Malekzadeh A et al. Lower lid blepharoplasty: com[paring fat reposition with fat removal based on orbital vector in patients referred to Farabi eye hospital in 2013. Int. J. Pharm. Res. Allied Sci., 2016, 5(3):168-173. 23. Olver JM. Botulinum toxin A treatment of overactive corrugator supercilia in thyroid eye disease. Br J Ophthalmol 1998;82:528-533. 24. Naik MN, Nair AG, Gupta A, Kamal S. Minimally invasive surgery for thyroid eye disease. Indian J Ophthalmol. 2015;63(11):847-853.

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

Advertorial Galderma

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Galderma Academies Masterclasses Congress engagements New injector training tools External expert development programmes

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A summary of the latest clinical studies Title: Comparison of 2.5% Agarose Gel Versus Hyaluronic Acid Filler, for the Correction of Moderate to Severe Nasolabial Folds Authors: Scuderi N, et al. Published: Journal of Cosmetic Dermatology, February 2021 Keywords: Dermal filler, Filler, Agarose, Biostimulatory Abstract: Agarose gel filler is a natural hydrocolloid with a three-dimensional structure similar to the extracellular matrix, with gel formed by hydrogen bonds and electrostatic interactions rather than through chemical cross-linking or polymerization. Objective: To determine efficacy and safety of 2.5% agarose gel filler for the correction of nasolabial folds. In this split-face study, efficacy, safety, and usability of 2.5% agarose gel were compared to those of NASHA-L. Assessments included the nasolabial fold (NLF) Wrinkle Severity Rating Scale (WSRS), Global Aesthetic Improvement Scale (GAIS [blinded investigator]), subject satisfaction, safety (adverse events), and usability. Sixty-six subjects were treated, and 46/66 (66.7%) were available for evaluation at 3 months, when mean change in WSRS was identical for both products (-1.1±0.4 for 2.5% agarose; -1.1±0.4 for NASHA-L). Scores for each product remained similar across all time points and began to return to baseline between 7 and 8 months. Ultrasound confirmed the longevity of both fillers between 7 and 8 months. All adverse events were transient in nature and resolved within 15 days. Most events were mild in nature, and the number of events was similar between the two fillers. Title: Long-term Therapy with Botulinum Toxin in Facial Synkinesis: Retrospective Data Analysis of Data From 1998 to 2018 Authors: Alipour S, et al. Published: Clinical Otolaryngology, February 2021 Keywords: Botulinum toxin, Injectables, Facial palsy Abstract: Treatment with botulinum toxin A (BoNT) is the therapy of choice for many patients with facial synkinesis. Repeated injections relieve hypertonicity and hyperkinesis of reinnervated mimic muscles. The study conducted an Retrospective analysis of patients’ data, who were treated for synkinesis with BoNT from 1998 to 2018. Injection pattern of BoNT was based on clinical symptoms, observations of the specialist and on previous treatment pattern. Onabotulinumtoxin (OnaBoNT), Incobotulinumtoxin (IncoBoNT) and Abobotulinumtoxin (AboBoNT) were available for treatment. Patients consulted our department for following treatment as soon as the symptoms re-occurred. Change in dosage and injection pattern, the time intervals between treatments over the entire therapy period. 73 patients were repeatedly injected. The median number of treatments was 18, the median treatment interval was 3.0 months. During the initial treatment, orbicularis oculi and the mentalis muscles were the most frequently injected muscles (94%). During repeated treatment, the number of injected muscles increased significantly, whereas the dose per muscle remained stable. We observed significant change in treatment dose and injection pattern of BoNT in patients with facial synkinesis. These results provide an orientation in dose finding and injection regimen of BoNT in the long-term course of therapy.

Title: The Effect of High‐intensity Focused Electromagnetic Procedure on Visceral Adipose Tissue: Retrospective Assessment of Computed Tomography Scans Authors: Kent D, Kinney B Published: Journal of Cosmetic Dermatology, February 2021 Keywords: Electromagnetic fields, Subcutaneous fat, Visceral fat Abstract: High levels of visceral adipose tissue (VAT) are associated with abdominal obesity and increased risk of metabolic deterioration. Recent studies showed that intensive physical exercise results in the reduction of subcutaneous and visceral fat. This study investigates the effect of supramaximal muscle contractions induced by a HIEFM procedure. Computed tomography scans of 22 subjects who received 8 HIEFM treatments of the abdomen were retrospectively evaluated for the changed in VAT. The CT scans were obtained at baseline and 1 month after treatment. The transverse slices at umbilical, infraumbilical, and supraumbilical levels were used to determine the cross- sectional area (CSA) of VAT through a semi-automated segmentation method. The outcomes indicate that HIEFM technology has a positive effect on VAT. However, further studies are necessary to validate these outcomes and to clarify the exact mechanism of VAT reduction. Based on our results, the HIEFM procedure may be a beneficial treatment option for patients with high VAT deposits. Title: Synergistic Effects of Autologous Platelet-Rich Plasma and Hyaluronic Acid Injections on Facial Skin Rejuvenation Authors: Hersant B, et al. Published: Aesthetic Surgery Journal, February 2021 Keywords: PRP, Hyaluronic acid, Injectables Abstract: Many therapeutic options are currently available for facial skin rejuvenation, but little evidence exists about the efficacy of combining such procedures. The method was to assess and investigate the synergic effect of HA and a-PRP injections on facial skin rejuvenation. For this randomized controlled prospective study, 93 eligible patients were enrolled and randomized into three intervention groups to undergo a series of three treatments sessions with either a-PRP, HA or Cellular Matrix-BCT-HA (PRP-HA) injected on facial cheeks. A total of 93 patients were included.Treatment with Cellular Matrix BCT-HA led to a very significant improvement in the overall facial appearance compared to groups treated with a-PRP and HA alone (p<0.0001). Participants treated with Cellular Matrix showed a 20%, 24% and 17% increase in FACE-Q score at 1 month, 3 months and 6 months post-treatment, respectively. For the HA group, the improvement of FACE-Q score was 12%, 11% and 6% at 1, 3- and 6-months post-treatment, respectively, while the a-PRP group showed a 9% improvement in FACE-Q score at 1 month and 11% and 8% improvement at 3- and 6-months post-treatment, respectively. Combining a-PRP and HA seems to be a promising treatment for facial rejuvenation with a very significant improvement in facial appearance and skin elasticity compared to a-PRP or HA alone.

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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Choosing colours for your brand When looking at colours for your brand, you should choose those that truly reflect who you are, what you do, how you do it, as well as where and when you do it. You should be able to fully identify why you have chosen a particular colour and what it means to you and your patients, rather than just choosing a colour such as rose gold because its popular. We are looking for meaning. To achieve this, you need to consider your brand and audience.

Choosing Colours for Clinic Branding Branding professional Russell Turner explores the impact of colour and provides tips for choosing a scheme for your clinic Colour is one of the most important tools when it comes to developing your brand. It can illustrate personality, character, warmth, charm, tone and hidden depths that can unify your message visually. It can be present in photography, illustration, decoration, livery and signage, as well as printed and digital collateral. Understanding the powerful role colour can play in creating meaningful relationships with your audience is key in recognising how this non-verbal asset must be unlocked.

A non-verbal communication tool Wherever there is light, there is colour. On illumination, colour is everywhere, but our perception of colour and what colour means is unique to each and every one of us. Colour is non-verbal in that we do not need to hear or read anything in order to gain a level of understanding from it. Colour can connect us to first-hand, taught and imagined moments, and can trigger emotional connections with those experiences, all without verbal communication. Neuroscientist Dr David Eagleman has studied in-depth the relationship of colours to taste, sound, music and other neural input. This is called synesthesia and is something that many of us experience to some degree or another.1,2

What’s more, when we do communicate verbally, many expressions call on colour to add weight to what we intend to say. For example, our emotions can become highlighted through phrases such as to be ‘green with envy’ or angrily ‘seeing red’, with sadness being described as ‘having the blues’. We may also refer to ‘colourful language’ when perhaps we hear profanity or words which may offend. Such associations, however, do not mean that everything we see bearing these colours have these traits. For example, I am yet to see ‘roll out the red carpet’ represent anger, which is an emotion often associated with red. So, capturing a mood with colour is an abstract idea and is based more upon an individual’s interaction with colour and the ability to accept idiosyncrasies of language as a guidance, not fact. This means that colour can say a huge amount, yet it depends on other variables such as the environment and context in which it is experienced, as well as linguistics and culture.1,2 Organisations have recognised the increasing value and importance in having a unique identity with colour as well as its use in words and pictures. When colour is used thoughtfully, brands can create clarity and understanding for the customer.

For your brand, consider: • Your value proposition: are you unique, creative, traditional, classical? • Your brand personality: are you friendly, professional, aloof, knowledgeable, gregarious? • Your tone of voice: are you bold, impactful, reserved, precise? • Your brand values: what do you uphold in all that you do? You should also think about your audience to build a customer profile. Consider who they are, their gender, their age, what they do, what their likes and dislikes are, what their spending habits are, whether they have children, are married, where they work, and anything else about them that might be of interest. Once you have a thorough understanding of this information you can start to look at the key emotional triggers that you want your brand, and the visual representation of the brand, to communicate. Emotional triggers of colour Imagine the first time your potential customers see your brand – either in clinic, on your website, in a photograph or even meet you or your team – and consider what emotions you want them to feel. While it is possible for an individual to experience more than one emotion at any one time, it is not always possible for those emotions to be experienced with the same level of intensity, which can be described as having mixed feelings.3 We, however, want to eliminate doubt. I suggest choosing five key emotional triggers you want your ideal patient to feel and choose five colours that may align with these feelings. For example, if one key emotional trigger that you want to elicit is the feeling of being safe, perhaps you will choose an aqua colour which often represents this (see Figure 1). Allow your colours to be in alignment with you, what you think and also what you

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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Primary: cannot be created by mixing/adding other colours and include red, yellow and blue Secondary: sit opposite each other and are the result of mixing the primary colours Tertiary: sit opposite each other and are the colours between primary and secondary colours Triad: three colours that sit evenly spaced on the colour wheel Compound: sit opposite each other and are the result of mixing the primary colours Analogues: immediately adjacent to one another on the colour wheel Square: four colours that are evenly spaced on the colour wheel Figure 1: The colour wheel

believe your audience would think. Consider colours that move you toward your goal in helpful ways and discard those that are not helpful in doing this. There are widely perceived meanings of colour and, like many trends, they evolve over time. Fads should be recognised and regarded with caution, otherwise you could end up with a brand that dates very quickly and could be expensive to redo. One such example is the desire a few years back to fill clinics with copper/rose gold. It has proven to be looked upon now as something that has been over-done. To help choose your colours, you can do the ‘colour wheel exercise’. It is important to remember that each colour you choose can have a different tone; a deep hard red can be tinted to a softer, warm red and a dark purple warmed to an aubergine and further still to a violet.2 The colour wheel exercise A colour wheel is a graphic that identifies 12 basic colours and their widely perceived meanings (Figure 1). The reason for this exercise is to find examples of colour in action. It allows us to see how those colours and words deliver the key emotional responses that we are looking for. It can help to give inspiration and to also look at other feelings that may arise, which can replace those that we originally considered as valuable or important. Interior designers, as well as artists, will evaluate colours in much the same way – often with mood boards that include textiles and materials to be used in the creative process. To take part in the colour wheel exercise

yourself, you will need 12 sheets of white A4 paper or card, glue, scissors, selection of magazines, various old materials/clothes, and a marker pen. The aim is to choose words, images and swatches of colour from the magazines and material and create 12 coloured A4 sheets (matching the colour wheel). Each sheet will only contain words and colours relating to one specific colour palette. Fill each sheet and use the marker pen to write additional words that the colours evoke on top of the colours. These sheets can then be arranged in a circle or in different orders to experiment what colours go with others, which colours add contrast, or which feel uncomfortable to you. There are methods that can be used such as choosing monochromatic, complementary, triad, compound colours, analogues, squares; ultimately you will begin to see what works. You can then refine this with paint chips from your DIY store. Designers will use a similar universal colour swatch called Pantone. Using these colours, revisit the ones that you align with key emotional triggers; you will then find that you are on the way to truly defining your brand colour. With our colour theory we focus on positive rather than negative – the reason for this is predominantly because everyone will have a reason to dislike a colour. Our aim is to find reasons to choose a colour – not why to avoid a colour.

Challenges One challenge for any brand owner is to try and disconnect personal feelings regarding colour and to look at the colour that is right for your brand and

your brand’s objectives. Within any brand colour palette, it is easy to find a way to include your favourite colour without it being your main brand identity colour. Photos, illustrations, uniforms, lighting, decoration, furniture – the possibilities are endless but remain objective. Remember too many colours at once can be overwhelming and may appear messy; this doesn’t mean reducing the number of colours in your palette, but it is advised not to use them all at once. Try to use a dominant colour and one secondary colour. Within one colour there may be several different tones of the same colour, so multiple colours may not be necessary. Knowing what colour to use in what situations comes back to what you want to achieve. For example, if you need colour to stand out, use colours with high contrast. Black on yellow for example. If you are trying to communicate calm in a message and your brand colours are more often associated with speed and energy, consider softer secondary colours that complement the primary palette. You might want to gain opinions from friends, colleagues and those whose views you value to help.

Use the language of colour Colour can have a direct and lasting effect on individuals, so it is important to have a good understanding of your target patient and the tone and mood that you want to communicate to them. This will give your message strength and clarity, while demonstrating that you understand your patients and what they wish to achieve. It will build lasting connections and lead to meaningful relationships. Apply this to all of the tangible elements of your business as part of your corporate identity strategy and you will have the foundation of powerful non-verbal visual language. Russell Turner is the founder of RWT Creative and has more than 30 years’ experience in branding and design. Having worked with brands such as The White Company, Hotel Chocolat and AstraZeneca, Turner now works with cosmetic clinics and brands, aiming to put emotional brand development at the core to build meaningful and lasting relationships. REFERENCES 1. Richard E. Cytowic, Wednesday Is Indigo Blue: Discovering the Brain of Synesthesia (The MIT Press), 2011. 2. Kassia St Clair, The Secret Lives of Colour, 2018. 3. Leon Seltzer, Can You Feel Two Emotions at Once? (US: Psychology Today, 2014) <https://www.psychologytoday. com/gb/blog/evolution-the-self/201406/can-you-feel-twoemotions-once>

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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above, I’ve also attached...” It’s small personal touches like these that help potential patients feel confident about using your service. This may sound obvious, but you’d be surprised at the difference between a cheery and welcoming response compared to an automated one. Make sure that you offer potential patients an opportunity to respond by saying things like, “I hope you are satisfied with the information above.” You can even check back in with them at a later date if you don’t hear from them in a while. Together, these factors guarantee engagement with potential patients, giving them an individual experience. Besides, the last thing you want to do is make them feel like they’re just a number.

Building Good Customer Service Digital communications managing director Tim Morris shares tips to enhance prospective patients’ experiences prior to their first appointment With 53% of service organisations expected to be using chatbots within the next 18 months,1 it is clear customer service is going down the artificial intelligence-orientated route. However, I believe that although there is a place for such digital interactions, in these current times, it’s never been more important for clinics to use real people to deliver the best possible customer service. According to a 2019 survey of 1,000 consumers conducted by business support company CGS, the top customer service scenario that caused consumers to feel the most nervous or anxious was, in fact, in healthcare situations.2 This highlights the importance for aesthetic clinics to deliver a great, personal and, most importantly, human customer service experience so both patient and professional can set realistic expectations and build initial relationships. So, here are some top tips on how you can boost business by providing the easiest, friendliest and most supportive services possible before the first face-to-face contact with patients in 2021.

Prioritise responding to email enquiries In a busy aesthetic clinic, where everything seems to be moving at 100mph and patients are frequently wanting results yesterday, it can often be the case that responding to an email drops off your to-do list. However, your business relies on swift and quality response to initial enquiries. According to statistics from SuperOffice, comprising research of 1,000 US companies, the average response time to get back to customer service requests over email is 12 hours and 10 minutes – this is far too long!3 So, when answering email enquiries, you should ensure to do so promptly. Make sure you reply with a personal introduction, as well as your standard business information, within the same working day of receiving the enquiry. CGS found that 86% of consumers actually prefer to interact with a human agent, in customer service.2 Therefore, when responding to emails make sure that you always use a positive, upbeat, and most importantly, human tone of writing. Asking a prospect, “How are you today?” is an example of a small thing that goes a long way. Also, offer avenues of support when they make their enquiries. When giving information about your services use phrases like, “There is some other information we believe may be useful to you,” and “In addition to the information

Employ good phone techniques The easiest ways to damage your clinic’s first impression with a new customer is simply not answering the phone competently. You only get one chance to make a great first impression. So, making sure you and your employees impress your potential patient with your first interaction over the phone is extremely important. Ensuring there’s a friendly and personable voice on the end of the line is an excellent place to start when answering a call because if a prospect doesn’t like their initial interaction with your clinic, they can easily take their business elsewhere. When talking over the phone to a customer use their name. In my experience, using a person’s name creates a connection with that individual. It helps you grab their attention and is a sign of courtesy and respect. Another vital thing to do on the phone is to use positive language. Turn your ‘maybe’ into a ‘definitely’ and your ‘I’ll try to do that’ into an ‘I will do that’. This language lets the prospect hear that your goal is to fulfil their needs. A customer wants someone as passionate about their needs as they are. Positive language and a glass-half-full mentality will allow you to develop a healthy relationship with your customer and increase your chances of converting the interaction to a face-to-face appointment. The next must-do is to make sure your call handlers know your services inside out. By doing this it means they won’t offer something you can’t deliver. Talk through the process of your service step by step. Once you have established this, the potential patient can’t be disappointed because they know exactly what they’re getting –

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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86% of consumers prefer to interact with a human agent particularly important when someone might not fully understand the treatments they’re asking for at the early stage of enquiry. Having an effective phone script for call handlers to use is one way to ensure a professional and informative interaction takes place. A phone script will allow you to deliver a consistent and effective message to patients, while also boosting the confidence of the operator. I appreciate that in a busy clinic it can be easier said than done to always get to the phone. For example, an aesthetic clinic providing a popular service may receive a large increase in enquiries at certain times in the year. To manage this, you can set up an effective phone answering system and ensure your staff are diligent at getting back to patients. For those who may be overwhelmed in dealing with calls, you can also outsource this, which is explored below.

ensure a swift and successful customer interaction. An additional customer service enhancement would be to provide human webchat operators who are available to take queries from priority messages to speed up customer interaction. This is something that someone in your clinic could be responsible for, or again you can outsource. A tip to provide great customer service over webchat is to make sure you watch your grammar. Avoid ellipses; those three dots may seem inconsequential, but they can actually make you sound condescending or indirect. Also avoid using all caps as they make it seem like you’re shouting at the person you’re talking to – not something a customer appreciates. You can provide fun and upbeat customer service without being sloppy. It’s important to keep live chats as personable as possible, but don’t forget to be professional, too.

Consider using webchats Webchat services allow patients to communicate directly with your aesthetic clinic online, via your website and/or social media, in real-time. It’s becoming increasingly popular for businesses to have a chat window on their website, which pops up as an overlay of the browser’s website page, allowing the user to type messages directly to the business. A recent HubSpot report showed that 90% of companies who used live chat found it to be a successful channel for helping customers.4 When running a webchat (which do come at a cost) it’s important to understand that not all webchat conversations have the same value. For example, one customer might want to learn how to book an appointment with you, while another may simply want to ask how to get back to the homepage. To combat this, you should provide priority routing for customers asking specific questions. Essentially, priority routing is where you push the most important questions to the front of the queue. You can also make webchat buttons highly visible on these pages to

Outsourcing your customer communications Some aesthetic clinics choose to outsource their customer service interactions to companies who can manage their phone calls, webchats and even emails. These services can give the same personal feel as if they were actually in your aesthetic clinic and will also make sure that you add value to the prospective patient’s experience. This is particularly helpful for enquires that come through out of hours. Outsourcing can be an excellent way to ensure that your communications are being handled appropriately and consistent at any time of day. It also frees up clinic time so you can get on with other important tasks, such as treating patients, in the comfort of knowing your customer service is being taken care of properly. Naturally, there is a cost involved to outsourcing but it can often be less than committing to a full-time in-house employee and is useful for further assistance if your current employees are feeling overwhelmed. Quality support also requires an initial

investment of your time if you want people to be well briefed. When outsourcing you want to ensure that you don’t lose the personal feel your aesthetic clinic already provides. To keep your personal approach, choosing a communications provider who places an emphasis on delivering a personal service and provides its staff with regular training is incredibly important.

Convert those enquiries into paying patients! Building a relationship with your potential patient is essential to making sure that you can convert initial enquiries to face-to-face appointments. Using real people in your customer service team not only helps your clinic deliver a great consistent customer service but also helps build a relationship that can lead to repeat business. If a patient feels comfortable, there’s a higher likelihood they’ll come back and use your services again. This shows how real people using positive communication can lay the groundwork for building better relationships with your potential patients. The better the relationship you have with a patient, the more your clinic will benefit in the long run. Aesthetic clinics that want to ensure that their customer service is in tip-top form in 2021 must guarantee that these personal approaches are in place. Disclosure: Tim Morris is the managing director of Cymphony, which offers client communication services to businesses. Tim Morris is the managing director of Cymphony, with previous experience as a general manager and business support specialist. Over his career, Morris has focused on developing and successfully executing stringent levels of customer service initiatives across a variety of sectors globally. REFERENCES 1. SalesForce, State of service report, 2019. <https://www. salesforce.com/blog/chatbot-statistics/#:~:text=53%25%20 of%20service%20organizations%20expect,technology%20 in%20the%20near%20future> 2. CGS, Customer Service Chatbot & Channels Survey, 2019. <https://www.cgsinc.com/en/resources/2019-CGS-CustomerService-Chatbots-Channels-Survey 3. SuperOffice, 5 ways to reduce customer response time, 2021. <https://www.superoffice.com/blog/responsetimes/#:~:text=For%20companies%20that%20do%20 respond,to%20respond%20to%20their%20email> 4. HubSpot, The state of customer service in 2020. <https://offers. hubspot.com/state-of-customer-service>

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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Understanding CPD Dr Kalpna Pindolia explores continuing professional development in aesthetic medicine – a responsibility of all healthcare professionals Continuing professional development (CPD) is learning activity that all responsible medical professionals undertake to keep patients safe and deliver a high standard of care. Aesthetics is a rapidly evolving, relatively new area of medical practice. CPD is a personally defined experience and ultimately your responsibility to direct and complete. With a plethora of training options, regulatory requirements, as well as the associated cost and time investment required, CPD in aesthetics may seem daunting. Here, we discuss CPD in more detail.

What is CPD? CPD is defined as ‘the process of lifelong uninterrupted learning and self-improvement for individuals and teams, which enable medical professionals to expand and fulfil their potential in maintaining a high medical standard and an ever-improving quality of care that meets the need of patients’.1 Apart from new learning, it may also reinforce and maintain existing good practice. Going beyond traditional continuing medical education (CME), it incorporates knowledge and practical skills, as well as broader concepts of accountability, ethics and professionalism. In aesthetics, it may also involve aspects of managing a business.

Why is CPD important? Well-prepared personal development plans (PDPs) that incorporate CPD help you keep up to date and allow you to meaningfully contribute to high standards of patient care. Apart from protecting patients, CPD also safeguards your colleagues, employer, your business and your professional career. Happily, it is often an inspiring process, contributing to work confidence, satisfaction and progression. In aesthetic medicine, CPD is particularly important as aesthetic practitioners may: • Enter the field later on the timeline of a traditional medical career • Be unfamiliar with private practice and aspects of running a business • Be time poor and work in multiple roles alongside aesthetics • Struggle to keep up with a rapidly evolving evidence base and changing trends • Work in full-time aesthetics autonomously with isolated practice

CPD for doctors, nurses and dentists CPD is a professional responsibility for most modern career paths. In medicine, it is additionally mandated by our professional codes of conduct. Specific groups have specific guidance which will direct your experience of CPD.

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The General Medical Council (GMC) has official guidance for CPD, but does not have a required fixed number of CPD credits for doctors.2 However, there are recommended guidelines which have useful parameters. For instance, according to the Federation of the Royal Colleges of Physicians of the United Kingdom, doctors are expected to complete about 50 hours per annum.3 The Royal College of Nursing (RCN) specifies that for revalidation, you undertake 35 hours of CPD relevant to your scope of practice as a nurse or midwife over the three years, prior to your revalidation date.4 For nurses, participatory learning is a key component of CPD where learning is part of personal interactions.5 Under the General Dental Council’s Enhanced CPD Scheme, dentists need to complete a minimum of 100 hours of verifiable CPD every five years.6,7 There are specific topics which must be included; for example, two hours dedicated to medical emergencies every year.8 The Joint Council for Cosmetic Practitioners (JCCP) stipulates that registered practitioners demonstrate evidence of CPD achievements that they have included in their appraisal/ revalidation as required by their respective Professional Statutory Regulatory Body. It also stipulates that a minimum of 50 hours of CPD must be demonstrated annually by all clinicians, of which a core element is aesthetic related.9

CPD hours or points? CPD is referred to as a number of hours, units, points or credits. Ultimately CPD relates to the time (or hours) spent in ‘active learning’. Active learning is the actual time spent learning something relevant for CPD objectives.10 For example, if a course starts at 9am and ends at 1pm with a 30-minute break, the CPD hours would be 3.5 CPD hours. CPD hours can also be estimated if there is no formal accreditation for an activity, as long as there is reasonable evidence that the activity has taken place, such as evidence of completion or register of attendance. There are companies that will independently scrutinise a learning activity to ensure strict integrity and quality, reaching universally set, objective standards. These companies will often identify how many points/credits that learning activity is worth. The relevant learning activities, many described below, will usually display the relevant logo such as those provided by CPD Group, CPD Healthcare, The CPD Certification Service (CPD UK), and The CPD Standards Office.11-14

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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Quick tips for CPD 1. Keep the type of CPD balanced and varied, it makes it more enjoyable! 2. Staying up to date is fine if you are not ready to advance in your clinical practice. 3. Remember it’s about covering breadth of knowledge and skills, as well as depth. 4. It is about the quality of your CPD and your reflective capacity, not necessarily the hours completed. 5. Shorter and informal CPD can be equally, if not more, impactful on improving your professional practice, so document it. 6. Try to keep a CPD log over time, rather than leave it to the last-minute rush before your appraisal date. 7. Take some time every so often to process and enjoy your CPD achievements, it is a great source of work satisfaction!

The Royal College of Nursing also accredits certain courses which may be relevant to your practice.15 For doctors and nurses, the balance of accredited and non-accredited CPD hours you present will be dependent on your personal development plan. In my personal experience with doctors, some formallyaccredited CPD usually appears at appraisal, as these courses are often preferred by virtue of their standardisation.

Types of CPD Following initial training in aesthetic medicine, there are many varied opportunities for CPD in aesthetics. Specific examples include: • Advanced qualifications, like the Level 7 Certificate or Postgraduate MSc, PGCert or PGDip • Attending conferences and industry days • Virtual, online training like webinars • In-person masterclasses, workshops and mentorship • Managerial responsibility, like conflict resolution or communication skills • Reading of articles, journals and books • Product-based learning • Team or peer-based discussion, like journal clubs and morbidity meetings • Relevant mandatory training, like basic life support and information governance • Aspects of work-life balance and resilience, for instance, stress management • Business-related courses, like marketing and legislative requirements Apart from clinical knowledge and skills, CPD can embrace: • Softer non-clinical skills such as leadership, management, academic and business knowledge • Formal (structured) and more informal selfdirected activity

• External as well as internal training • Niche and broader training • Regional, national and international needs from the profession

Identifying your CPD needs Self-evaluation is key in formulating your CPD plan. For doctors and nurses, you need to develop your own plan in accordance with your scope of practice. For doctors, your CPD activities should be shaped by personal evaluation of both your professional needs and the needs of the service and the people who use it.2 For instance, if you work in aesthetics for 25% of your professional time, your CPD may encompass approximately this proportion of your personal development plan (PDP) or more, if you are a novice just entering a new field. If aesthetics is your fulltime work, your CPD would be around topics relevant to aesthetics. To identify your needs, it is worthwhile to consider CPD topics: • Common to all doctors, dentists or nurses • For all colleagues in your broad area and then niche aesthetic practice • For needs unique to you, your specific scope of work and career pathway • In response to personal scenarios, including patient and colleague feedback • Varying your type, depth and breadth of learning

(MAG).16 There are also alternative online platforms like Clarity or Fourteen Fish which collate the same data. Nurses submit their documentation online to the NMC. Dentists submit their declaration via their eGDC online and may use services like Isopharm to develop PDPs with verified CPD. Whichever method you choose to document your CPD, it should stimulate reflective practice by asking the following questions: • Why did I do the activity? • What were my significant learning points? • Have I identified areas of further learning as a result for my next PDP? • What is the impact on my clinical practice?

Deliver excellence through CPD True CPD is all about your individual, lifelong journey to becoming an excellent aesthetic practitioner. As long as you view your practice from a reflective perspective, personal and professional growth always come from CPD. While our patients will benefit, so will you, as you become more experienced and confident. After all, even an ‘expert’ does not know everything, so lifelong learning is the key to success medical careers.

Each month, Aesthetics publishes a CPD article worth 1 point. You can read this on p.26 and contact the team via editorial@aestheticsjournal.com to receive your CPD certificate. Dr Kalpna Pindolia is an experienced emergency medicine and maritime medicine doctor and is director of education at Harley Academy as well as an aesthetic practitioner at Story Clinic, London. She is a lead GMC appraiser and is passionate about the responsible practice and patient safety in aesthetic medicine. Qual: MB BCh (2000)

Documenting CPD Medical regulatory bodies require collection of evidence of CPD as part of the appraisal and revalidation process. Supporting information is usually provided using a structured process. Doctors may use the Physicians, CPD app to log and reflect on their ongoing CPD throughout the year. Ultimately, their CPD is presented on a specially-devised electronic form called the Medical Appraisal Guide

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Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

J OIN THE VI R T UAL CER EMONY

The Aesthetics Awards will now be held as a virtual ceremony, providing an afternoon of glitz, glamour and fun with a celebrity host leading the proceedings.

R EGIS T RAT ION OP E NING SOON A ES TH ETICSAWAR DS .CO M

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In The Life of Alison Telfer

The clinic owner and nurse prescriber tells us how she balances work and family life I had to sleep in -30 degrees and set up a tent while I was on cross-country skis. I do it because once I’m home from these trips, I have a renewed sense of energy which helps me to keep going in everyday life for the next few months.

I start my working day by... Getting some fresh air! During the first lockdown I started walking to and from work instead of driving, and I’ve found this makes such a difference to my mental state. It’s only a half-an-hour walk, but it gives me some alone time and allows for some separation between home and work. I typically start at my clinic, The Glasshouse Clinic in Clapham, London, at 9am. I always aim to get there 30 minutes before I start seeing patients so that I can get everything ready for the day and take care of any emails or admin. From that point onwards, I have a steady stream of patients and my day is made up of consultations, procedures and reviews. On average, I see between 20-30 patients every day. I only do injectables as I’m lucky enough to have a team of aesthetic therapists who work for me and take care of the dermatological side of things. On Tuesdays this routine differs as I work longer hours, typically from 8am-8pm. This is because five years ago I made the decision to give up working on Saturdays as I wanted more time at home to be with my family. All the patients I would have seen on Saturday I can now fit in by doing extra hours on Tuesday, so it hasn’t impacted my work or my patients at all. It’s a very full-on day though, so I’m always pretty exhausted afterwards.

A defining day in my career...

How I unwind after work… I’m always very strict on not bringing my work home with me, so from 8pm until 8am there is no work talk allowed in my household! My husband and I have a rule that if I do come home and complain about something work-related, I have to make sure that I sort it first thing the next day, so it doesn’t continue. I love my job, but I want to keep the two worlds separate and I believe that work shouldn’t encroach on your family space. I’m also very lucky in the sense that I have an amazing clinic manager and team, so if I’m not in the clinic myself I’m not concerned that it won’t be run properly or well without me, which helps me to relax.

It’s amazing to think that my opinion and expertise is valued My other project involves... As well as running my own two clinics, the other in Wimbledon, I also host a podcast with consultant plastic surgeon Mr Adrian Richards called Plastic Fantastic where we interview big names from the industry. We pre-recorded a lot of our episodes over the summer lockdown because we had a lot more free time, but now we’re back performing medical treatments, we have to find ways to fit it into our schedules whenever we have gaps. If there is downtime when I’m in the clinic, I’ll use it to research and reach out to people who we’d like to feature on the podcast in the future.

I spend my evenings after work with my family, and we just chill out, have dinner and watch TV. At the minute we’re all watching The Serpent on BBC together. It’s nice now that my children are teenagers because we can watch dramas like that together, instead of me being forced into another viewing of Peppa Pig!

I remember around eight years ago I was sat in my garden and I received a call from Allergan asking if I would be involved with some of their teaching. I had to pinch myself! It’s amazing to think that my opinion and expertise is valued, and that people want to hear what I have to say. Training others has changed my career a lot and it has provided a whole new dynamic to working in aesthetics. I love teaching, because it can be so rewarding to help new injectors become more confident in their work and I love to see them flourish. It’s also allowed me to meet and get to know more of my industry peers. Although I love being an injector and working in the clinic, it can sometimes be a bit lonely and isolating, so I’m very grateful that I have been given opportunities to get out and about and do something a bit different.

Why I love aesthetics... We change lives! People think it’s a vapid industry, but we really can make a difference to how people feel about themselves, and it’s so rewarding. I remember once after I injected a woman’s chin she thanked me because she finally had enough confidence to dump her horrible boyfriend!

My favourite treatment… I do enjoy doing facial fillers the most, because there is such an artistry to it and each face is different.

In my spare time...

In the future I’d like to…

Something a lot of people don’t know about me is that I actually like to go on expeditions every year. I go by myself, without a phone or Wi-Fi. The first one I did was crossing the Atlas Mountains in Morocco, and since then I’ve also crossed the Arctic. It’s brutal!

I have a desire to be a magistrate. If I worked a day or two less a week, I could potentially get into doing that alongside aesthetics, so it’s something I want to look into.

Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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The Last Word Mr Ali Juma debates whether the term filler’ is still fit for purpose The definition of dermal in the Oxford Dictionary is ‘relating to the skin or dermis’, while filler means ‘a substance used for filling cracks or holes in a surface, especially before painting it’.1 The simplicity of the wording choice, ‘dermal filler’, perhaps was relevant at its inception when the filler was injected within the dermal layers. However, I believe that the nomenclature ‘dermal filler’ is not reflective of the complexity, sophistication and the five decades of research, which have gone into developing and refining these products. Today, the name doesn’t take into consideration the advances made with dermal fillers, which reflects the limitations in our understanding – and perhaps complacency – in thinking up a new name for the products. Our inquisitive and curious nature favours that we delve more into the advancement of science to achieve higher levels of excellence.

The advances of dermal fillers Patients’ and clinicians’ demands have been the main driver behind advances in dermal fillers. These demands include longer-lasting, biocompatible and affordable products, which achieve natural outcomes. The principles of beautification and golden ratio facial proportioning with the least adversity, risks and complications must also be kept in mind.2 What started its journey injected within the dermal layers has now moved further into the subcutaneous and supraperiosteal anatomical realm. Now we have at our disposal dermal fillers that allow us the ability to be more innovative in treating patients, thus pushing the boundaries in achieving clinical excellence and higher satisfaction. The question which stems to mind: is dermal filler just a filler? Or is it a sophisticated system utilised by skilled clinicians to rejuvenate, and appropriately proportion patients’ faces? At the start of one’s journey injecting facial dermal fillers, the traditional teaching was to treat anatomical areas like the nasolabial fold in isolation. However, the last few decades have led to advances in the knowledge of facial anatomy, the ageing process of the face, the layers affected, bony resorption of the facial skeleton, in addition to volume loss in the deep facial fat compartments. Advances in dermal fillers including diversity in their rheology, cohesiveness, biodegradability and mouldability mirrored this. The manufacture of these products has become so advanced that a tailor-made product can be used to achieve a highly refined outcome, especially when injected by an experienced and skilled clinician. Incorporating local anaesthetic into the product syringe means it can now be injected less painfully, therefore more product can be injected in one treatment, thus facilitating better patient tolerance and compliance. Add to this the ability to use these products in different anatomical areas at different depths in the face, thus achieving beyond what earlier fillers could have achieved. Volumisation, contouring, myomodulation and hydration, in addition to neocollagen formation, are changes that dermal fillers can conjure. Volumisation of the deep facial fat compartments can be achieved by replacing volume lost. One such example is lifting and rejuvenating the mid-face. A deep injection of HA with

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a concentration of around 20mg/ml above the maxilla periosteum can replace lost volume whilst giving lift. Injecting of HA with approximately 17.5mg/ml following this may ‘dermal volumise the deep fat pads to add further lift secondary to inflating them. Myomodulation is a newer concept popularised by Brazilian plastic surgeon Dr Mauricio de Maio. It improves facial symmetry through balancing of volume distribution, in addition to harmonising the action of muscles groups working in synergy, thus creating a happy and rejuvenated face.3-5 In my opinion, this concept will shift the dynamics of facial rejuvenation, beautification and proportioning to new dimensions beyond the cosmetic realm; however, the paradigm will shift into the restoration of function and appearance, in parallel. In doing so, balanced facial movements and positive emotional attributes are achieved. I believe facial contouring relies on two factors: volumisation and myomodulation. Both influence facial contour by lost volume replacement in a convex surface, which has flattened and sagged with ageing. Added to this, it also tensions muscles that have altered in length as a result of facial tissue laxity and displacement, altering their lever arm. Hydration can also be achieved. A HA dermal filler with a low HA concentration of approximately 12mg/ml is an example of a product used to hydrate the skin and adjacent tissues. It will be more hydrophilic, absorbing water in multiples of its weight. By absorbing so much water, the filler helps to hydrate the skin and the adjacent tissues. This adds vibrancy and volume, which enhances the rejuvenated look of the treated visage. In so doing, further softening of facial lines results.6 Neocollagen formation with dermal filler leads to the formation of a matrix of collagen. In the first instance type III collagen is formed, which is converted to type I in time. A second benefit is the formation of elastin. All this leads to increased dermal thickness and angiogenesis. This helps soften the ageing rhytids and adds to the effectiveness of the treatment.7

We are now beyond ‘dermal fillers’ It is obvious from the dermal fillers’ capabilities noted that a new name should be considered as a starting point in looking at these products with a different eye. They act as more of a rejuvenating system and less so as a ‘filler’. It is also important to consider the most crucial variable in the treatment algorithm; namely, the human factor. The skilled clinician is the most important variable who will see the future of HA and similar fillers as rejuvenating systems, rather than substances used for ‘filling holes or cracks in a surface’ and in so doing, aspiring to achieve continued excellence. Mr Ali Juma is a consultant plastic and reconstructive surgeon with 19 years’ experience. He is the proprietor of the Clinic @51 in Liverpool. Mr Juma served as an honorary lecturer at the University of Liverpool for nine years and as an examiner for the RCS for seven years. Qual: MB BS (Lon), FRCS (Plast)

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Reproduced from Aesthetics | Volume 8/Issue 4 - March 2021

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March 2021: The Injectables Issue

Articles inside

In The Life Of Alison Telfer

Understanding CPD

Building Good Customer Service

Choosing Colours for Clinic Branding

Abstracts

Advertorial: Galderma

Case Study: Treating the Neck

Understanding the Science Behind Melasma

Case Study: Male Nasolabial Folds

Advertorial: Perioral Rejuvenation using BELOTERO

Addressing Filler Complications

Managing Health Anxiety

Treating the Deep Pyriform Space

CPD: Infraorbital Hollows

Advertorial: Restylane Skin Boosters

News Special: Dropping the Filter

Beyond Beauty