MARCH 2023: Growing Your Aesthetic Practice

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Dr Jeremy Isaac and Alex Henderson discuss common thread lifting complications

Chloé Gronow details the value of blogging, attracting patients and building a brand

VOLUME 10/ISSUE 4 - MARCH 2023 Blogging About Your Practice
Thread Complications
Opening Your Own Clinic Practitioners and business owners provide advice
starting your own clinic Understanding Vitamin C CPD Balsam Alabassi analyses the properties and uses of vitamin C in skincare HYALURONIC ACID EXPERTS #AUTHENTICBEAUTY #VPOURLAVIE JOINTHE COMMUNITYATACE2023!
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The latest product and industry

16 IMCAS World Congress 2023

The 24th International Master Course on Aging Science Congress has taken place in Paris

18 News Special: Government Rejects Filler Prescription Plans

Aesthetics reports on the Government’s latest regulation updates

20 Network With Your Specialty

Discover, network and celebrate medical aesthetics at ACE 2023

CLINICAL PRACTICE

23 Special Feature: Opening an Aesthetic Clinic

Practitioners and business owners provide advice on launching a practice

31 CPD: Understanding Vitamin C

Balsam Alabassi analyses the uses and properties of vitamin C in skincare

37 Lumenis ULTRApulse Alpha Makes UK Debut at ACE

Once in a generation technology to WOW patients and providers

38 Case Study: Utilising Ultrasound

Dr MJ Rowland-Warmann shares a case using ultrasound when addressing a dermal filler complication

43 Spotlight On: Alluzience

A look at the next step in botulinum toxin formulation

45 Treating Telangiectasia with Laser

Dr Ahmed El Houssieny details the treatment of telangiectasia

51 Avoiding Thread Lifting Complications

Dr Jeremy Isaac and Alex Henderson discuss thread lift complications

55 A History of Dermal Filler

Dr Kam Lally provides an overview of the development of dermal filler

60 Utilising GetHarley Services

Dr Sindhu Siddiqi discusses the benefits of using GetHarley in her clinic

61 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE

62 Blogging to Boost Patient Numbers

Chloé Gronow details the value of creating a blog to attract patients

65 Incentivising Your Team to Sell

Vanessa Bird discusses incentivising your team to sell ethically

68 Networking in Aesthetics

Miss Priya Chadha and Lauren Gibson share advice on making valuable connections in the specialty

71 Time to Go Paperless

Save time and reduce no-shows with Aesthetic Nurse Software

72 Creating an SEO Content Strategy

Rick O’Neill discusses how to optimise your content with an SEO strategy

77 In The Life Of Dr Catherine Fairris

Dr Catherine Fairris chats about juggling her practice and BCAM presidency

78 The Last Word: Choosing a Business Partner

Mr Dalvi Humzah and Telisha Jenkinson debate the pros and cons of working with a business partner

News Special: Government Rejects Filler

Prescription Plans

Page 18

Special Feature: Opening an Aesthetic Clinic

Page 23

Clinical Contributors

Balsam Alabassi is the founder of DermRefine Skin Clinic based in Mayfair London. She is a university graduate of Pharmacology and Pharmacy with more than 20 years’ healthcare experience in both community and hospital settings.

Dr MJ Rowland-Warmann is the founder and lead clinician at Smileworks clinic in Liverpool. She holds an MSc in Aesthetic Medicine and has a special interest in the management of complications. She is a KOL for Clarius Mobile ultrasound and GE Healthcare Ultrasound.

Dr Ahmed El Houssieny is the founder and medical director of Bank Medispa in Cheshire. He is a faculty member of Allergan and Lynton. Dr El Houssieny is also an Honorary Lecturer at the University of Chester, as well as an associate member of BCAM.

Dr Jeremy Isaac practises at Wish Skin Clinic in Port Talbot. He is a country expert and national trainer for Teoxane as well as a trainer for Aesthetic Medicine Pathways. He is on the JCCP training and education committee and is a founder of MAP-IQ.

Alex Henderson is an independent nurse prescriber with 12 years’ industry experience and two of her own clinics in the Southwest. Henderson has experience in training practitioners on filler and toxin courses, as well as PDO threads on behalf of 4T Medical.

Dr Kam Lally graduated in medicine from the University of Oxford, went on to qualify as a GP and is the Royal College of General Practitioners national aesthetic medicine lead. He is a global KOL for Teoxane, HansBiomed International, AlumierMD and Novo Nordisk.

Contents • March 2023
NEXT MONTH IN FOCUS: PROMOTING ESG IN AESTHETICS • Treating Transgender Patients • A History of the Menopause 08 News
news
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That time of the year has finally come –this month, we get to find out the deserving Winners for The Aesthetics Awards 2023! I can’t wait to come together as a community once again to celebrate and recognise all of you who are doing so much to progress our fantastic industry, whether that’s through exemplary patient care, clinical research, education, clinic support or innovative technologies. I am looking forward to getting dressed up and seeing you all at Grosvenor House on March 11! Of course, this prestigious event follows ACE 2023 – the first conference and exhibition in the UK aesthetics calendar this year. This is the perfect place for you to gather and connect with like-minded aesthetic professionals, learn new techniques through watching live clinical demonstrations and discover the newest products to enhance your practice. The clinical education is fantastic this year, with some great speakers from the industry’s top injectable brands (read more on p.20). Remember, all talks are CPD verified! You also shouldn’t miss our

Clinical Advisory Board

new In Practice Zone and Theatre for all your business and non-clinical needs. In this issue of the Aesthetics journal, we have a lot of content from ACE speakers, with a special focus on growing your aesthetic practice. There are many ways to grow your practice, whether it’s investing in new treatments (ACE is perfect for this) or looking at interesting ways to run your clinic. For those new to opening their own clinic, we have spoken to four successful business owners for their words of wisdom (p.23). We also explore the importance of content creation (p.62) and SEO (p.72), as well as how you can stimulate growth through getting your team incentivised to sell your products (p.65). We also delve into the power of networking for enhancing your career and the ways you can do this in our fantastic community (p.68). Of course, we have a great collection of peer-reviewed clinical articles, alongside news and industry updates.

Please do let us know what you’ve enjoyed learning about this month by stopping by our Aesthetics Members’ lounge at ACE on March 10-11. You can also chat to the team about writing for the journal, or if you are not already a Full Member of Aesthetics, you can secure your Membership with the team. We look forward to seeing you there!

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

Sharon Bennett is chair of the British Association of Cosmetic Nurses (BACN), previous UK lead of the BSI committee for aesthetic non-surgical standards, and member of the Clinical Advisory Group for the JCCP. She is a trainer and registered university mentor in cosmetic medical practice, and is finishing her MSc at Northumbria University. Bennett has won the Aesthetics Award for Nurse Practitioner of the Year and the Award for Outstanding Achievement.

Sharon Bennett, Clinical Lead

Mr Naveen Cavale has been a consultant plastic, reconstructive and aesthetic surgeon since 2009. He has his own private clinic and hospital, REAL, in London’s Battersea. Mr Cavale is the national secretary for the ISAPS, president of the Royal Society of Medicine, and vice-chair for the British Foundation for International Reconstructive Surgery.

Miss Elizabeth Hawkes is a consultant ophthalmologist and oculoplastic surgeon. She is the lead oculoplastic surgeon at the Cadogan Clinic, specialising in blepharoplasty and advanced facial aesthetics. Miss Hawkes is a full member of the BOPSS and the ESOPRS and is an examiner and fellow of the Royal College of Ophthalmologists.

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

PORTFOLIO MANAGEMENT

Alison Willis • Director

Dr Mayoni Gooneratne (MBBS, BSc, MRCS, MBCAM, AFMCP) was an NHS surgeon before establishing The Clinic by Dr Mayoni and founding Human Health – an initiative combining lifestyle with traditional and functional medicine to provide a ‘cell-up’ regenerative approach to aesthetics. She is also the co-founder of The British College of Functional Medicine.

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 Souphiyeh Samizadeh is a dental surgeon with a Master’s degree in Aesthetic Medicine and a PGCert in Clinical Education. She is the founder of the Great British Academy of Medicine and Revivify London Clinic. Dr Samizadeh is a Visiting Teaching Fellow at University College London and King’s College London.

PUBLISHED BY

T: 07747 761198 | alison.willis@easyfairs.com

EDITORIAL

Shannon Kilgariff • Editor & Content Manager

T: 0203 196 4351 | M: 07557 359 257 shannon@aestheticsjournal.com

Holly Carver • Senior Journalist | T: 0203 196 4427 holly.carver@easyfairs.com

ADVERTISING & SPONSORSHIP

Courtney LeBorgne • Event Director

T: 0203 196 4300 | M: 07818 118 741 courtney.leborgne@easyfairs.com

Judith Nowell • Business Development Manager

T: 0203 196 4352 | M: 07494 179535 judith@aestheticsjournal.com

Chloe Carville

• Sales Executive

T: 0203 196 4367 | chloe.carville@aestheticsjournal.com

Emma Coyne • Sales Executive

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

Email:

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

Dr Stefanie Williams is a dermatologist with a special interest in adult acne, rosacea and aesthetic medicine. She is the founder and medical director of multi-award winning EUDELO Dermatology & Skin Wellbeing in London, and creator of Delo Rx skincare. She is the author of three books and has published more than 100 scientific articles, book chapters and abstracts.

ARTICLE PDFs AND REPRO

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

Aesthetics Media

Ellie Holden

• Journalist | T: 0203 196 4265 ellie.holden@easyfairs.com

Kate Byng-Hall • Journalist | T: 0203 196 4265 kate.byng-hall@easyfairs.com

DESIGN

Peter Johnson

• Senior Designer

T: 0203 196 4359 | peter@aestheticsjournal.com

T: 020 3196 4372 | emma.coyne@easyfairs.com

MARKETING

Aimee Moore • Marketing Manager

T: 020 3196 4370 | aimee.moore@easyfairs.com

Emma Kurzyca • Marketing Assistant

T: 020 3196 4306 | emma.kurzyca@easyfairs.com

Editor’s letter
PROGRESS EDUCATION IN AESTHETICS!
editorial@aestheticsjournal.com HELP
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.
© Copyright 2023 Aesthetics. All rights reserved. Aesthetics is published by Aesthetics Media Ltd, which is registered as a limited company in England; No 9887184
Aesthetics Aesthetics @aestheticsjournaluk

Talk #Aesthetics

#Aestheticsjournal

Dr James Jack @tarquinmedicalaesthetics

Hugo loved the article exploring filler longevity in the latest edition of the Aesthetics journal!

Regulation

Government considering increased aesthetic premises standards

In its response to the 2022 Select Committee Report on the Impact of Body Image on Mental and Physical Health, the Department of Health and Social Care (DHSC) has announced it will consider introducing premises standards for practitioners performing non-surgical cosmetic procedures in England.

Currently, English practitioners providing non-surgical aesthetic treatments are not required to meet any premises standards before performing them, as only certain medical procedures require a Care Quality Commission (CQC) registration.

#IMCAS 2023

Miss Sherina Balaratnam @sthetics_clinic

An incredible expert symposium at IMCAS Paris, formally launching EMFACE in Europe.

#Menopause

Frances Turner Traill @frances_turner_traill

What a phenomenal packed day at the inaugural Menopause in Aesthetics conference in London.

The DHSC acknowledges that, “There are currently no specific premises standards for beauty salons and non-CQC-registered premises providing non-surgical cosmetic procedures. We will consider whether specific premises standards are needed and what they should include. We also want to ensure that we do not duplicate inspection regimes. We will, therefore, continue to work with the CQC to ensure that, if introduced, any new premises standards operate consistently with regulatory frameworks already in place.”

In a statement following this news, chair of the Joint Council for Cosmetic Practitioners (JCCP) Professor David Sines said, “The JCCP remains firmly of the opinion that the DHSC should require all practitioners who provide non-surgical procedures that are included within the scope of the new license must provide evidence that they possess a premises license that is designed to meet the specific needs of the aesthetics sector.” Aesthetics will continue to report on developments in aesthetic regulation as they emerge. Turn to p.18 to read more on the Government’s response in our News Special.

Advertising

ASA issues ruling against hair loss medication ads

#Awards CCR @ccrlondon

Emma and Jude from our wonderful sales team have won big at the AEO People’s Awards 2023!

#Networking

Mrs Sabrina Shah-Desai @drsabrinashahdesaiofficial

A fun evening with Aesthetics Solutions and UltraClear Laser, plus some lovely colleagues.

The Advertising Standards Authority (ASA) has issued a ruling against an online supplement provider based in Leeds after it advertised prescription-only medications (POMs) for hair loss to the public.

The ASA found that the site had posted before and after images of patients, alongside images of people taking pills identified as Finasteride, in the adverts. The ads were accompanied by an ‘Online Consultations’ heading stating, “We connect you to a UK registered prescriber who assesses your case and recommends the best course of treatment.”

The defendant stated that they were aware that the product was a POM, but that they explicitly stated that a consultation with a healthcare professional was required to receive the treatment, so they didn’t believe they were infringing on any rules.

However, the ASA ruled that the ads implied the customers would be able to choose what treatments they received regardless of the outcome of a consultation, suggesting the POM would be available to anyone who wanted it. The ASA ruled that the site could not share similar ads in the future, and POMs should not be promoted publicly.

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
Follow us on Instagram @aestheticsjournaluk

ACE 2023 to offer world-class education

This month, ACE 2023 will be returning to the Business Design Centre to offer delegates a jam-packed agenda across two days. As well as numerous networking opportunities and seeing the latest innovations in the aesthetics market, ACE 2023 has got plenty of educational content for you to watch and learn from across the two days. Our Agenda at a Glance is in your copy of the journal this month, showcasing the wide array of content on offer this year, as well as some of the biggest companies and speakers returning to ACE, including our Headline Sponsor Teoxane. With Masterclasses from Allergan Aesthetics, Church Pharmacy, Dermaroller, Lumenis and SkinCeuticals, as well as Symposiums from Croma Pharma, Galderma, Prollenium and Neauvia, there will be plenty of opportunities to learn throughout the two days.

Courtney LeBorgne, event director at Aesthetics, said, “We are so excited to welcome the aesthetics specialty back to ACE 2023. This year, we have got some of the biggest companies and speakers to take to the stage, offering fantastic education and innovations on the market. Plus, don’t miss out on our networking opportunities on March 10, with our In Practice drinks followed by networking drinks with Hydrafacial. It’s not one to be missed!” ACE will be taking place on March 10-11. Turn to p.20 to register for free now.

Wellness

Government rejects ‘menopause leave’ proposals

The UK Government has rejected the Women and Equalities Committee’s suggestion to implement ‘menopause leave’ or employment adjustments for those experiencing symptoms of menopause. The Government also rejected proposals to make the menopause a protected characteristic under The Equality Act, which would have criminalised discrimination based on whether someone is going through the menopause.

The Women and Equalities Committee initially made these suggestions following a report in July 2022 which showed that side effects of the menopause were pushing women out of work and suggested that talent would be able to remain at work for longer if employers made ‘reasonable adjustments’ to account for their symptoms. However, the Government has said these changes could cause “Unintended consequences which may inadvertently create new forms of discrimination, for example, discrimination risks towards men suffering from long-term medical conditions.”

The Conservative chair of the committee, Caroline Nokes, called the Government’s dismissal of the suggestions “A missed opportunity to protect talented and experienced women from leaving the workforce and leaves me unconvinced that menopause is a government priority.”

the social media platform (Hootsuite, 2023)

(The Guardian, 2023)

Dermal filler reversal procedures increased by 57% from 2021 to 2022

(The Aesthetic Society, 2023)

40% of customers have reported using facial skincare more frequently since the pandemic (NPD, 2023)

More than 75% of menopausal women experience symptoms, with 25% describing them as severe

(British Menopause Society, 2023)

Almost 65% of 2,000 black survey respondents had experienced prejudice in healthcare settings

(British Medical Journal, 2023)

Conference
On Instagram, 62% of users research brands and products while on
Out of every 10 young people aged 12-21 in the UK, eight say they dislike and are embarrassed by their bodies
Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
Vital Statistics

Events diary

10th-11th March

ACE 2023

www.aestheticsconference.com

11th March

The Aesthetics Awards 2023 www.aestheticsawards.com

21st April

BACN Spring Symposium www.bacn.org.uk/events

23rd May

British Association of Sclerotherapists Conference www.bassclerotherapy.com/events

30th September

BCAM Conference 2023 www.bcamconference.co.uk

6th-7th October

CMAC 2nd Global Conference www.cmac.world

Dermal Filler

Study supports combination approach for lip augmentation

A new clinical study has highlighted that using both cannula and needle, two hyaluronic acid fillers and combining two injection plans can provide both lip projection and fullness. The study published in Journal of Cosmetic Dermatology included 30 female patients aged 20-73 years.

A topical anaesthetic was applied at the junction of the upper and lower lips, as well as on the white lip. Intramuscular retro-trace injections of Stylage M were conducted through a 27 gauge cannula at the level of the upper and lower hemi-lip. Then, intradermal injections of Stylage Lips using a 33 gauge needle were carried out on the lip border as well as the cupid’s bow. Rheological assessment showed that passage through a 33 gauge needle did not alter the viscoelastic properties of filler. After the procedure, no side effects were observed except for standard bruises and oedema. The study demonstrated that dissociating the anatomical zones of the lip during the procedure by means of different hyaluronic acids in the muscular and dermal planes would safely provide both lip projection and fullness for a natural and lasting effect.

VIVACY, manufacturer of Stylage dermal fillers, will be exhibiting at ACE on March 10-11. Turn to p.20 to register for free.

Education

Dr Raj Acquilla and Julie Horne to hold masterclass

Shirley Ballas chats about treatments on Loose Women

Strictly Come Dancing head judge

Shirley Ballas has appeared on ITV programme Loose Women to chat about procedures. Her recent NeoGen Plasma, Morpheus8 and Obagi Skincare facial transformation took consumer headlines by storm after she sought treatment to feel better in herself.

ITVX show puts spotlight on ‘botched’ treatments

New episode of the ITVX Tonight programme – Botched? Inside the Beauty Business – looks into how safe aesthetic treatments are. Journalist Lucrezia Millarini investigates practitioners not following industry standards, and questions whether increased legislation would fix it.

The Skincare Hoax: new book on skincare basics

American dermatologist Dr Fayne Frey has released a new book for patients –The Skincare Hoax: How You’re Being Tricked into Buying Lotions, Potions & Wrinkle Cream – discussing what skincare ingredients really do and what basics to include in your regimen.

Aesthetic practitioner Dr Raj Acquilla and aesthetic nurse Julie Horne will be hosting a masterclass in April. During the two-day masterclass, the pair will be leading sessions themed around diversity of genotype and morphology across generations, specifically addressing structural variations between patients from Europe, Africa, Asia and the Middle East. They will also explore the unique approaches needed for patients of different generations, from patients in their twenties through to those in their sixties. The event will be taking place on April 22-23 at Nobu Hotel, London.

Dr Raj Acquilla will be speaking at ACE on March 11. Turn to p.20 to register for free.

Recruitment

Galderma appoints new head of marketing

Pharmaceutical company Galderma has welcomed Jackie Tuzee as the UK head of marketing for aesthetics. Tuzee will have overall marketing leadership of the aesthetics brands, including the Galderma neuromodulator portfolio Restylane and Sculptra, explains the company. Previously, Tuzee was brand business director for SkinCeuticals at L’Oreal, leading the marketing, sales and training functions.

Tuzee said, “I’m thrilled to be joining Galderma in the aesthetics business unit. Galderma has a unique competitive advantage with an integrated dermatology approach to managing skin across prescription, aesthetics and consumer indications.”

Galderma will be exhibiting at ACE on March 10-11. Turn to p.20 to register for free.

IN
What’s trending in the consumer press
THE MEDIA
Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com

Dr Mayoni Gooneratne joins Clinical Advisory Board

Aesthetic practitioner Dr Mayoni Gooneratne has become the latest addition to the Aesthetics portfolio’s Clinical Advisory Board. Dr Gooneratne is an aesthetic practitioner with a surgical background, and now specialises in women’s intimate health and wellness. She is the founder of Dr Mayoni’s Human Health – an initiative championing the use of functional medicine to tackle the root causes of ill health and aesthetic concerns.

Dr Gooneratne joins clinical lead nurse prescriber Sharon Bennett, nurse prescriber Jackie Partridge, plastic surgeons Mr Naveen Cavale and Mr Adrian Richards, ophthalmologist and oculoplastic surgeon Miss Elizabeth Hawkes, dental surgeon Dr Souphiyeh Samizadeh, aesthetic practitioner Dr Tapan Patel and dermatologist Dr Stefanie Williams on the Board.

She commented, “I am truly honoured and utterly thrilled to be involved in Aesthetics in this way. The aesthetics specialty has a lot to gain from a better understanding of the science of longevity and wellness. We are also in the incredible position in aesthetics of having time and space to be able to recognise, educate and support our patients with their cellular health too.”

Dr Gooneratne will be speaking at ACE on March 11. Turn to p.20 to register for free.

Regulation

MHRA to offer industry support at ACE

Representatives from the Medicines and Healthcare product Regulatory Agency (MHRA) will be visiting ACE 2023 on March 10-11 to offer advice and support to both practitioners and companies working within aesthetics.

For the first time, the MHRA will have a booth at the Aesthetics Members’ lounge to give visitors the opportunity to speak to representatives about choosing reputable products and suppliers, and the dangers behind counterfeit products. The MHRA representatives will also have examples of counterfeit products that have been seized in the past to showcase the difficulties behind identifying them. By UK law, all manufacturers of medical devices offered or exhibited for supply in the UK must be registered with the MHRA, and nearly all devices are publicly available and published online.

If any exhibitors are found not to be compliant or are operating illegally, for example, they are promoting medical products that are not registered with the MHRA or have fake UKCA/CE/EC certificates, then products will be seized.

Courtney LeBorgne, event director of Aesthetics, said, “As both media providers and event organisers, we at Aesthetics take regulation, upholding standards and ensuring patient safety seriously. We are excited to have the MHRA accept our invitation to come back at ACE 2023 as this allows us to ensure that exhibitors are upholding these standards themselves and are being compliant with the industry regulations. It also ensures that we are helping the aesthetic community stay educated with the importance of choosing reputable suppliers for their businesses.”

A spokesperson from the MHRA stated, “We are really looking forward to attending ACE 2023 to support those working within the aesthetic community to purchase legitimate, properly-sourced products which comply with the UK regulations. We will also be on hand to answer any questions relating to the new Medical Device Regulations that the UK Government intends to introduce by Spring 2023, which will likely be in force by July 2024.”

BACN UPDATES

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

BACN SPRING SYMPOSIUM 2023

Join us on April 21 at The Royal Society of Medicine for our second annual Spring Symposium!

The BACN Spring Symposium is set to be a fantastic event, designed specifically to focus on advanced practice. Attendees will have the opportunity to hear from expert speakers, as well as meet and chat with fellow practitioners, exhibitors and industry leaders to help shape the future of your clinic.

So far, Dr MJ Rowland-Warmann and Dr Lee Walker are confirmed to speak at the London event, with more leading names within the medical aesthetics specialty soon to be released.

We’ve had a fantastic response from members so far, and we are already more than 80% sold out. Whether you’re looking to make new contacts, establish partnerships or simply catch up with old friends, we’d love to see you there! Bookings can be made via the BACN website at www.bacn.org.uk/events, or by scanning the QR code below.

WINTER NEWSLETTER

The BACN Winter 2022/23 newsletter was published on February 24. Members will have received an email newsletter with exciting updates from BACN chair Sharon Bennett and CEO Paul Burgess MBE, as well as upcoming event information and exclusive videos. It is also available to view online now in the BACN Member’s Area, along with all previous newsletters to revisit.

ESTABLISHING A BACN CHARITY

The BACN has started the process of setting up a separate charitable body (subject to approval by the charity commissioners) to coordinate our education and training activities, with a focus on patient safety and protection for the public. We will be looking for BACN members to become Trustees, and would love to hear from you if you are interested in taking part. For more information, please contact pburgess@bacn.org.uk with the subject line ‘BACN Charity Trustee’.

This column is written and supported by the BACN

Aesthetics journal
Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com

AWARDS

A night of recognition and celebration

ALLSKIN MED unveils new UK ambassador

Dual-certified facial aesthetic surgeon Dr Paris Acharya is the new UK brand ambassador for skincare brand ALLSKIN MED. The brand ALLSKIN MED by Cantabria Labs has patented technologies, combined with ingredients in dermatology, to adapt regimes for all skin types and use products that work in synergy with in-clinic treatments to enhance results, explains the company.

Dr Acharya said, “This partnership means so much to me as ALLSKIN MED takes a holistic approach to skincare combining science, safe formulations and effective results in a harmonious fashion. The philosophy behind the ALLSKIN MED products and protocols enables us to feel happy and proud within our skin.”

In just under two weeks, the biggest event in the aesthetics calendar will be taking place at Grosvenor House, London! We are so excited to bring the industry together and see more than 1,000 of you to celebrate and recognise all the achievements of the aesthetic specialty in the last 12 months. The Awards ceremony will take place on the evening of March 11, after the second day of ACE, and is the perfect way to round off two jam-packed days of education.

The evening will involve a drinks reception and afterparty sponsored by Hydrafacial, a delicious three-course dinner and the exciting Awards ceremony with celebrity host Cherry Healey, followed by dancing and live music.

Look out for the Winners!

Tickets for the Awards are SOLD OUT, so if you missed out on a ticket, we’re making sure you can still take part in the ceremony from home. Keep an eye out on the Aesthetics Instagram @aestheticsjournaluk to find out all the Winners, Highly Commended and Commended companies and individuals as they’re announced! Make sure to tag us on Instagram with your reactions. Results will be LIVE on the Aesthetics website from March 13, alongside photos and a video with highlights of the night, so make sure to keep your eyes peeled to see if you can spot yourself! The full list will also be revealed in the April issue of the journal. Good luck to everyone who was shortlisted!

A big thank you!

We also want to take this opportunity to say a massive thank you to all of the Aesthetics Awards Judges who have spent hours looking at each entry and deciding on this year’s Winners; as well as all of our incredible Sponsors! We can’t wait to see everyone at the ceremony and celebrate such an incredible year in aesthetics!

AesthetiCare, the exclusive UK partner for Cantabria Labs, will be exhibiting at ACE on March 10-11. Dr Acharya will be speaking on behalf of the company on March 10. Register for free by turning to p.20.

Development

AestheticSource to distribute PRIORI

Skincare brand PRIORI has appointed AestheticSource as its official distributor in the UK and Ireland. According to the company, PRIORI offers a range of professional peel systems which address a variety of patient concerns including pigmentation, lines and wrinkles, sun damage and hormonal blemishes. The company also has adaptive skincare ingredients within its products including DNA Enzyme Complex to repair damage to the skin’s DNA, allowing the cells to function correctly; IR Complex to provide broad-spectrum protection by reducing IR-A induced cellular damage and Advanced Moisture Complex to address causes of dry skin, adds the company.

Lorna Bowes, CEO of AestheticSource, said, “I am delighted to expand the AestheticSource portfolio with a brand known for its cutting-edge ingredient technologies developed by skin-focused scientists that have formulated major breakthroughs in skincare. We have always been and remain passionate about products that provide results without downtime or compromising the skin barrier.”

AestheticSource will be exhibiting at ACE on March 10-11. Turn to p.20 to register for free.

Representative
Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com

Injectable Croma Pharma introduces PhilArt range

Aesthetic pharmaceutical company Croma Pharma has added a range of skinboosters to its portfolio. The range, named PhilArt, aims to improve patients’ skin quality, rejuvenating the skin and add radiance while restoring the skin’s elasticity and promoting hydration, according to Croma Pharma. The company explains that the application range stretches from the face, scalp and neck to the décolletage and hands. The PhilArt range offers four injectables, suitable for all skin types and age groups. The first two products – PhilArt, used for adding radiance and rejuvenating the skin for young and mature patients, and PhilArt Eye, for the delicate area around the eyes – were launched at IMCAS World Congress in January. The second two injectables, PhilArt Hair and PhilArt Next, will follow by the end of Q1, 2023. Croma Pharma will be exhibiting at ACE on March 10-11. Turn to p.20 to register for free.

Skin

Hydrafacial unveils new booster

Aesthetic treatment company Hydrafacial has partnered with Omorovicza to launch a new booster for skin rejuvenation. According to the company, the booster works in combination with Hydrafacial’s existing three-step protocol as it cleanses, extracts and hydrates the skin.

The latest formula includes retinol, vitamin C and E, which aims to optimise cell renewal and stimulate collagen and elastin production; hyaluronic acid spheres, which aim to increase skin volume; and arabinogalactans and amino acids to detoxify the skin and boost microcirculation. The booster also contains patented Healing Concentrate from Omorovicza with zinc, magnesium, copper and calcium to firm, repair and protect the skin, explains the company.

Lauren Gibson, UK&I country manager, said, “The latest Omorovicza Advanced Skin Renewal booster joins a range of well-known brands, offering even more personalisation opportunities for clinics and spas. This allows consumers to choose from a more prescriptive menu of scientifically validated ingredients, all delivered through Hydrafacial technology.” Hydrafacial is the Networking Drinks sponsor at ACE on March 10-11. Turn to p.20 to register for free.

Expansion

Cutera recruits new team members

Aesthetic device company Cutera has increased its UK team with four new roles to increase customer support.

In order to drive customer success, the company has four new key account managers across the UK: Skye Barber in the Southwest, London and Wales; Justine Stephens-Parker in the North and Northern Ireland; Abigail Pottinger in the Midlands and Kristina Latonaite for the Southeast and London. Tim Taylor, general manager for Cutera in the UK and Ireland, commented, “We are delighted to be able to create these new customer support roles in response to the growing demand for our products and services.”

Cutera will be exhibiting at ACE on March 10-11. Turn to p.20 to register for free.

Branding Teoxane unveils new rebrand

Aesthetic manufacturer Teoxane has launched its new rebrand, designed to celebrate diversity and authenticity. The rebrand, showcased at IMCAS in January, aims to enhance the brand’s awareness across cultures and audiences. Its new tagline, ‘Inject more beauty into your life’, aims to encapsulate the brand’s ethos that ‘small acts of self-care, done in the right way, can change lives’, adds the company.

Teoxane is the Headline Sponsor at ACE 2023 on March 10-11. Register for free by turning to p.20.

Education Evolus Tour brings education across the UK

Medical aesthetic company Evolus has announced a series of regional roadshow dates across the UK, allowing medical professionals to learn more about Evolus and its toxin Nuceiva.

According to the company, the tour will explore anatomy, research, regulation and social media guidelines.

Suse Alexander, general manager of Evolus UK, says, “I’m thrilled to be out on the road again, bringing our Evolus Tour to our aesthetics healthcare professional customers and those who are curious. We have partnered with Professor Sebastian Cotofana, Dr David Eccleston and six more regional experts to explore current topics and how you can evolve the future of beauty.” The tour is set to visit Bristol, London, Birmingham, Manchester and Durham this March.

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com

Professor Syed Haq’s Expert Insights

Consultant physician Professor Syed Haq is internationally renowned for his research into both aesthetics and ageing science. Alongside his groundbreaking Alzheimer’s research, he is an advocate of regenerative medicine. Here, Aesthetics shares his insights into the specialty during a climate of innovation…

What’s your ethos for recommending treatments?

My top tip is to have a cooling-off period after an initial consultation so patients aren’t too hasty when accepting treatments, but also have time to realise their benefits. Make sure to be open about downtime, expected results and cost.

How should practitioners learn about new treatments on the market?

My first port of call is talking to colleagues about their experiences or what they’ve heard. If you’re looking to find new innovations, industry conferences like ACE, CCR or IMCAS are a great way to learn more. Make sure to read the evidence and consider your clinic demographic before committing to anything new.

How do you recommend practitioners further their medical education?

Master’s degrees in Aesthetic Medicine are a great way to develop knowledge, and I’ve seen a number of colleagues complete doctorates to hone in on specific areas of expertise. Other options like training courses or dermatology diplomas are also great. Education is essential to avoid complications.

You feel threads are becoming more popular, what are your top tips for successful treatment?

Administering threads isn’t for the faint-hearted so ensure you’re confident. It’s essential to conduct thorough training and perform supervised treatments with CE marked products to avoid danger points. It’s crucial for patient safety to use a cannula, and molded PDO threads give the best lift.

The future of toxin is bright – what recent innovations are you seeing?

Multiple brands including Croma Pharma, Evolus and Galderma have brought out new toxins recently, reflecting innovations in the field. Toxins are becoming longer lasting, but there are emerging topical and liquid forms as well.

What three treatments are the cornerstone of your practice?

1. Botulinum toxin is the classic

2. Dermal fillers which offer natural volumising and profile balancing

3. Rejuvenating products are a growing market for me: think HArmonyCa from Allergan, PhilArt from Croma Pharma or Plenhyage XL from DermaFocus.

Awards

The Aesthetics Awards to take place this month

The Aesthetics Awards returns this month, highlighting the top achievements in the aesthetics specialty over the past year. With judging and voting now closed, more than 260 Finalists across the Awards’ 25 categories are hoping for a chance of being awarded Commended, Highly Commended or Winner statuses at this year’s event. We also have five exciting new Awards sponsors this year. Skin rejuvenation company SkinadeMD Surgical Programme will be sponsoring the Consultant Surgeon of the Year Award, device company Lumenis will be supporting the Best Clinic London Award and training company MAP-IQ will be sponsoring the Best Clinic Midlands and Wales. Furthermore, aesthetic treatment company Hydrafacial will be supporting Best New Clinic, UK & Ireland and compression garment manufacturer Macom Medical will be sponsoring the Best Surgical Result Award. Shannon Kilgariff, editor and content manager of Aesthetics, commented, “The Aesthetics Awards return this month and I’m so excited to celebrate with the industry after all the fantastic achievements over the past year. From practitioners, companies, products and clinics, the Awards aim to recognise the very best in aesthetic medicine and represent the highest standards in clinical excellence, product innovation and practice achievement. I can’t wait to celebrate with everyone soon!” The Aesthetics Awards will be taking place on March 11 at Grosvenor House, London after the second day of ACE 2023.

Environment

IBSA Derma releases fourth sustainability report

Pharmaceutical company IBSA Derma has published its fourth sustainability report with the aim to reduce its environmental footprint. According to the company, the fourth report presents a more in-depth environmental analysis, and results show how IBSA is pursuing the goal to reduce its footprint and operate to a more efficient use of resources. The report highlights a -24.4% in the use of fossil fuels in the Swiss subsidiary compared to 2018, -3% in water consumption in the Italian subsidiary compared to 2020, -22% in the production of waste in the Chinese subsidiary compared to 2020 and -7% in electricity consumption in the French subsidiary compared to 2019. The company explains that the new report witnesses the completion of the transition which began in 2021 with the renovation of Cosmos, the largest production plant of the IBSA Group, located in Switzerland. The production hub is designed according to sustainability criteria, ranging from the selection of sustainable materials to the use of clean energy, to satisfy the increase in production through the installation of photovoltaic panels, explains IBSA. Director of HA-Derma, the exclusive distributor of IBSA in the UK and Ireland, Iveta Vinkler, said, “It’s a privilege to be representing a company like IBSA which is not only leading the way in the hyaluronic acid innovation, but despite the global success the company has been experiencing in recent years, is not blind to the effects this can have on the environment, and continues taking actions towards being a more sustainable business.” HA-Derma is the VIP sponsor at ACE on March 10-11. Register for free by turning to p.20.

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com

London Regenerative Institute launches in London

The London Regenerative Institute (LRI) officially launched in January with a welcoming breakfast at the luxurious Corinthia London hotel.

In a private dining room at the opulent Corinthia, founders of the LRI plastic surgeons Dr Tunc Tiryaki and Dr Steven Cohen shared insights into the use of stem cells and exosomes in reversing the ageing process of cells and aiding recovery postsurgery through cell regeneration.

Research into these areas will continue as part of the LRI’s international research initiative. At the Corinthia, patients will be able to rehabilitate post-surgery at the Cadogan Clinic in Chelsea, receiving five-star care and various regenerative treatment options, according to the LRI. This will include epigenetic and blood testing, followed by ‘biohacking’ advice on areas such as diet, exercise and lifestyle, as well as ‘longevity’ treatments including dermal fillers, platelet-rich plasma therapy and exosome treatments. Co-founder Dr Cohen commented, “Identifying disease before it manifests and employing preventative treatments and therapies is the gold standard solution to reversing ageing. We are committed to offering the most advanced regenerative treatments, personalised to the unique needs of each patient.”

Conference Report

Inaugural Menopause in Aesthetics Conference

On February 10, the inaugural Menopause in Aesthetics (MIA) conference was held at the Waldorf Hilton in London.

350 delegates and 100 live streamers gathered to further knowledge and awareness of the difficulties which are experienced by half of the population, but are rarely discussed due to stigma or shame.

The speakers highlighted that aesthetic practitioners build a trusting relationship with their patients, so are well placed to aid them through holistic wellness.

MIA chair and aesthetic practitioner specialising in menopause and intimate health Dr Shirin Lakhani said, “For too long, women’s health has been ignored and their symptoms diminished. Thankfully this is starting to change. The focus of aesthetic medicine is changing away from simply correcting the signs of ageing to the management of the entire ageing process.” The event covered a wide breadth of topics, including the psychological impact of the menopause, the menopause’s influence on patients’ skin, hormonal treatments for the menopause, weight management and sexual wellbeing.

Aesthetic practitioner, founder of Human Health and MIA co-chair Dr Mayoni Gooneratne commented, “When talking about wellness with patients, the conversation shouldn’t be just about hormones. It should be about what information there is for women and how are they going to support themselves through other lifestyle measures, because there are plenty. Lots of women who come to me walk away without any hormone treatments but are in a better position to make decisions about their health.”

Menopause in Aesthetics will return on February 24, 2024 at The Grand Connaught Rooms, London.

News in Brief

Nuceiva receives Australian approval

Medical aesthetic company Evolus has announced that its neurotoxin Nuceiva has received approval for sale in Australia. The Australian Therapeutic Goods Administration (TGA) has provided regulatory approval for Nuceiva (prabotulinumtoxinA) for aesthetic purposes. Evolus says this has significantly expanded the company’s international marketing opportunities. David Moatazedi, president and chief executive of Evolus, commented, “This approval is the latest example of our commitment to broaden our international presence, which is a key component to reaching our aspiration of $500 million in total revenue by 2028.”

Dermalogica launches course for melanin-rich skin

Skincare brand Dermalogica has debuted a free online training course to strengthen industry knowledge on melanin-rich skin. The course, Treating Melanin-Rich Skin, aims to strengthen foundational knowledge of Fitzpatrick skin types IV-VI. The three modules cover patient experience, the science of melanin-rich skin structure, how different conditions present in darker skin, and what contraindications may occur. Dermalogica will be exhibiting at ACE on March 10-11. Turn to p.20 to register for free.

BAS unveils sclerotherapy conference

The British Association of Sclerotherapists (BAS) will be holding its conference in May. The conference will include a line-up of speakers, live treatment demonstrations as well as opportunities to network with peers and exhibitors. President of BAS, Philip Coleridge Smith, said, “We are thrilled to be hosting our first face-to-face meeting since lockdown! The audience will comprise of phlebologists, vascular surgeons and nurses, all eager to learn, share best practice and discover how to refine their sclerotherapy technique.” The conference will be taking place at Dorney Lake Conference Centre in Windsor on May 23.

Aesthetic Technology Ltd acquired by Omni Partners

Investment manager Omni Partners LLP has acquired British manufacturer Aesthetic Technology Ltd (ATL). The new acquisition and investment aims to accelerate ATL’s international expansion and product development into further medical treatment pathways and help facilitate ATL’s growth plans, the company explains.

ATL will be exhibiting at ACE on March 10-11. Register for free by turning to p.20.

On the Scene
Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com

IMCAS World Congress

2023, Paris

Aesthetics reports on the 24th annual International Master Course on Aging Science Congress in Paris

On January 26-28 in Paris, France, the 24th annual International Master Course on Aging Science Congress (IMCAS) was held in the Palais des Congrès de Paris.

More than 15,500 delegates from 136 different countries congregated to further their medical knowledge, gathering alongside 322 exhibitors from around the globe.

The ‘IMCAS Impact’ highlighted the focal points of the congress –education, technology, safety and ethics – which were conveyed through more than 300 hours of educational content from 851 different speakers across 198 sessions.

Some of the biggest aesthetic companies in the world presented clinical findings and performed live demonstrations. Galderma showcased its new Holistic Individualised Treatment (HIT) protocols Kiss & Smile and Balanced Profile, alongside results of studies into new liquid toxin Alluzience and PLLA injectable Sculptra. Meanwhile, Teoxane focused on elevating aesthetics, with emphasis on danger zones and full-face transformation using Teosyal dermal fillers. Other companies presenting innovations included BTL Aesthetics, Croma Pharma, HA-Derma, Merz Aesthetics and Neauvia.

The IMCAS Scientific Board, chaired by honorary president and founder of IMCAS Dr Benjamin Ascher, stated, “Amidst an era of innovation and rapidly evolving medical science, the expansion of medical and surgical aesthetics requires modern training that is scientifically credible and responsive to modern patient needs. This edition of IMCAS World Congress explored medical education with a curative emphasis on new technology, safe methods of practice and scientific transparency.”

Advanced education

The first day of content included the popular cadaver workshop, which provided anatomical expertise delivered through live cadaveric dissections. The session highlighted danger zones of the face and body during injections and surgery, and was complemented by

ultrasonographic imaging from dermatologist Dr Peter Velthius and plastic surgeon Dr Steven Weiner.

The Global Market Summit 2023 on the second day presented the results of research into current trends. The summit revealed that the value of the aesthetics specialty is expected to triple in 10 years, moving from 5.7 to 18.9 million euros between 2014 and 2026. It also confirmed that injectable products represented the largest proportion of the aesthetics market, with a projected growth rate of 8.1% per year between 2022 and 2026.

La Tribune conference further highlighted areas of growing interest in aesthetics, with panels of top practitioners and business owners discussing topics including energy-based devices, sustainability and keeping up with market trends.

Live facial surgery demonstrations took place on the final day, alongside talks covering dermatology, non-surgical procedures, surgery, regenerative medicine and the future of aesthetic technology.

Showcasing innovations

A number of innovations were given particular attention at this year’s congress, one being exosome research. Plastic surgeon Dr Steven Cohen said, “Since the early fat transfer procedures more than 20 years ago, we have made continuous progress by observing the infinitely small which hold great promise: exosomes. Collaboration between laboratories and doctors will improve procedure quality and efficacy for patients.”

Ultrasound technology was also in the spotlight, with dermatologist and scientific director of IMCAS Dr Hugues Cartier commenting, “I think we will soon see more and more devices arriving on the market, which will open up options for practitioners. One must not forget that in aesthetics, doctors have a strict obligation to provide due care, and in all likelihood this will include the use of ultrasound.” Finally, Dr Velthius presented the hypothesis that artificial intelligence (AI) will become a major force in aesthetics, saying, “Current research is heading in that direction with bone structure analysis which could enable us to preventatively counteract ageing, and I hope that in the future, aesthetic medicine will become more scientific and less dependent on the artistic capabilities of practitioners.” The IMCAS World Congress will return to Paris on February 1-3, 2024.

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
Further learning and networking opportunities are just around the corner at ACE 2023, with a focus on the UK aesthetics scene. Register for free by scanning the QR code.
STAND E2

from the point of manufacture to the point of administration, since they can cause serious complications when used inappropriately by unqualified and untrained practitioners. Dr Fairris is disappointed that dermal filler will not attain prescription-only status. She cites patient safety as the main concern, saying, “We are all aware of the dangers associated with dermal filler that far exceed the dangers associated with many other types of injectables. As far as BCAM is concerned, the fact that the Government has thus far said they won’t be making dermal fillers prescription-only is not an adequate response. We will continue to push for tighter legislation around fillers.”

Government Rejects Filler Prescription Plans

In mid-February, the UK Government’s Department of Health and Social Care (DHSC) issued an official response to the 2022 Select Committee Report on the Impact of Body Image on Mental and Physical Health.1 The response included a number of updates to the proposed licensing of non-surgical cosmetic procedures in England, including the news that any licensing scheme will be delayed beyond the original deadline of July 2023.

One of the biggest updates issued is the confirmation that dermal fillers will not become classified as prescription-only devices (PODs) in England, raising debates on how patient safety can be maintained alongside administering filler.2 Aesthetics spoke to the industry’s key associations to hear their views on this response, including chair of the Joint Council for Cosmetic Practitioners (JCCP) Professor David Sines, president of the British College of Aesthetic Medicine (BCAM) Dr Catherine Fairris, chair of the British Association of Cosmetic Nurses (BACN) Sharon Bennett and director of Save Face Ashton Collins.

Spotlight on filler

The DHSC has emphasised its commitment to “Taking forward work to introduce a licensing scheme for non-surgical cosmetic procedures in England,” but dermal filler will not become a POD as part of the scheme. Professor Sines explains that fillers do not currently require a prescription because they are not designated as medicines. Fillers are regarded by the Medicine and Healthcare products Regulatory Agency (MHRA) as being cosmetic products or devices rather than medicines, meaning they do not fall within the Government’s designated criteria to require a prescription. He advises that further safeguards are necessary to ensure fillers are effectively controlled

Professor Sines states that the JCCP would have preferred if dermal filler had been assigned POD status, but advises that in the absence of this request, there are ways in which fillers can be made safer in the UK. He explains that another issue involving dermal fillers is the prevalence of low-quality products, often caused by parallel importing – a process whereby products enter the country through importation that is independent of centralised authorisation.3 He states that if this can be brought under control by the MHRA, more filler procedures will be safe. “Dermal filler safety is partly brought about through traceable and responsible manufacture, secure supply chains and stringent product control,” he says. However, Bennett has highlighted that if dermal fillers were to become PODs, non-prescribing medical practitioners, such as nurses, would face issues with their stock. She says, “The BACN recommends that all aesthetic nurses complete a prescribing qualification, but currently, there are lots of excellent nurses who are not

Summarising the Government response

Last month’s Government statement contains a range of updates, summarised as follows:2

• The DHSC has re-emphasised its commitment to introducing a licensing scheme for non-surgical cosmetic procedures in England

• The introduction of a licensing scheme is to be delayed beyond the original deadline of July 2023

• Dermal fillers will not become classified as PODs

• Possessing the right insurance cover is crucial for aesthetic practitioners

• The Government will consider introducing premises standards for non-surgical cosmetic procedures, independent of Care Quality Commission (CQC) registration

• Nationally-recognised training standards will be considered

• Stricter regulation of medical aesthetic devices is to be considered, including extending CE certification marking recognition in the case of relevant devices

• Misleading information and false advertising of medical aesthetic procedures on social media requires attention

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
Following the UK Government’s confirmation that dermal fillers will not be prescription-only devices in England, Aesthetics reports on the industry response to this update

yet prescribers. If dermal fillers were to become PODs, it would cause stock issues that would impact day to day practice. Nurses would struggle to personalise treatment for their patients if they only had a finite amount of product on hand.”

Addressing complications

A key facet which all the association representatives feel is holding back stricter regulation surrounding dermal fillers is underreporting of complications related to aesthetic treatments.4 Currently, there is no framework requiring complications to be reported, and non-medics are not accountable for any adverse events they may cause.

The Government has acknowledged that “All cosmetic procedures have some risks. They can lead to serious complications if they’re not performed correctly and can affect an individual’s mental health if the results are not as expected.” It is currently unclear whether or not this acknowledgment will translate into the establishment of a centralised complication reporting system.

Collins points out that effective recording of aesthetic complications would include practitioners reporting incidents in which they prescribed hyaluronidase on behalf of other practitioners as well as their own complications, and the NHS recording patients reporting to GPs or A&E with aesthetics-related complaints.

Aesthetic practitioners are obliged to report any complications they cause or witness through the MHRA Yellow Card reporting system, and they should report to the product manufacturer.4,5 Advice can also be sought through associations like the Aesthetic Complications Expert (ACE) Group World,6 the Complications in Medical Aesthetics Collaborative (CMAC) or the JCCP.4

Nonetheless, Collins argues that a complete overhaul of aesthetic regulation is required to safeguard patients due to ‘under-enforcement’ of current legislation. “If you go on Instagram now,” she says, “you could find a non-medic advertising a botulinum toxin treatment and get injected that same day because legislation just isn’t enforced strongly enough. At Save Face, our experience in the sector has led us to the opinion that even if dermal fillers were to be made prescription-only, that legislation would likely be under-enforced as is the case with toxin.”

Focusing on training

The Government seems to have suggested an alternative to tighter filler regulation, in the form of more solid national training standards. The response states, “Those who offer non-surgical cosmetic procedures to the public should be suitably trained and qualified. We recognise there is a need for nationally recognised standards covering the education, training and qualifications required for the administration of non-surgical cosmetic procedures.” Indeed, Bennett agrees that standardised training should be implemented in order to ensure doctors, dentists, nurses and other medics have the necessary skills to perform cosmetic procedures. She comments, “You can’t just come out of medical school and go straight into injecting filler or toxin. You need to acquire a whole new set of skills to administer injectables safely, and that would be best controlled through standardised training that’s delivered by experienced assessors.”

However, many disagree with the fact that it appears that such training would be open to non-medics as well as medical professionals. Dr Fairris is opposed to this idea, saying “Without careful and considered implementation, we could be left in a situation where anyone who presents a certificate saying they have completed a training course could be given licence to partake in

injectable treatments without any medical experience to cope if something goes wrong. A layperson does not have the appropriate clinical knowledge or indeed the qualifications to avoid or treat adverse events like vascular occlusions.”

Moving forward

Many professionals within the aesthetics specialty feel that if meaningful change is to be brought about by the DHSC, more thorough consultation will be required. Bennett shares, “In my personal view, I hope that as the consultation progresses, a proper committee is put together with medical professionals who really understand the treatments and associated risks, rather than just laypeople or the same consultants we’ve seen before.”

Dr Fairris shares that BCAM will be working with the BACN to support the Government’s research in order to ensure that medical practitioners have a say in the legislation that is formed. As the July 2023 deadline is not to be reached, however, it is unclear how long the consultation process will take, nor indeed how long it will be until any legislative changes are introduced.

This response from the UK Government has shown that a great deal of further examination and deliberation will be required before any legislative updates are actioned. Indeed, Bennett says, “It’s good that the Government is looking at cosmetic medicine, but my fear is that a more serious consultation needs to take place before any decisions are made, looking at all the pros and cons, risks and benefits of any course of action.”

Professor Sines concludes, “Whilst there are some shortfalls in the Government’s plans that the JCCP hopes will be addressed, the Government’s commitment to tightening non-surgical aesthetic regulation is a big step in the right direction towards protecting the safety of patients seeking cosmetic treatments.”

The BACN and BCAM will be exhibiting at this year’s ACE in London on March 10-11. Scan the QR code to register to attend for free.

REFERENCES

1. House of Commons Health and Social Care Committee, The impact of body image on mental and physical health (UK: UK Parliament, 2022) <https://publications.parliament.uk/pa/cm5803/cmselect/ cmhealth/114/report.html>

2. Joint Council for Cosmetic Practitioners. ‘Press Release - The Department of Health and Social Care Response to the 2022 Select Committee Report on the Impact of Body Image on Mental and Physical Health’ (UK: JCCP, 2023).

3. Copsey M and Te Reo H. ‘Purchasing Aesthetic Injectables’ Aesthetics journal (UK: Aesthetics, 2022) <https://aestheticsjournal.com/feature/purchasing-aesthetic-injectables>

4. King M. ‘Reporting Complications in Aesthetic Practice’ Aesthetics Journal (UK: Aesthetics, 2023) <https://aestheticsjournal.com/feature/reporting-complications-in-aesthetic-practice>

5. Medicine and Healthcare products Regulatory Agency. ‘Yellow Card Reporting Site’ (UK: MHRA, 2023) <https://yellowcard.mhra.gov.uk/>

6. ACE Group World ‘Reporting a Complication’ (UK: ACE Group, 2023) <https://uk.acegroup.online/ policies/reporting-a-complication/>

7. Fox A and Wood N. ‘Government moves to bring in licensing to administer Botox and fillers’ (UK, Wales Online, 2022) <https://www.walesonline.co.uk/news/uk-news/government-moves-bringlicensing-administer-23246389>

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com

Network With Your Specialty

Discover, network and celebrate medical aesthetics at ACE 2023

We know how much the aesthetics industry values networking; connecting with peers, brands and top medical practitioners for that all-important advice on techniques, protocols or how to run a successful practice. ACE 2023 will bring you all these opportunities and more. If you are new to the world of aesthetics, this is also a great occasion to create those longstanding connections that will help you throughout your career.

Join us at ACE to experience unmissable networking opportunities alongside CPD-verified content for the complete learning and development experience.

Official Networking Drinks sponsor Hydrafacial is hosting a gathering at the end of Day 1 on March 10! After a full day of learning, relax with your colleagues and enjoy a drink with them. It’s the perfect chance to catch up on your favourite learning of the day and discuss which sessions you found most beneficial. Lauren Gibson, Hydrafacial country manager UK&I, commented, “ACE 2023 is the event of the year for aesthetic professionals, and we couldn’t be more delighted to announce Hydrafacial as the Networking Drinks Sponsor. As a brand we support collaboration in the industry, and networking with other industry

professionals is key to staying informed and innovative.” Head to the Hydrafacial stand C3 at 17:00!

NEW In Practice Zone & drinks reception

New for this year is The In Practice Zone, where business gurus will provide you with their top tips and tricks for success, as well as new ideas and solutions to grow your practice. You can delve into first-class educational content all around your favourite business topics in the In Practice Theatre, sponsored by PLIM, as well as discovering all the companies, products and support services which can help make your life easier in clinic and drive your business forward. The companies which will welcome you into the In Practice drinks are:

• AesthetiDocs

• Aesthetic Nurse Software

• e-clinic

• Enhance Insurance

• Hamilton Fraser

• InDesk

• Inspire to Outstand

• MeTime

• PLIM

• Web Marketing Clinic

Shannon Kilgariff, editor and content manager of Aesthetics and curator of the In Practice Theatre, commented, “While practitioners excel in clinical techniques and theory, often they need a lot more support when it comes

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
Networking Drinks sponsored by Hydrafacial

to running a successful business. That’s why this year at ACE 2023, we are hosting the In Practice Networking Drinks, so visitors can connect with the best in business and like-minded colleagues over a glass of bubbly.” To attend the free drinks, make sure you head over to the In Practice Zone at 16:30 on March 10!

Enjoy an exclusive VIP experience with HA-Derma

HA-Derma will be returning as the ACE VIP Lounge sponsor, to offer speakers and Aesthetics Awards Judges and Finalists an exclusive area to network throughout the two days. VIPs can enjoy complimentary refreshments and a cocktail happy hour with peers and colleagues.

HA-Derma is hosting a session in the

Brand NEW event app for 2023!

The ACE event app will contain everything you need from the full conference programme and interactive floorplan to an option to prearrange meetings, as well as to favourite sessions and exhibitors to create your own schedule. These features will ensure your time out of the clinic is maximised and you build those all-important connections.

DOWNLOAD THE APP HERE TO GET PLANNING!

Innovation Stage – HA-DERMA: The Key Factors of Successful Integration of Profhilo® Into Your Clinic with Julie Scott on 11 March at 12:00.

Dedicated networking opportunities & product launches

Walk the show floor to discover the industry’s most respected manufacturers, suppliers and brands. There will be plenty of opportunities to network and find out all about the products and services that can benefit your clinic. There will be endless stand demos, drinks, treats, activities and competitions happening over the two days. Exclusive product launches happening at ACE include:

• BTL Aesthetics: EMFACE muscle stimulating device – Stand L11

• Church Pharmacy: Yvoire Y-Solutions 720 dermal filler – Stand E1

• Croma Pharma: Detox face mask and new injectable – Stand C1

• Galderma: First-ever launch of a liquid toxin in the UK – Stand E3

• SkinCeuticals: A.G.E Interrupter Advanced cream – Stand E4

ACE is also supported by associations including ACE Group World, BACN, BCAM, and other trusted industry partners to ensure we always promote best practice and betterment within the aesthetics industry. Situated on stands around the show floor, be sure to drop in and chat with reps or arrange a coffee with them via the app, to ensure that your clinic is meeting the highest industry standards.

Celebrate with top practitioners at The Aesthetics Awards

Join the aesthetics community on March 11 for the biggest night in the calendar. Network with Judges, Finalists and the specialty’s elite as you enjoy a glorious evening of fun, dancing and celebration with your friends, colleagues, and team. Tickets are now sold out, but follow us on social @aestheticsjournaluk from 21:00 on March 11 to catch the live results as the Winners are revealed. Get involved by commenting on our posts and sending us your live reactions!

Remember to look out for the ACE Agenda at a Glance leaflet in this issue to start planning your CPD-approved learning experience. We can’t wait to see you all there!

Register FREE now

Headline Sponsor

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com

CUTTINGEDGE KOREAN AESTHETICS

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Opening an Aesthetic Clinic

Practitioners and business owners discuss their experiences of opening a new aesthetic clinic and provide advice for starting out

After working in aesthetics for several years, you may decide to take the next step in your career – opening your own premises. While this could be the end goal for a lot of you, it might be hard to know exactly how to get there or where to begin.

To help you navigate this, we spoke to practitioners and business owners to get their advice on how you can get started on planning your own clinic, as well as how to face any potential challenges that might present along the way.

All clinics mentioned in this article are Finalists at this year’s Aesthetics Awards, symbolising their success as business owners and their commitment to excellence in customer service, patient care and patient safety.

Taking the leap

Nurse prescriber Julie Scott started out in aesthetics in 2003, and nine years ago, she decided to make the move to open her own practice in Essex. She explains, “I opened my clinic to be autonomous and have something to put my name to. At this point in my career, I wanted to be able to create the exact environment I wanted my patients to have treatments in. I wanted to control the look and feel of it, and to see all my patients in one place.”

Aesthetic practitioner Dr Wassim Taktouk notes that opening his own clinic was always part of the plan, but he needed to wait for the right time. He explains, “I wanted to do things my way and the only way that could happen would be to have my name on the door. My biggest fear was that if I acted too early, I would be sitting around in an empty clinic waiting for the phone to ring. That’s why I waited until I had built a sufficient patient database and I knew I could fill every appointment every day of the week. I waited 11 years before taking the step. We finally opened in London in 2021.”

Nurse prescriber Frances Turner Traill opened her first clinic in Inverness in 2008 after working for two cosmetic clinic companies and a private hospital. “The reason for opening was my eagerness and passion to really take my medical aesthetics experience to the next level. That and the immediate demand for my services,” she says. Co-founder and business director Ali Shah opened Dr Sobia Medispa in 2017 alongside his wife Dr Sobia Syed. He notes that after Dr Syed completed her aesthetics training, she hired space in another practice before deciding to take the next step. “As a practitioner, after completing your training and building up your skills, it

can be hard to know where to go next, but we didn’t want to rush it. Dr Syed wanted to make sure she had perfected her skills and expertise and built up a patient base before we took the leap together and opened up a business.” It’s important to note that many employers do not permit the transfer of patients when one of their staff members leave. This is usually clearly stated in the employee’s contract. This doesn’t usually relate to practitioners who are working under their own business and are hiring their own treatment room in a clinic.

Starting out

Shah notes that it took a few years for him and Dr Syed to feel ready to take the step to expand and open a dedicated clinic. He explains, “It’s important to remember that opening a clinic isn’t something you can do quickly or easily – it took us a few years to feel completely safe to do so. As a practitioner, the main thing you should focus on when you start out in your career is creating good results and keeping patients safe. When you do this, you’ll get patients who book in for repeat treatments and refer you to friends and family. We also used social media and had a distinct marketing strategy as a tool to create awareness.” He adds that gradually Dr Syed built up enough loyal patients for them to feel they could comfortably open a clinic and have a steady stream of patients and income.

Shah adds that completing thorough market research is essential to find the correct geographic location and premises and have the appropriate treatment menu. He explains, “Prior to opening the clinic

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
Figure 1: Dr Sobia Medispa clinic. Images courtesy of Ali Shah

Welcome to the future of Hybrid Injectables

HArmonyCa™ is a Hybrid Injectable that combines hyaluronic acid (HA) with calcium hydroxyapatite (CaHA), which may give your patients the benefits of an immediate lift effect from HA and sustained collagen stimulation associated with CaHA, for a new way to facial harmony.1–3,*,†

Produced and funded by Allergan Aesthetics, an AbbVie company. Please see HArmonyCa™ IFU for the full list of contraindications, warnings and precautions.1

* Results from a pre-clinical animal study of HArmonyCa™ with results demonstrated over 12 weeks.2 † Results from a pre-clinical animal study of HArmonyCa™ with results demonstrated over 8 weeks.3 HArmonyCa™ Lidocaine is referred to as HArmonyCa™. HArmonyCa™ is a dermal filler intended for facial soft tissue augmentation and should be injected into the deep dermal and sub-dermal layers.1

For use in patients ≥ 18 years old only. ©AbbVie 2023. All rights reserved.

Adverse events should be reported.

Reporting forms and information can be found at:

UK adverse events reporting https://yellowcard.mhra.gov.uk/

Adverse events should also be reported to Allergan Ltd.

UK_medinfo@allergan.com or 01628 494026

Irish adverse events reporting https://www.hpra.ie

Adverse events should also be reported to Allergan Ltd.

UK_medinfo@allergan.com or 01628 494026

FOR HEALTHCARE PROFESSIONALS ONLY
UK-HAR-230011 February 2023
Lidocaine
M032 V01.
2. Allergan Aesthetics.
INT-HAR-2150036. HArmonyCa™ Lidocaine. Lift capacity. Jul 2021. 3. Allergan Aesthetics.
INT-HAR-2150040. HArmonyCa™ Lidocaine. Collagen stimulation. Jul 2021.
References 1. Allergan Aesthetics. HArmonyCa™
IFU.
2021.
Data on File.
Data on File.
Model has not been treated with HArmonyCa™

we looked into some key aspects such as demographic and average treatment spend, as well as competitor analysis. The area we ended up opening the clinic in had a lack of reputable aesthetic clinics, so there was a real gap in the market and the consumer need was there. We spoke to our own patient base to find out what people really wanted from us, so that we could design our products, services and premises with safety and the patient journey in mind.”

Scott advises that the first step when looking for your premises should be to consider carefully whether you want to be visible (such as on a high street) or very discreet, and whether you can make this environment accessible and safe for patients. On the interior of the clinic, she notes, “When deciding on furniture and equipment, consider what you can get second-hand and what you need to invest in new. For example, my couch and product shelves (actually most of my furniture) were second-hand when I opened, but I invested in a bright, high-quality clinical lamp and a new fridge.” She also recommends getting a customer relationship management (CRM) system from the beginning.1 She explains, “You will need it down the line to track patient notes, and it is a hassle to transfer from paper. Set up something like call answering to help you work independently so you don’t miss enquiries when you’re treating. And of course, it’s imperative to create an online presence (social media and your website – you will need both and shouldn’t have just one) that matches your in-clinic environment.”

Dr Taktouk says that when starting out, he knew to ensure that he had a competent and reliable team to accompany him on the journey. He also notes that his initial focus was on establishing a strong brand identity to help him stand out from the competition. “Making an impact in a market that was already overcrowded and competitive was always in the back of my mind,” he says.

Turner Traill agrees on the importance of hiring the right people, noting, “Having your own clinic allows financial freedom, but can also be your greatest burden and worry, especially if you become unwell or need time off. You must build a great team around you – you need to remember that a wheel does not turn on its own.”

Turner Traill also advises solidifying your unique selling point before you commit to opening your business. She notes, “Whilst the start-up process for both of my clinics differed significantly, the most important thing I learnt is to pay attention to demand. The ‘build and they will come’ era has gone now, and medical aesthetics is in a period of consolidation whereby we are drilling down our niche and specialty skills with our team across our two sites.”

Facing challenges

Dr Taktouk outlines that becoming completely independent was a difficulty for him in the early stages. He explains, “Adapting to my new role as a leader presented its own unique challenges. In the early

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
“Don’t feel like you have to make your own policies and procedures from scratch –you can use templates from complication groups and other organisations which will help massively”
Julie Scott
Figure 2: Taktouk clinic. Image courtesy of Dr Wassim Taktouk Figure 3: Facial Aesthetics Clinic. Image courtesy of Julie Scott

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stages of the business, I was a solo operator and had to fill numerous roles by myself, including those of a doctor, accountant, receptionist, manager and marketer, which was a demanding and tiring experience. Furthermore, it was difficult to delegate tasks once I had grown accustomed to handling everything myself, particularly when I am a person who likes to maintain control.”

Scott found that her biggest challenge when opening her practice was the shift to working independently and having to constantly motivate herself to be proactive. She notes, “I overcame this by creating a network and not allowing myself to get isolated. I attended study days, was active in attending my regional British Association of Cosmetic Nurses meetings, attended all the conferences such as ACE and CCR and got myself out there and built connections.” Scott adds that building this support system was crucial for helping to tackle any anxiety about opening her business, and also the worry of how many patients would come through the door.

Turner Traill says that she found the switch between the NHS and aesthetics the most challenging part of becoming a business owner, specifically in terms of finance. She explains, “The most difficult hurdle for me to overcome at the outset was charging for my services after decades of working in the NHS. As practitioners, we manage expectations, laying down strong foundations and planning outcomes. Equal balance of these two approaches (financial and duty of care) is what has led to success in my own experience.”

Medical vs. cosmetic clinics

Another key thing to remember when opening a clinic is whether you will need to become registered with a clinic regulator. It’s obligatory for aesthetic doctors/nurses/dentists in Scotland to practise in a clinic registered with Healthcare Improvement Scotland.2 It is currently voluntary for clinics in England, Wales and Northern Ireland to register for the Care Quality Commission, Healthcare Inspectorate Wales, and the Regulation and Quality Improvement Authority, unless they are performing what are defined as ‘medical treatments’. Some of these include:3

Shah and Dr Syed found working with external parties slightly challenging, such as builders or designers. He notes, “To combat this, make sure you go into it with a completely clear vision of exactly what you want and make sure you constantly have safety and the patient journey in the back of your mind when doing so. That way, it will be clearer for everyone else you’re working with too.”

Opening another premises

Turner Traill opened her second clinic in 2014, a much larger five-room space, with her husband as the chief financial officer. On her decision to expand the business, she notes, “The first clinic was very entrepreneurial in spirit; I had a new service to offer and simply wanted to deliver it to the very best of my abilities. The second clinic was far more strategic in planning with feasibility studies and

1. Treatment of disease, disorder or injury

2. Surgical procedures

3. Diagnostic and screening procedures

4. Services in slimming clinics

5. Threads

In an aesthetic setting, point number one could relate to the following: dermatological conditions, bruxism, migraines, psychological distress from appearance (face or body) such as scars and transgender concerns.3 Therefore, those seeking to open their own clinics should ensure they meet regulatory conditions and factor in the time and commitment to facilitate this.

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
“The ‘build and they will come’ era has gone now, and medical aesthetics is in a period of consolidation whereby we are drilling down our niche and specialty skills”
Frances Turner Traill
Figure 4: FTT Skin Clinics. Image courtesy of Frances Turner Traill

go go go

Letybo® brings practitioners a new option to the current aesthetic market and provides aesthetic professionals and their patients with a notable efficacy and confirmed tolerability.

1. Mueller DS, Prinz V, Adelglass J, Cox SE, Gold M, Kaufman-Janette J et al. Efficacy and Safety of Letibotulinum Toxin A in the Treatment of Glabellar Lines: A Randomized, Double-blind, Multicenter, Placebo-controlled Phase 3 Study. Aesthet Surg J. 2022; 42(6): 677- 88. ; 2. Letybo® smPC, https://www.medicines.org.uk/emc/product/13707 2022

Undesirable

effects:

new ways ADLET0822UKf (QR: VID2LET0822UK) Date of preparation: August 2022
1,2,*
*Letybo® is indicated for the temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows in adults <75 years old seen at maximum frown (glabellar lines), when the severity of the facial lines has an important psychological impact. **Response rate was defined as a ≥ 1-point reduction in FWS at maximum frown based on the investigators assessment. References:
Most
SmPC. Legal Category: POM; Pack size: Packs containing 1 5ml vial. Multipack containing 2 (2 packs of 1) vials; Price list: UK - 1x5ml: 65GBP, 2x5ml: 120GBP; MA Number: PL 29863/0002; PA Number: PA0846/001/001; MA Holder: Croma-Pharma GmbH, Industriezeile 6, 2100 Leobendorf, Austria; Date of preparation: 11/04/2022; Unique ID no CRP001/001; Adverse events should be reported. Reporting forms and information can be found at: UK - http://yellowcard.mhra.gov.uk/ or search for MHRA Yellow Card in the Google Play or Apple App Store. IE - HPRA Pharmacovigilance Website: www.hpra.ie. Adverse events should also be reported to Croma Pharma GmbH on 0118 206 6513 94% response rate 4 weeks post injection 1,** Demonstrated high patient satisfaction2 Proven consistent effi cacy and tolerability with repeated injections for up to 12 months 1,2 Scan for Reconstitution Instructions Finalist
Letybo 50 units powder for solution for injection; Abbreviated Prescribing Information: Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: One vial contains 50 units botulinum toxin type A produced by Clostridium botulinum. After reconstitution each 0.1 mL of the solution contains 4 units. Indication: For the temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows in adults <75 years old seen at maximum frown (glabellar lines), when the severity of the facial lines has an important psychological impact. Dosage and administration: Should only be administered by physicians with expertise in this treatment. Posology: The recommended dose is a total of 20 units divided into five injections of 4 units (0.1 mL) each: 2 injections in each corrugator supercilii muscle and 1 injection in the procerus muscle. Botulinum toxin units are not interchangeable from one product to another. Doses recommended are different from other botulinum toxin preparations. Treatment interval should not be more frequent than every three months. In the absence of any undesirable effects secondary to the previous treatment session, a further treatment session with at least a three-month interval between the treatment sessions is possible. The efficacy and safety of repeat injections beyond 12 months has not been evaluated. Special populations: No specific dose adjustment is required for use in the elderly older than 65 years of age. Letybo is contraindicated in patients 75 years or older. There is no relevant use in the paediatric population. Method of administration: Intramuscular use. Care should be taken to ensure that Letybo is not injected into a blood vessel. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome, amyotrophic lateral sclerosis). Presence of acute infection or inflammation at the proposed injection sites. Patients with bleeding disorders. Warnings and Precautions: Injection into vulnerable anatomic structures must be avoided. Avoid use when the muscle shows excessive weakness or atrophy. Risk of eyelid ptosis following treatment. Procedurerelated events: Needle-related pain and/or anxiety have resulted in vasovagal responses, including transient symptomatic hypotension and syncope after treatment with other botulinum toxins. Pre-existing neuromuscular disorders: Patients with unrecognised neuromuscular disorders may be at increased risk of clinically significant systemic effects including severe dysphagia and respiratory compromise from typical doses of botulinum toxin type A. Hypersensitivity reactions: An anaphylactic reaction may occur after injection of botulinum toxin. Epinephrine (adrenaline) or any other anti-anaphylactic measures should therefore be available. Local or distant spread of toxin effects: Adverse reactions possibly related to the spread of toxin distant from the site of administration have been reported. Patients may experience exaggerated muscle weakness. Swallowing and breathing difficulties are serious and can result in death. Use not recommended in patients with a history of dysphagia and aspiration. Patients should be advised to seek immediate medical care if swallowing, speech or respiratory disorders arise. Pregnancy & Lactation: Not recommended during pregnancy or lactation and in women of childbearing potential not using contraception.
common effects are headache and injection site reaction. Very rarely aspirational pneumonia. For full list of side effects, consult
2023

projections, most likely because of my husband’s analytical skills and having a greater understanding of the business side of things.”

Turner Traill says that the main consideration for her when opening a second clinic was geographical location. She explains, “I had a wide database covering Scotland. I chose the clinics wisely, both premises serve all major motorway and transport links. I find that city centre clinics are not always easy to get to and accessible for parking, which is why I chose the building that I did. My Hamilton clinic was previously a hairdressing salon, which saw people traveling from across a very large area, so I knew in terms of access it would work.”

Considering outsourcing

Opening your own clinic can be quite a task, but there are many elements that you can outsource to other professionals if you find you can’t do it on your own. Scott states, “I’m someone that is a control freak and I like to keep as much as I can in-house, because I don’t think anyone can understand my business quite like I can. However, if you don’t have a team, you can outsource tasks like social media if you are incredibly involved in your message, as well as web design/SEO if that’s not your strong suit. I’d also recommend sourcing an accountant who understands VAT in aesthetics, as that’s something we haven’t learnt before. Also, don’t feel like you have to make your own policies and procedures from scratch – you can use templates from complication groups and other organisations which will help massively.”

Shah explains that the combination of his business acumen and Dr Syed’s clinical knowledge and NHS experience helped Dr Sobia Medispa succeed, and he recommends that practitioners source external business help should this not be within their skillset. He says, “Medics want to deliver the results and the treatments, but often they are not business minded because they have not had the training. By working alongside someone who has this knowledge and can explain business strategies to you, it will help cause less confusion and stress in the long run.” You can read more about how you can implement external help in our article on Utilising Outsourcing.4

Maintaining success

Dr Taktouk states that in order to maintain success, he prioritises transparency and authenticity. He says, “I only endorse products or services that I believe in. Additionally, I establish realistic expectations for my patients. Cultivating a workplace culture without egos was crucial to me, and fostering an environment where we all support each other and work together collaboratively is the ultimate definition of success in my view.”

Scott says that your ultimate goal as a practitioner should be to provide your patients with the best possible service you could imagine. She explains, “Take pride in your environment and make it special for patients every time they visit. Make sure that how you speak to your patients through your website and social media reflects how you act when they walk through your door. You need to never sit back on your laurels, and never let your ego get in the way – be kind, generous and genuine. And lastly, to maintain success I think it’s so important to have a go-to person in the industry who has your back – a mentor or valued colleague or friend – for when you need bolstering and support, and you can do the same for them.” While opening your own clinic can have tremendous benefits, Scott advises practitioners not to rush into the decision too quickly. She notes, “It’s not for everyone to have their own clinic. I urge people in the early days not to get into a huge investment so quickly. Some practitioners will also want to walk away and not have the stress of running their own clinic, and that’s ok too! You can still be hugely successful this way. Success isn’t defined by having a clinic – I know practitioners who travel to other clinics to practise and do brilliantly. I wouldn’t do it any other way, but there’s more than one way to define success.”

The In Practice Zone at ACE 2023 has all the products, services and companies you need to start building a successful business. Make sure to attend the talks, as well as the In Practice networking drinks on March 10 at 4:30pm to get their advice! Scan the QR code to register for free.

REFERENCES

1. Aesthetics journal, Electronic Record Keeping in Aesthetic Clinics, 2015, <https://aestheticsjournal. com/feature/electronic-record-keeping-in-aesthetic-clinics>

2. Health Improvement Scotland, Regulation of Independent Clinics, 2016, <https://www. healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/independent_ healthcare/regulation_of_clinics.aspx>

3. Julia Sevi, Tips for CQC Success, 2015 <https://aestheticsjournal.com/feature/tips-for-cqc-success>

4. Stuart Rose, Utilising Outsourcing, 2022, <https://aestheticsjournal.com/feature/utilising-outsourcing>

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
Figure 5: Facial Aesthetics Clinic. Image courtesy of Julie Scott

C+ Correcting Complex 30%™

As seen in this issue of Aesthetics Journal

Controls Melanin Production

24%

Reduction in melanin production compared to untreated tissue(1)

Protects against Blue Light (High-Energy Visible Light) induced oxidative stress

82%

Protection from reactive Oxygen Species induced by High-Energy Visible Light(2)

Reduces formation of free radicals after environmental exposure

89%

81%

Reduction in Reactive Oxygen Species after 3 hours of exposure to Urban Dust (pollution e.g. exhaust particulates)(3)

Reduction in Lipid Peroxidation(3)

Revision Skincare® was founded to change the way professional skincare results are achieved.

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References:

1. In vitro method to assess the ability of the C+ Correcting Complex 30%TM product to reduce melanin production in MelanoDermTM 3D in vitro co-culture skin model after 14 days. Zahr, A; Kononov, T. (2019). Efficacy and Tolerability of a Novel Antioxidant formulation containing 30 (w/w)% of Tetrahexyldecyl Ascorbate, a lipid-soluble form of Vitamin C. Poster exhibited at: American Academy of Dermatology (AAD) Annual Meeting; March 1-5 2019; Washington, DC. Results may vary.

2. In vitro MatTekTM EpiDermTM tissues were used as a model to assess the ability of the C+ Correcting Complex 30%TM product in protecting against HEV light induced Reactive Oxygen Species (ROS). Zahr, A; Kononov, T. (2019). Efficacy and Tolerability of a Novel Antioxidant formulation containing 30 (w/w)% of Tetrahexyldecyl Ascorbate, a lipid-soluble form of Vitamin C. Poster exhibited at: American Academy of Dermatology (AAD) Annual Meeting; March 1-5 2019; Washington, DC. Results may vary.

3. In vitro assay using HEKn to assess the ability of the MelaPATH® Technology to reduce Urban Dust (NIST® SRM® 1649b) induced intracellular Reactive Oxygen Species (ROS) and Lipid Peroxidation. Data on file. Results may vary.

Understanding Vitamin C

Pharmacist Balsam Alabassi analyses the use of vitamin C in skincare and the benefits of different formulations

As we age, the skin undergoes many changes, including fine lines and wrinkles, pigmentation, laxity and texture. Both intrinsic and extrinsic factors play a vital role in the ageing process where external ageing is mostly attributed to ultraviolet (UV) radiation through the action of free radicals.1 Vitamin C is a powerful ingredient in mitigating these changes.2-4

Antiageing properties

Vitamin C plays a vital role in the delay of premature skin ageing, decreasing UV-induced sun damage and age spots, promoting collagen synthesis and improving the appearance of fine lines and wrinkles, as well as acne.5 Vitamin C functions as a co-factor for the enzymes prolysyl and lysyl hydroxylase – the enzymes that are responsible for stabilising and cross-linking the collagen molecules. In addition, it stimulates lipid peroxidation, leading to the formation of malondialdehyde, which in turn stimulates collagen gene expression.6

Levels of vitamin C have been shown to be lower in those with aged or photodamaged skin.7 Vitamin C also functions as a co-factor for proline and lysine hydroxylases that stabilise the collagen molecule and promote expression of collagen genes, therefore serving as a powerful stimulator of collagen and elastin production to make it a valuable antiageing ingredient.8 In addition, vitamin C chelates copper ions which serve as enzymatic co-factors for tyrosinase and may play a role in the inhibition of melanogenesis.9 It also aids in wound healing due to

its co-factor activity for the synthesis of collagen where impaired wound healing is an indicator of low vitamin C levels.7

Protection against UV damage

Vitamin C serves to protect the skin against UV-induced free radicals. Free radicals are atoms that are missing an electron in their outer shell.10 They behave as scavengers, hunting for their much-needed electron from the skin, leading to subsequent damage. Vitamin C exerts its antioxidant function by readily donating its electron to the free radical, thereby sparing the skin from free radical damage.7 The reactive oxygen species also initiate the signal transduction cascade, leading to the upregulation of protein-1 (AP-1) and nuclear factor-B, while downregulating the transforming factor which subsequently upregulates matrix metalloproteinases (MMPs) to induce in collagen degradation.11

This is coupled with an increase in elastin accumulation, leading to the formation of wrinkles, photodamage, hyperpigmentation, telangiectasias, solar elastosis and textural changes.4

It has been shown that vitamin C may inhibit the activation of AP-1 to reduce MMP formation, sparing collagen from being damaged.7 UV radiation has also been implicated in the formation of oedema and hyperpermeability, which are associated with overexpression of vascular endothelia growth factor (VEGF).9

Vitamin C may also have a role in targeting the vascular component of melasma as it possesses an anti-angiogenic effect, as well as regulating the expression of VEGF, which is the main regulator of physiological and pathological angiogenesis. This is a crucial function as VEGF overexpression has been linked to skin inflammation, psoriasis, phototoxicity and even skin cancer.9

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
Figure 1: Electron transfer from the antioxidant to the free radical, sparing the skin from free radical damage Antioxidant Electron Transfer Free Radical
For vitamin C to be effective, the concentration must be higher than 8%

So, it stands to reason that many skincare experts advise applying vitamin C prior to sunscreens. This combination creates a powerhouse of protection against UV radiation as sunscreens do not totally block free radicals produced by UV exposure.12

Skin lightening properties

Vitamin C inhibits the action of tyrosinase enzymes that is responsible for the conversion of tyrosine into melanin, resulting in a decrease in melanin production through the interaction with copper ions at the tyrosinase-active sites.4

Tyrosinase is a copper-containing glycoprotein that serves as an enzyme. It is crucial for melanin biosynthesis in melanosomes.

Vitamin C interacts with copper ions at tyrosinase-active sites, thereby reducing the action of tyrosinase responsible for the conversion of tyrosine to melanin, which in turn results in diminished melanin formation.13

Vitamin E replenishment

Vitamin C is instrumental in the replacement of vitamin E – a much-needed lipophilic antioxidant that serves to protect the cell membranes against oxidative stress while maintaining balanced

collagen infrastructure in the skin.14 The role of vitamin C is to protect against oxidative stress cellular damage by scavenging reactive oxygen species. Vitamin C regenerates the antioxidant form of vitamin E by reducing the tocopheroxyl radicals, thereby protecting the cell membranes from free radical damage.14

Vitamin C formulations

A number of formulations including modified derivatives of vitamin C have been developed in order to achieve stability, absorption and potentiate action of this crucial antioxidant, because healthy skin requires both water- and lipid-soluble nutrient components, including hydrophilic and lipophilic antioxidants.1

Other antioxidants

Formulating vitamin C with other antioxidants such as vitamin E has been shown to increase the potency of vitamin C, as well as influence its stability.1 Vitamin C can also aid in regenerating vitamin E, which is lipophilic in nature.15 The combination of the two vitamins results in a synergistic effect, thereby protecting the hydrophilic and lipophilic compartments of the cell, leading to synergic protection against UV damage. Furthermore, combining vitamin C and vitamin E with ferulic acid, which is also a powerful antioxidant, enhances the formulation.12

On the other hand, derivatives of ascorbic acid such as magnesium ascorbyl phosphate, ascorbyl-6-palmitate and dehydroascorbic acid are stable at a neutral pH and have been shown to play a comprehensive role in skincare formulations. Despite their numerous antioxidant benefits, they have not been shown to increase levels of L-ascorbic acid in the skin.16

L-ascorbic acid

L-ascorbic acid is a water-soluble molecule that is highly unstable and does not effectively penetrate the skin.17 However, formulating L-ascorbic acid at pH levels below 3.5 through various methods enhances both skin stability and penetration.13 Experiments on this were conducted in white Yorkshire pigs. The skin was shaved with an electric shaver 24 hours before the experiment began, to allow healing of any skin nicks. Experiments were performed under controlled conditions. Results showed that 15% formulations of L-ascorbic acid were tested at pH levels between 2.0 and 5.0. Tissue levels of L-ascorbic acid were enhanced only at formulation pH levels less than 3.5. The study demonstrates the critical importance of formulation pH for percutaneous absorption of L-ascorbic acid. Low pH is essential for enhanced absorption and delivery of L-ascorbic acid.13 Although L-ascorbic acid’s derivatives have demonstrated antioxidant activity, it is L-ascorbic acid itself that has been shown to have the most effective antioxidant action to influence changes of transdermal epidermal water loss.16

Vitamin C derivatives, on the other hand, have been shown to influence the viscoelastic to elastic ratio, therefore implying that their role may impact the deeper skin layers to influence collagen function, supporting the cutaneous structures.16 Encapsulating L-ascorbic in a lipid soluble sphere may aid its absorption deeper into the skin. The transdermal delivery of topical L-ascorbic acid

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
6 hours 24 hours % Penetration % Penetration 30% THD ascorbate 11% 15% 20% L-ascorbic acid 0.1% 0.1%
Table 1: Comparative absorption of THD ascorbate and L-ascorbic acid into the skin with time intervals of six to 24 hours18
Although L-ascorbic acid’s derivatives have demonstrated antioxidant activity, it is L-ascorbic acid itself that has been shown to have the most effective antioxidant action

into the skin is directly dependent on formulation. For vitamin C to be effective, the concentration must be higher than 8%.18 Formulations of 20% and above have been proven to be effective, however, they have their limitations as they may induce skin irritation.12,13

The barriers of L-ascorbic acid

The challenges facing the use of L-ascorbic acid are mainly related to the stability of the molecule. Penetration into the lipid barrier of the skin is limited due to its water-soluble hydrophilic properties, which is repelled by the stratum corneum. Increasing the acidity of the formulation can overcome this limitation, which may be at the expense of skin irritation.19 High doses of L-ascorbic acid are needed to induce an anti-angiogenic effect, as well as to regulate the expression of VEGF which may aid in targeting the vascular components of melasma. However, using a high concentration of L-ascorbic may induce skin irritation.9

Despite the potential effectiveness in the treatment of melasma, L-ascorbic acid has poor penetration into the skin due to its hydrophilic properties.12 It has been shown that lowering the pH can enhance absorption. However, repeated use of formulations with a pH of less than 3.5 may lead to skin irritation, burning and local inflammation.13

Furthermore, L-ascorbic acid has the potential to generate a more persistent reactive oxygen species such as hydrogen peroxide H2O2, potentially rendering it as a pro-oxidant.20

Tetrahexyldecyl ascorbate

Tetrahexyldecyl ascorbate (THD) is a lipid-soluble ester and may behave as a precursor of L-ascorbic acid. It has been evidenced that THD undergoes enzymatic conversion to L-ascorbic acid, with better stability and the ability to penetrate the skin’s lipid outer layer to decrease sun damage, wrinkle formation and hyperpigmentation.20 These attributes make THD a popular ingredient in the skincare market, compared to other vitamin C derivatives.20 In addition, the ability of THD to efficiently penetrate the skin and convert to L-ascorbic acid provides a more efficient antioxidant profile to manage the vascular component in the reduction of melasma.9 THD has been demonstrated to have some limitations with regards to its stability, as its stability and transdermal penetration may possibly be compromised by the oxidant-rich environment of the skin. Therefore, despite its promising potential, it provides inadequate antioxidant protection when it is rapidly exposed to free radicals.20 Due to interest in the attributes of THD, much work has gone into finding a way to formulate it in a more effective way to benefit the skin. It has been shown that applying a synergistic approach by incorporating acetyl zingerone (AZ) in THD formulations has the ability to physically quench and neutralise free radicals. This may lengthen the half-life of THD and hinder the production of hydrogen peroxide, which is generated as a biproduct of the interaction of the ascorbic acid derivative and the free radical.20

Combining THD with AZ has been shown to diminish MMP enzyme action and increase the production of collagen through dermal fibroblast.20 Although THD decreased oxidative stress action on keratinocytes, the combination of THD with AZ abolished it.19

In 2019, scientific researchers Dr Alisar Zahr and Dr Tatiana Kononov explored such formulations. Their findings have shown that THD ascorbate penetrated the skin after six to 24 hours compared to L-ascorbic acid at 20% at pH <3.5.19

There was 82% more protection against free radical damage induced by high energy visible light (blue light) during a 120-minute exposure. In addition, there was a 24% reduction in melanin suppression.19

Their study also demonstrated that this formulation improved the integrity of the skin, including the epidermis, dermal-epidermal junction (DEJ) and the dermis. This study has shown that this formulation increased the production of collagen four-fold compared to a placebo, and also showed a significant decline in wrinkle depth. Despite its high concentration, the formulation was well tolerated throughout the duration of the study.19

Most antioxidants scavenge or neutralise free radicals so they cannot continue to break down cellular structures such as lipids, proteins and DNA. This is apparent with formulations that contain vitamin C and vitamin E. However, there are preparations with THD which do not contain vitamin E. This is due to THD’s lipophilic nature that does not require vitamin E to stabilise or facilitate its penetration into the skin.21

These preparations have also achieved THD stability by incorporating acetyl zingerone, which is a derivative of the phytochemical zingerone from zingiber officinale (ginger). It has been shown that antioxidant acetyl zingerone neutralises and quenches free radicals and chelates metals, leading to the improvement of wrinkle appearance, redness, pigmentation and photoageing, in addition to being microbiome friendly.9 These preparations are also formulated with a pH of 4.5 to 5.5, targeting the skin’s neutral pH of 4.7-5.2. Due

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
It has been shown that vitamin C may inhibit the activation of AP-1 to reduce MMP formation, sparing collagen from being damaged

Dr David Eccleston Sebastian Cotofana M.D., Ph.D*

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to the lipophilic nature of THD, pH does not serve as the rate limiting step. Therefore, no pH adjustments of <3.5 are needed to achieve stability and efficiency.16 Achieving formulations with near to neutral pH can harmonise with the skin’s microbiome to minimise irritation, which subsequently may create micro tears in the skin, leading to inflammation.21

Incorporating sodium carboxymethyl beta-glucan – a prebiotic composed of glucan isolated from the cell wall of baker’s yeast, which is a beta-(1-3)-linked polyglucose belonging to a class of compounds known as biological response modifiers – has been shown to protect the skin from oxidative stress, boost hydration and speed up skin recovery.21

Formulating a blend containing 30% (weight per weight) of the lipid-soluble form of vitamin C, THD, acetyl zingerone, hydrolysed eruca sativa leaf and plantago lanceolata leaf extract work well synergistically to target multiple pathways within the skin to provide antioxidant protection.10

Consider packaging

When formulating vitamin C in skincare, careful consideration of the packaging is needed. L-ascorbic acid is a highly unstable molecule. Many factors can impact on its stability, including air, light and heat, to name a few. Ideal packaging to preserve the integrity of vitamin C should be dark, opaque and in an air-tight pump dispenser to deliver a fresh dose of vitamin C with each application.17

Prioritising active ingredients

The role of vitamin C and its application in the field of dermatology and skin health is vast. Vitamin C has become a staple in the skincare capsule wardrobe. Topical vitamin C is a multitasking antioxidant that plays an integral role in targeting photodamage, collagen production, wound healing, pigmentation and much more to aid skin health.7 Nevertheless, it is important to distinguish between the various formulations of vitamin C, as not all preparations have equal or comparable effects.

Balsam Alabassi is the founder of DermRefine Skin Clinic based in Mayfair London. She is a university graduate of Pharmacology and Pharmacy with more than 20 years’ healthcare experience in both community and hospital settings.

Qual: Bsc, MPharm, PG Cert IP

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Test your knowledge!

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

Possible answers

Questions

1. Vitamin C plays a role in targeting the vascular component of melasma due to:

2. Vitamin C inhibits the following enzymes:

3. An example of a vitamin C derivative is:

4. Tetrahexyldecyl ascorbate (THD) if described as:

5. The stability of Tetrahexyldecyl ascorbate (THD) is enhanced by combining it with:

REFERENCES

a. Vasoconstriction effect

b. Thermodynamic effect

c. Angiogenic effect

d. Antiplatet effect

a. Lipase

b. Amylase

c. Aldehyde dehydrogenase

d. Tyrosinase

a. Ascorbyl -6-palimitate

b. Sodium hyaluronate

c. Retinyl palmitate

d. N-Acetyl cystine

a. Water soluble ester

b. Lipid soluble ester

c. Acid soluble ester

d. Alkaline soluble ester

a. Cetyl acetone

b. Acetyl salicylate

c. Acetyl zingerone

d. Acetyl hexapeptide-3

Answers: C,D,A,B,C

1. P. Rattanawiwatpong , R.Wanitphakdeedecha, , A.Bumrungpert, and M. Maiprasert, ‘Anti‐aging and brightening effects of a topical treatment containing vitamin C, vitamin E, and raspberry leaf cell culture extract: A split‐face, randomized controlled trial’, Journal of Cosmetic Dermatology

2. A .Grzybowski and K. Pietrzak, ‘Albert Szent-Györgyi, 1893-1986, The scientist who discovered vitamin C’, Clinics in Dermatology

3. F.Al-Niaimi & N.Chiang, ‘Topical Vitamin C and the Skin: Mechanisms of Action and Clinical Applications’, The Journal of clinical and aesthetic dermatology

4. F.Addor, ‘Antioxidants in dermatology’, 2017, Anais Brasileiros de Dermatologia,

5. J . M. Lü, ‘Chemical and molecular mechanisms of antioxidants: Experimental approaches and model systems, 2009, ’ Journal of Cellular and Molecular Medicine

6. Telang, P., 2013. Vitamin C in dermatology. Indian Dermatology Online Journal, 4(2), p.143.

7. P.Humbert, M.Haftek, P.Creidi, C.Lapière, B.Nusgens, A. Richard, D.Schmitt, A.Rougier, and H.Zahouani, ‘Topical- ascorbic acid on photoaged skin. Clinical, topographical and ultrastructural evaluation: double-blind study vs. placebo’, 2003, Experimental Dermatology

8. J.Pullar, A.Carr, and M.Vissers, ‘The Roles of Vitamin C in Skin Health’, 2017, Nutrients

9. A.Hinek, H.Kim, Y.Wang, A.Wang, and T.Mitts,‘ Sodium l-ascorbate enhances elastic fibers deposition by fibroblasts from normal and pathologic human skin’, 2014, Journal of Dermatological Science

10. R.Kelm, A.Zahr, T.Kononov and O.Ibrahim, ‘Effective lightening of facial melasma during the summer with a dual regimen: A prospective, open‐label, evaluator‐blinded study’, 2020, Journal of Cosmetic Dermatology

11. K.R. Kwon, ‘Attenuation of UVB-induced photo-aging by polyphenolic-rich Spatholobus suberectus stem extract via modulation of MAPK/AP-1/MMPS signaling in human keratinocytes’,2019, Nutrients

12. S.Pinnell, , H.Yang, M.Omar, N.Riviere, H. DeBuys, L.Walker, Y. Wang, and M. Levine, ‘Topical L-Ascorbic Acid: Percutaneous Absorption Studies’, 2001, Dermatologic Surgery

13. P. M.Campos, G. M.Gonçalves & L. R. Gaspar, ‘In vitro antioxidant activity and in vivo efficacy of topical formulations containing vitamin C and its derivatives studied by non-invasive methods’, 2008, Skin research and technology)

14. Traber, M.G. and Stevens, J.F. (2011) “Vitamins C and E: Beneficial effects from a mechanistic perspective,” Free Radical Biology and Medicine, 51(5), pp. 1000–1013. Available at: https://doi. org/10.1016/j.freeradbiomed.2011.05.017

15. Lin et al, Ferulic acid stabilizes a solution of vitamins C and E and doubles its photoprotection of skin, 2005

16. Ravetti Ascorbic acid in skin health,” Cosmetics, 2019, https://doi.org/10.3390/cosmetics6040058

17. Al-Niaimi, F., & Chiang, N. (2017). Topical Vitamin C and the Skin: Mechanisms of Action and Clinical Applications. The Journal of clinical and aesthetic dermatology 10(7), 14–17.

18. N.Stamford, ‘Stability, transdermal penetration, and cutaneous effects of ascorbic acid and its derivatives’, 2012, Journal of Cosmetic Dermatology

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19. A.Zahr, and T.Kononov, `Efficacy and tolerability of a novel antioxidant formulation containing 30 (w/w) % of tetrahexyldecyl ascorbate, a lipid-soluble form of vitamin C’, Journal of the American Academy of Dermatology, 2019, https://doi.org/10.1016/j.jaad.2019.06.739>

20. R.Colven, and S.Pinnell,’Topical vitamin C in aging’, Clinics in Dermatology, 1996

21. AestheticSource, data on file

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com

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Case Study: Utilising Ultrasound

While working as an experienced medical aesthetic practitioner, dealing with complications from other injectors can be a regular occurrence. This is particularly true nowadays, which I believe is due to the prevalence of lay injectors providing treatment with little to no anatomical knowledge. It’s been my experience that these injectors generally regard dermal filler treatments as another beauty procedure until they go wrong and become medical procedures. As non-medics lack the knowledge and prescribing rights to cope with these situations, this leaves their patients without the appropriate care, leading to my complications clinic always being full.

This article will present one example of how I used ultrasound imaging – an invaluable tool in my clinic – to assist me when treating an aesthetic complication in a female patient.

Medical history

The patient, a 46-year-old woman, was referred to my complications clinic two months after receiving dermal filler injections in her forehead from a non-medic injector. The patient had originally sought aesthetic treatment because she felt long-term medical issues (which had no bearing on the complication itself or how I dealt with it) had left her looking tired and older than her age, and she wanted to feel fresher and more confident again. I soon ascertained that the patient was aesthetic-naïve, meaning she had very limited knowledge of aesthetic procedures and had never had an injectable treatment before, so had trusted her prior injector without doing further research into the procedure in question. The original injector had advised the patient that she would benefit from forehead filler for facial rejuvenation, and the patient had agreed despite the injector not informing her of any of the risks involved.

Dermal filler of an unknown brand was administered with a needle across the central and lateral parts of the forehead, as could be seen through diffuse swelling in the area. The patient told me the original procedure was painful, and immediately afterwards she experienced debilitating headaches, followed by episodes of pain comparable to migraines. The severity of this pain forced the patient to become temporarily housebound and take time off work. The patient contacted the original injector who administered hyaluronidase after initially being slow to assist. As the injector was a non-medic, I was unable to determine whether the hyaluronidase used had been obtained via a medical prescriber, or if it was a counterfeit product bought online. Following this, the injector told the patient that she could do nothing more for her, but the side effects persisted, so she went to see a medical practitioner in London who then referred her on to my complications clinic.

Anatomical considerations

The forehead is one of the riskier facial areas to inject because of the thin tissue and rich vascular network which has anastomoses to the ophthalmic circulatory system.1 When considering forehead injections, there are techniques which focus on injecting both above and below the frontalis muscle. The forehead arteries are expected to run deep to the frontalis in the lower parts of the forehead and cross to its surface closer to the hairline.1 The distribution of vessels is extremely variable, and as such, the precise location of vessels can only really be pinpointed by using ultrasound prior to and during forehead augmentation. Due to the limited tissue depth, it can also be difficult to discern whether the injections are above or below the frontalis without confirmation from ultrasound imaging.

There are multiple important vessels to consider when injecting the forehead.1 Firstly, the supratrochlear artery travels cranially in the forehead. Adjacent to this is the supraorbital artery which, again, takes a similar course. Both are terminal branches of the ophthalmic artery. Slightly laterally at the side of the forehead, there are connections between the supraorbital and the superficial temporal arteries, which supply blood to the temple. All these arteries have potential connections to the eye through ophthalmic circulation and anastomoses, so the area contains a network of interlinked high-risk vessels.1

Several complications could arise as a result of inaccurate injections in the forehead. Because there is so little space in the layers of the

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
Dr MJ Rowland-Warmann shares a case of a patient with filler-related pain in her forehead and how she used ultrasound when addressing the complication
Figure 3: Guided removal of filler with hyaluronidase under ultrasound using a needle Figure 2: Ultrasound showing proximity of the dorsal nasal artery to filler deposit Figure 1: Ultrasound showing proximity of supraorbital artery to filler deposit

forehead, incorrect filler placement can cause compression of the vasculature, leading to venous blockage or vascular irritation. This can subsequently cause hypervascularity – a proliferation of blood vessels.2 An occlusion can cause ischemia and necrosis of the skin, but in my experience, 90% of such cases are treatable if caught early (under two and a half days).

The biggest cause for concern is that occluding one of these arteries could easily send a filler embolus into the eye if care is not taken to avoid injecting into any vessels. Large emboli cause sudden, catastrophic blindness.3 However, it is theorised that smaller emboli may cause choke activation – a protective mechanism which shuts off certain areas of skin tissue detects noxious stimuli3 – but which, when affecting the eye, can lead to ischemia of the retina and irreversible vision disturbance in as little as 15 minutes.4

Addressing the complication

Patients who have experienced complications are often emotionally damaged, in addition to being in a great deal of pain. These patients frequently have self-blame, so reassurance that the situation is not their fault and that you will take care of them is central to their management. However, the initial consultation must also introduce the possibility that you may not be able to completely rectify the issue –patients’ expectations must not become inflated. Complications are often difficult, not only from a patient management but also a clinical perspective, and complete resolution is sometimes not achieved. When treating this patient, ultrasound imaging using a GE Venue Go ultrasound device with a 4-20 MHz linear probe allowed me to locate the filler deposit with its excellent resolution for imaging of superficial facial tissues. Figure 1 shows the ultrasound probe approximately 3cm above the brow, with the image depicting the patient’s right supraorbital artery highlighted in red; the black structure next to it is filler. The areas are visible as such because they are anechoic, meaning no sound waves from the ultrasound machine are reflected back. The lack of colour in the black deposit indicates that filler is in that area because the machine has not detected any blood flow within this fluid (gel) filled structure.

Figure 2 shows that the filler had also been placed close to the dorsal nasal artery, causing further risk as this is a branch of the ophthalmic artery. The filler had caused irritation and hypervascularity, both of which led to painful oedema. Because the filler was not injected intravascularly but was still compromising the vessel, I class this as a vascular adverse event rather than an occlusion.

Sometimes, flooding an area with hyaluronidase will rectify a filler-related complication if the product’s exact location is not known or ultrasound is unavailable.5 However, filler can become encapsulated, meaning a shell has formed around the product which hyaluronidase would not be able to breach without direct injection into it. The reasons for this can include patient immune or inflammatory responses owing to poor quality filler, placement or intra-procedural factors. The ultrasound imaging allowed me to inject directly into the filler capsules.

As can be seen in Figure 3, the needle can be accurately guided to the deposit. I injected a total of 300 units of hyaluronidase into the affected areas using a 1ml syringe and a 27 gauge, 1.75 inch needle. This particular needle was appropriate for use alongside ultrasound because it can be seen clearly in the images but is still thin enough to be flexible and mitigate the risk of tissue trauma. I find cannulas for guided dissolution can lack efficacy due to their inability to penetrate the hyaluronic acid deposit.

I was able to treat this complication in one half-an-hour session. The

patient experienced some bruising, but within a matter of hours she reported a significant improvement in her pain, and the headaches had subsided within three or four days. By the time I reviewed her two weeks post-procedure, she was no longer experiencing headaches at all.

The virtues of ultrasound

This case is an illustration of why ultrasound is crucial both when injecting into riskier areas and when addressing complications. Without ultrasound, I would not have been able to identify the exact location of the filler or which vessel it was obstructing. Using ultrasound is a skill I would recommend any medical aesthetic practitioner to hone, both for the sake of complication management and performing injectable treatments safely. To achieve a good level of proficiency, the best approach would be to use ultrasound most days for routine procedures. This consistency will help you become comfortable using the machine, familiar with vascular mapping and well-versed in adapting your technique to incorporate risk mitigation. This can be reassuring to patients because it demonstrates that you are prioritising their safety.

It is important to remember that not all ultrasound devices will provide the same results. Many practitioners use handheld machines which are exceptional for their size, but these will not supply as clear an image as a hospital-grade cart system like the one I use. However, especially when patients have significant complications and are upset, litigious or angry, I cannot take chances with image quality.

Acknowledging your limitations in this respect is crucial when considering which complication cases you choose to take on; there is no shame in saying that your technology or expertise is not advanced enough for more complex complications and referring the case. There may even be opportunities to shadow during such cases to see how they are managed, and indeed, I welcome referring practitioners to my practice for this. Ensuring you have sufficient insurance cover to treat complications is also crucial. We are all medical professionals, and we all need to continue to develop risk reduction skills; ultrasound is a brilliant tool to help us do this.

Dr MJ Rowland-Warmann is the founder and lead clinician at Smileworks, a dental and facial aesthetic clinic in Liverpool. She holds an MSc in Aesthetic Medicine (with distinction) from Queen Mary University of London and has a special interest in the management of complications, writing extensively on the subject. She is a KOL for Clarius Mobile ultrasound and GE Healthcare Ultrasound, and offers ultrasound training via the Smileworks HUB.

Qual: BDS, BSc, MSc Aes.Med., MClinDent Orthod., PGDip Endod., PGCert MedEd., Dip.MJDF

REFERENCES

1. Kim H, et al. Ultrasonographic Anatomy of the Face and Neck for Minimally Invasive Procedures: An Anatomic Guideline for Ultrasonographic-Guided Procedures. 1st ed. (Germany: Springer, 2021)

2. Schelke L, et al. ‘Early ultrasound for diagnosis and treatment of vascular adverse events with hyaluronic acid fillers’ Journal of the American Academy of Dermatology (US: AAD, 2019) <https:// pubmed.ncbi.nlm.nih.gov/31325548/>

3. Taylor G, et al. ‘The Functional Anatomy of the Ophthalmic Angiosome and Its Implications in Blindness as a Complication of Cosmetic Facial Filler Procedures’ Plastic and Reconstructive Surgery (US: Williams & Wilkins, 2020) <https://pubmed.ncbi.nlm.nih.gov/32590524/>

4. Tobalem S, et al. ‘Central retinal artery occlusion – rethinking retinal survival time’ BMC Ophthalmology (2018) <https://pubmed.ncbi.nlm.nih.gov/29669523/>

5. DeLorenzi C. ‘New High Dose Pulsed Hyaluronidase Protocol for Hyaluronic Acid Filler Vascular Adverse Events’ Aesthetic Surgery Journal. 37(7), pp. 814-825. < https://pubmed.ncbi.nlm.nih. gov/28333326/>

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com

Introducing the new era

Alluzience, 200 Speywood units/ml, solution for injection - Prescribing Information (United Kingdom)

Presentation: Each vial contains 125 Speywood units of Clostridium botulinum toxin type A haemagglutinin complex in 0.625 ml of solution.

Indications: Alluzience is indicated for the temporary improvement in the appearance of moderate to severe glabellar lines (vertical lines between the eyebrows) seen at maximum frown in adult patients under 65 years, when the severity of these lines has an important psychological impact on the patient.

Dosage: Botulinum toxin product units differ depending on the medicinal products. Botulinum toxin units are not interchangeable from one product to another. Doses recommended in Speywood units are different from other botulinum toxin preparations.

Paediatric Population: The safety and efficacy of Alluzience in children aged up to 18 years have not been established. The use of Alluzience is not recommended in patients under 18 years. Method of administration: Alluzience should only be administered by a healthcare practitioner with appropriate qualifications and expertise in this treatment and having the required equipment, in accordance with national guidelines. A vial of Alluzience should only be used to treat a single patient, during a single session. Remove any make-up and disinfect the skin with a local antiseptic before administration. The intramuscular injections should be performed using a sterile needle with a suitable gauge. Dosing and treatment intervals depend on assessment of the individual patient’s response. The median time to onset as reported subjectively by patients was 3 days (the majority of patients reported an effect within 2 to 3 days with some patients reporting an effect within 24 hours). An effect has been demonstrated for up to 6 months after injection. The treatment interval should be no more frequent than every 3 months.

Administration instructions: The recommended dose is 0.25 ml of solution (50 Speywood units) divided into 5 injection sites, 0.05 ml of solution (10 Speywood units) administered intramuscularly into each of the 5 sites: 2 injections into each corrugator muscle and one into the procerus muscle, near the nasofrontal angle. The anatomical landmarks can be more readily identified if palpated and observed at patient maximum frown. Before injection, place the thumb or index finger firmly below the orbital rim in order to prevent extravasation below the orbital rim. The needle bevel should be pointed upward and medially during the injection. In order to reduce the risk of ptosis, avoid injections near the levator palpebrae superioris muscle, particularly in patients with larger brow-depressor complexes (depressor supercilii). Injections should be made into the central part of the corrugator muscle, at least 1 cm above the orbital rim. General information: In the event of treatment failure or diminished effect following repeat injections, alternative treatment methods should be employed. In case of treatment failure after the first treatment session, the following approaches may be considered:

• Analysis of the causes of failure, e.g. incorrect muscles injected, inappropriate injection technique, and formation of toxin-neutralising antibodies

• Re-evaluation of the relevance of treatment with botulinum toxin A.

Contraindications: Hypersensitivity to the active substance or to any of the excipients. Presence of infection at the proposed injection sites. Presence of myasthenia gravis, Eaton Lambert Syndrome or amyotrophic lateral sclerosis.

Precautions and Warnings: Care should be taken to ensure that Alluzience is not injected into a blood vessel. Injection of Alluzience is not recommended in patients with a history of dysphagia and aspiration. Adverse reactions possibly related to the spread of toxin effect distant from the site of administration have been reported very rarely with botulinum toxin. Swallowing and breathing difficulties are serious and can result in death. Very rare cases of death, occasionally in the context of dysphagia, pneumopathy (including but not limited to dyspnoea, respiratory failure, respiratory arrest) and/or in patients with significant asthenia have been reported following treatment with botulinum toxin A or B. Patients should be advised to seek immediate medical care if swallowing, speech or respiratory difficulties arise. Alluzience should be used with caution in patients with a risk of, or clinical evidence of, marked defective neuro-muscular transmission. These patients may have an increased sensitivity to agents such as botulinum toxin, and excessive muscle weakness may follow treatment. It is essential to study the patient’s facial anatomy prior to administering Alluzience. Facial asymmetry, ptosis, excessive dermatochalasis, scarring and any alterations to this anatomy, as a result of previous surgical interventions, should be taken into consideration. Dry eyes have been reported with use of Alluzience in periocular regions. Attention to this side effect is important since dry eyes may predispose to corneal disorders. Protective drops, ointment, closure of the eye by patching or other means may be required to prevent corneal disorders. The recommended dose and frequency of administration for Alluzience must not be exceeded. Patients treated with the recommended dose may experience exaggerated muscle weakness. Caution should be taken when Alluzience is used in the presence of inflammation at the proposed injection sites or when the targeted muscle(s) show excessive weakness or atrophy. As with all intramuscular injections, use of Alluzience is not recommended in patients who have a prolonged bleeding time. Each vial of Alluzience must be used for a single patient treatment during a single session. Any excess of unused product must be disposed of and specific precautions must be taken for the inactivation and disposal of any unused solution.

This Prescribing Information is continued on the next page

THE 1 ST READY-TO-USE * BOTULINUM TOXIN TYPE-A IN EUROPE

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The launch of Alluzience will be live-streamed on 9th March 2023, 5-7pm. Register for a free account at medfx.co.uk and join the mailing list to receive the details.

Antibody formation: Injections at more frequent intervals or at higher doses may increase the risk of neutralising antibody formation to botulinum toxin. Clinically, the formation of neutralising antibodies may reduce the effectiveness of subsequent treatment.

Traceability: In order to improve the traceability of biological medicinal products, the name and the batch number of the administered product should be clearly recorded.

Sodium content: This medicine contains less than 1 mmol sodium (23 mg) per 125U vial, that is to say essentially ‘sodium-free’.

Interactions: Concomitant treatment with Alluzience and aminoglycosides or other agents interfering with neuromuscular transmission (e.g. curare-like agents) should only be used with caution since the effect of botulinum toxin may be potentiated. No interaction studies have been performed.

Pregnancy, Breastfeeding and Fertility: Pregnancy: There are only limited data from the use of botulinum toxin type A in pregnant women. Animals studies do not indicate direct or indirect harmful effects with respect to reproductive toxicity. As a precautionary measure Alluzience should not be used during pregnancy. Breastfeeding: It is unknown if Alluzience is excreted in human milk. Alluzience should not be used during breast-feeding. Fertility: There are no clinical data examining the effect of Alluzience on fertility. There is no evidence of direct effect of Alluzience on fertility in animal studies.

Effects on ability to drive and use machines: Alluzience has a minor or moderate influence on the ability to drive and use machines. There is a potential risk of localised muscle weakness or visual disturbances linked with the use of this medicinal product which may temporarily impair the ability to drive or operate machinery.

Undesirable Effects: A majority of adverse reactions reported with Alluzience in clinical trials were of mild to moderate intensity and reversible. The most frequently reported adverse reactions were headache and injection site reactions. The incidence of adverse reactions tended to decrease with repeated treatments. Adverse effects related to the spread of toxin effect distant from the site of administration have been very rarely reported with botulinum toxin (excessive muscle weakness, dysphagia, aspiration pneumonia with fatal outcomes in some cases). Adverse Drug Reactions Observed in Clinical Studies were as follows:

Very common (≥ 1/10): Headache, injection site reactions (periorbital haematoma, haematoma, bruising, pain, paraesthesia erythema, swelling, pruritus, oedema*, rash*, irritation*, discomfort*, stinging*), asthenia*, fatigue*, influenza-like illness*; common (≥ 1/100 to < 1/10): Facial paresis*, eyelid ptosis, eyelid oedema, brow ptosis, dry eye, lacrimation increased, asthenopia*, muscle twitching (twitching of muscles around the eye)*; uncommon (≥ 1/1,000 to <1/100): Dizziness*, eyelid twitching, visual impairment*, vision blurred*, diplopia*, hypersensitivity (eye allergy, hypersensitivity, rash), rash*, pruritus*; rare (≥ 1/10,000 to < 1/1,000): Eye movement disorder*, urticaria*

*additional adverse drug reactions only observed with powder formulation of the same active substance in clinical trials

Prescribers should consult the summary of product characteristics for further details.

Packaging Quantities and Cost: Pack containing x2 vials: £ 160.00 excluding VAT.

MA Number: PL 03070/0009

Legal Category: POM

Further information is available from:

Galderma (UK) Ltd, Evergreen House North, Grafton Place, London, NW1 2DX. Telephone: +44 (0)300 3035674

Date of Revision: September 2022

*Alluzience is a liquid formulation with no need to reconstitute.

Reference: 1. Alluzience SmPC 2022.

Adverse events should be reported. United Kingdom

Reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

Adverse events should also be reported to Galderma (UK) Ltd:

E-mail: medinfo.uk@galderma.com Tel: +44 (0)300 3035674

UKI-ALZ-2200048 DOP February 2023
THIS INFORMATION IS INTENDED FOR HEALTHCARE PROFESSIONALS ONLY • THIS ADVERTISEMENT HAS BEEN CREATED AND FUNDED BY GALDERMA. The beginning of this Prescribing Information is on the previous page
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Spotlight On: Alluzience

A look at the next step in botulinum toxin formulation

Botulinum toxin is the bread and butter of aesthetics, and year on year continues to be the most popular treatment in medical aesthetic clinics 1 All approved BoNT-A products (or formulations) in Europe come in powder form and require reconstitution with sodium chloride before use – until now. With continuing advancements in technology, this month sees the official launch of Alluzience at ACE 2023 – the first ever ready-to-use neuromodulator (ABont-A liquid toxin).

What is Alluzience?

Produced by global pharmaceutical company Galderma, Alluzience is a liquid formulation that avoids any calculations to reconstitute the product from powder to liquid form.2 It is approved for treatment of moderate to severe glabellar lines.2

Aesthetic practitioner Dr Kuldeep Minocha, who was one of the first UK practitioners to use the toxin in the UK, comments, “Alluzience is a brand new abobotulinumtoxin that comes reconstituted straight from the manufacturer, which makes my life a lot easier! I’m one of the earliest users of Alluzience in the UK and have been using it since March 2022. I’ve injected around 300 patients so far and I can tell you that every single patient has been completely blown away with the result and has requested repeat treatment with this particular product.”

Clinical studies

According to the company, the decision to make ABont-A liquid toxin available to the UK after previously being launched in 2021 was based on pooled data from two pivotal trials run by Galderma. The two studies looked at a total of 372 patients with moderate to severe glabellar lines who were treated with either ABont-A liquid toxin (n=250) or placebo (n=122). This data demonstrated that more than 50% of patients reported an effect within two to three days, including 23% of patients within one day.2 The results were demonstrated to last for up to six months after injection with ABont-A liquid

toxin.2 The responder rate at day 29 was significantly higher for patients treated with ABont-A liquid toxin compared to the placebo (p<0.0001).2

Another 2020 study of 185 patients looked to evaluate the six-month efficacy, safety and patient satisfaction of this brand new, ready-to-use abobotulinumtoxinA solution for injection (ASI) of glabellar lines. Results showed

wellbeing; feeling more attractive, confident, self-accepting and happy.2

Recently, a 2022 study on 150 female subjects between 18 and <65 years of age with moderate to severe glabellar lines showed that 94% felt that the treatment session was good and exceeded their expectations, whilst 77% reported improvement in the appearance of their glabellar lines at month six.4 Furthermore, 100% of the investigators strongly agreed or agreed that Alluzience saves time, is easy to use, easy to learn and met their expectations. In addition, 81% preferred using Alluzience over another well-used toxin.4

The majority of adverse reactions reported with ABont-A liquid toxin in clinical trials were of mild to moderate pain and this was reversible.2 The most frequently reported adverse reactions were headaches and injection site pain.2

that the ASI was significantly efficacious for improving moderate or severe glabellar lines vs. placebo by investigator and patient assessment. The ASI was associated with high patient satisfaction, and comparable safety profile to abobotulinumtoxinA.3

Other study outcomes on patient satisfaction one-month following injection indicate that 85.2% of the patients receiving ABont-A liquid toxin were either satisfied or very satisfied compared to 9% for placebo patients.2 Alongside this, at one month, more than eight out of 10 (85%) patients treated with ABont-A liquid toxin reported improvements in their psychological

REFERENCES

Treatment considerations

Galderma explains that Alluzience should only be administered by doctors, nurses and dentists, with appropriate qualifications and expertise in this treatment using the required equipment.2 Dosing and treatment intervals depend on assessment of the individual patient’s response/reaction to the procedure, and the treatment interval should be no more frequent than every three months.2

To learn more about the newest toxin on the market, come to ACE 2023 in London on March 10-11 for the official launch of Alluzience. Register free on p.20.

1. American Society of Plastic Surgeons, Annual Report, 2020, <https://www.plasticsurgery.org/documents/News/Statistics/2020/plasticsurgery-statistics-full-report-2020.pdf>

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
2. Galderma, ALLUZIENCE Summary of Product Characteristics, 2022, available upon request from Galderma. 3. Ascher B, Rzany B, Kestemont P, et al. Liquid Formulation of AbobotulinumtoxinA: A 6-Month, Phase 3, Double-Blind, Randomized, Placebo Controlled Study of a Single Treatment, Ready-to Use Toxin for Moderate-to-Severe Glabellar Lines., Aesthet Surg J. 2020;40(1):93–104. 4. Gerber PA, Hilton S, Chadha P, et al., ‘Ready-to-use abobotulinumtoxinA solution versus powder onabotulinumtoxinA for treating glabellar lines: Subjects’ and Investigators’ experience’, 2022. Figure 1: 52-year-old patient before, one day and one month after treatment with Alluzience by Dr Christoph Martschin. Before One day after One month after

For more information, please contact Lutronic

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Treating Telangiectasia with Laser

Dr Ahmed El Houssieny details the presentation of telangiectasia and outlines considerations for treatment

Smooth, even-toned skin is something most aesthetic patients aspire to achieve from treatment in our clinics. As a first-base approach, we should be recommending that patients invest in medical-grade skincare products and advising them of a suitable regimen to follow. Sometimes, however, certain skin concerns call for more targeted treatment. This is the case for vascular lesions such as telangiectases.

Presentation and causes

Also known as spider veins or facial thread veins, telangiectases are tiny blood vessels that cause thread-like red lines on the skin. They generally form gradually and appear in clusters in different areas across the face. Telangiectases’ vessel diameter is usually between 0.2-0.5mm and the distribution is defined by linear, matted and combined patterns, with a depth of 200-250 microns.1 Some patients suffering from telangiectasia may experience pain or itching, but most concerns relate to how it looks.1

Research suggests that patients with skin types I-III, a history of significant sun exposure and/or long-standing rosacea are predisposed to presenting with telangiectasia.1,2 Additionally, telangiectasia can be associated with hypertension, or as part of the clinical manifestations of connective tissue disorders such as scleroderma. Alcoholism, because blood flow is affected; pregnancy, due to increased pressure on venules; and ageing in general, as blood vessels begin to weaken, have also been linked to the condition.1,2

Practitioners should take care to diagnose telangiectasia appropriately, as there are certain underlying disorders associated with it such as Sturge-Weber disease and xeroderma pigmentosum. One in particular to be cautious of is hereditary haemorrhagic telangiectasia (HHT), which is an inherited disorder of the blood vessels in skin and internal organs that can cause excessive bleeding. Symptoms include frequent

nosebleeds, red or dark black blood in stools, shortness of breath, seizures, small strokes and a port-wine stain birthmark.2

Treatment options

There are various options available to treat telangiectasia. If it is caused by a medical condition, such as HTT mentioned above, then it’s important that you identify and treat this, which should then resolve the telangiectases. If aesthetic-based, then you can consider:

• Laser – uses a single wavelength of light, which is absorbed by molecules (chromophores) that can convert the light energy to heat energy, which then destroys the abnormal blood vessels.3

• Intense pulsed light (IPL) – like laser, IPL targets chromophores to heat and destroy the telangiectases, but instead uses several wavelengths of light in the same beam.3

• Sclerotherapy – injection of a chemical solution into the veins that causes the lining of the blood vessel to collapse and clot. This then turns into scar tissue which eventually fades from view.4

• Electrosurgery – a small cautery tip is applied on the skin along the lengths of the telangiectases or at the route of the vessel and allows an electric current to coagulate the lesions which, as above, will lead them to disappear.4

• Microphlebectomy – performed using hooks which allow the practitioner to extract veins through minimal skin incisions or needle punctures.5

• Thermocoagulation – uses radiofrequency energy to cause thermal damage to destroy and fade the veins.5

Your treatment choice will depend on your skillset and, most importantly, the best option for the patient. Here, I will focus on the evidence behind light and laser-based approaches, as this is the most common treatment approach that I use and is proven to be effective.

Treatment approach

As described above, laser and light-based treatments work on the principle of selective photothermolysis, whereby light energy –from the laser or IPL device – targets specific chromophores that can convert the light into heat and destroy them, without damaging surrounding tissue.3

McCoppin et al. explain that the intended target, or chromophore, of telangiectasia is largely intravascular oxyhaemoglobin, although deoxyhaemoglobin and met-haemoglobin are targeted as well.6

The principal absorption peaks of oxyhaemoglobin are in the blue-green-yellow portion of the visible range at 418, 542 and 577 nm. The authors highlight that there is also absorption between 700 and 1100 nm, although this is less.6

This means that there are a number of types of lasers that can be used to treat telangiectasia, with research indicating that pulsed dye laser (PDL), potassium-titanylphosphate (KTP) and IPL sources are the most standard options.6

KTP

KTP laser light is created by passing the near-infrared light of 1064 nm Nd:YAG through a KTP crystal, which doubles the frequency and halves the wavelength to emit a 532 nm green light.7

The small spot sizes available of 1mm or less can be useful for tracing out individual telangiectases. According to McCoppin et al., the range of longer pulse durations (1-100 ms) allows the KTP pulses to expand the intravascular ‘steam bubble’ gradually without vessel wall rupture. One of the benefits of KTP is that patients do not experience purpura (small flat spots on the skin) following treatment.6

A large-scale study of 647 patients with vascular lesions was conducted in 2014. It found that 77.6% of those treated with KTP laser had complete clearance or marked improvement after six weeks. Only 5.8% of participants experienced adverse events, all of which were minor and the main one being swelling which reduced after a couple of days.8

Other research has cited 90% clearance or marked improvement in telangiectasia following KTP treatment (49 patients),9 66.1% clearance or marked improvement (146 patients)10 and 75-100% clearance of telangiectases in 93.9% of 66 participants.6

One of the main disadvantages of KTP laser is that its use is limited to patients with skin

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com

types I-III. This is because, along with the targeted oxyhaemoglobin chromophores, the green light is also absorbed by melanin chromophores, which can therefore lead to dyspigmentation.6 Another downside, in my opinion, is that while the small spot sizes are good for linear telangiectases, more diffuse or widespread vascular conditions such as rosacea or port wine stains can be difficult to treat. Other side effects are that it can produce erythema and oedema lasting six to 12 hours after treatment, while blistering, scabbing and bruising can occur.8 As with all aesthetic treatments, the risk of severe side effects is reduced with appropriate use.

PDL

PDLs use an organic dye mixed in a solvent as the lasing medium. PDLs have wavelengths of 585 or 595 nm, with pulse durations of 0.45-40 ms.11

The larger spot sizes, which range from 2-10mm, deliver a fluence averaging 5-10 J/cm2, which allow for deeper dermal penetration and destruction of larger blood vessels.11 It has been advised that treatment areas should not overlap by more than 30%, to prevent excessive thermal damage that could result in blistering or scarring.6

A review of 326 articles on treating rosacea (one of the most commonly associated conditions of telangiectasia) with PDL was conducted in 2022. Results suggested that clinical improvements of more than 50% clearance were noted in 68.6% of participants treated with PDL.12 Another study of 30 patients found that telangiectases were resolved in 93% of participants after a single treatment,13 while

a further suggested that the average improvement in 19 patients was 53.9%.14

Post-treatment purpura is one of the most undesired effects of PDL – often increasing patient dissatisfaction and elongating downtime.15 Some devices have non-purpuric settings, however it has been reported that improvement may be greater when purpura is induced in thicker telangiectases.16

Other side effects associated with PDL treatment include redness, swelling and itching that may last for a few days post treatment, changes in skin pigment and blistering – although this is rare when used in safe hands.11

IPL

While the laser options discussed are proven to produce positive results for the treatment of telangiectasia, IPL also offers an effective solution.17 With wavelengths ranging from 500 to 1200 nm, most IPL devices will use filters to refine the energy output for the intended treatment.18 Studies indicate positive results with IPL use. One, comprising 140 patients with linear and spider facial telangiectases, reported excellent results in 67.1% of participants, good in 30.7% and poor in 2.1% out of those who took part.19 Another demonstrated that 95.3% of 107 patients showed improvement in their telangiectases six months post-treatment.20 An additional study found that 90% of 30 patients with facial telangiectases had more than 50% clearance post-treatment. Significantly, 27% had more than 75% clearance.19 Adverse events include blisters, dyspigmentation and scar formation; as with other treatments, these can be limited with appropriate patient selection and proper use.19 A disadvantage of IPL treatment is that there are many variations between systems, and low power IPLs may give unsatisfactory results. To avoid this, it’s essential to choose IPLs that can deliver high fluences in short pulse train durations.

In my experience, deeper vessels will need treatment with an Nd:YAG laser rather than IPL (or PDL/KTP laser) to induce the most effective results. My device of choice is the Lynton Lumina, which is a multi-platform system that includes IPL and Nd:YAG laser,

allowing me to tailor treatment to individual patients (Figure 1).

Comparisons

There have been numerous studies undertaken that compare the various devices available for the treatment of telangiectases.16,19,21 In those analysing PDL vs. IPL, most found equal efficacy and safety results. One study (p=19) suggested while both effective, PDL had a better outcome in terms of appearance, but IPL was preferred by patients because there were fewer side effects.21 Likewise, in a study comparing IPL with KTP by analysing literature, both were found to achieve marked improvement after one session. It was, however, highlighted that the KTP caused slightly more discomfort and oedema than the IPL, yet it was described as faster and more ergonomically flexible.16 It should be noted that larger study groups are required for more informative data.16

Considerations for investment

A laser or IPL device is an expensive investment, so it’s important to carefully consider your options before purchasing. I would recommend evaluating your current patient demographic and thinking about whether you want to grow this or expand into different areas. Don’t be afraid to ask the distributor or manufacturer lots of questions, read plenty of clinical studies (not just the ones conducted by the company), and seek advice from your peers.

Dr Ahmed El Houssieny is the founder and medical director of Bank Medispa in Hale, Cheshire. He is a faculty member of Allergan and Lynton. Dr El Houssieny is also an Honorary Lecturer at the University of Chester, as well as an associate member of BCAM and Cheshire Aesthetic Practitioners.

Qual: MBBCH

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com Treatment Focus Telangiectasia
Before After
Figure 1: 56-year-old female patient before and six weeks after two sessions with Lumina, using IPL.
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Avoiding Thread Lifting Complications

Minimally-invasive thread lift procedures involving barbed suture insertion have become a popular alternative for correcting facial tissue ptosis.1 The increased demand has resulted from improved material technology, an understanding of biomechanics, an appreciation of facial dynamics and the ageing face paradigm.1

Thread lifting technology is a non-surgical facial rejuvenation procedure accomplished through mechanical repositioning of the ptotic soft tissue envelope with collagen biostimulation, resulting in improved skin texture.2 To achieve optimum thread lift results, practitioners must have good underpinning knowledge in muscle kinetics, soft-tissue anatomy, thread mechanics and immunologic processes associated with the procedure.3

Profound ptosis manifested by soft and hard tissue age changes is impossible to reverse with injectables alone.3 Soft tissue dermal fillers are used to revolumise deep and superficial fat compartments. However, once these compartments have descended with the ageing of the bony skeleton, filler augmentation will not fully reposition the ptotic tissue, instead only volumising in the descent position.3

In this article, we will be exploring how polydioxanone (PDO) threads can give overall improvement to patients’ faces, and some of the complications which can occur.

History

The non-resorbable barbed thread was introduced in 1989 by Russian surgeon Mr Marlen Sulamanidze to lift the ptotic facial tissue.4 Manufactured from polypropylene, the efficacy and safety of the thread allowed for the emergence of variants of the original anti-ptosis suture (APTOS) threads.4

In 2011, the Food and Drug Administration (FDA) in Korea, which is the world-leader for thread innovations, approved mono 6-0 PDO threads.5 In 2014, China approved PDO absorbable threads and included polycaprolactone (PCL). Poly-L-lactic acid (PLA) threads were then approved in 2018.2 Until 2014, Silhouette Soft was the UK’s primary supplier of biodegradable threads, which were composed of polylactic acid monofilament (PLA) with moulded absorbable

cones of copolymers: glycolic and lactic acid (PLGA).2

Since 2014, NeoPharmaUK Ltd introduced the first multi-directional barbed (cog) threads suitable for the treatment of mild to moderate tissue ptosis.5 With increased popularity for PDO thread lifting procedures over this period of time, issues began to surface. Training and stock supplies have been of questionable quality with many companies and practitioners importing illegally CE marked products, in combination with ‘overnight’ trainers farming out courses to capitalise on the ‘in demand’ non-surgical alternative to a facelift.5

In 2016, The Association of Polydioxanone Threads (APDOT) was founded to raise standards and accredit practitioners, as well as being a directory to ‘look up’ PDO thread branding and check on its legitimacy. However, this was quickly replaced with the regulatory body the Care Quality Commission (CQC).5

By 2018, the CQC ruled PDO thread lifting as a ‘surgical procedure’ and any healthcare professional performing this treatment would need to meet full requirement for surgical procedures. Now a regulated practice, practitioners in the UK should be aware that they would require CQC registration to offer this treatment.5

Thread classification includes absorbable or non-absorbable, natural or synthetic and multifilament or monofilament.4 Threads can be moulded, cut or smooth, and the barbs are bidirectional or multidirectional. Barbs are a feature of threads which allows simple anchoring into the soft tissue. By gathering the tissue, this allows for lifting and positioning temporarily. Moulded threads have barbs placed onto them, maintaining the integrity of the thread core and tensile strength. Cut threads have the barbs cut into them, affecting the integrity which helps them dissolve quicker. Threads can be used alone or in conjunction with injectables to minimise over-filling.4

Complications

Facial areas with significant muscle activity, such as the perioral region, can be challenging for thread lifting procedures. Excessive lifting of the ptotic soft tissues cranially would be opposed to muscle contraction and upset muscular balance.3 Practitioners who lack an understanding of thread techniques will contribute to the failure of the lifting effect, causing ‘cheese

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
Dr Jeremy Isaac and Alex Henderson discuss the common complications which can arise from thread lifting procedures

wiring’, which describes the process of suture material cutting through soft tissue, reducing longevity. In addition, facial nerve injury is a severe, but rare complication, which can be avoided by the practitioner having a thorough knowledge of facial anatomy.2 Common complications from PDO threads are bruising or haematoma which can be uncomfortable for two to three days but should resolve. In a meta-analysis of 26 studies and 8,190 patients, the complication rates for APTOS, Contour, Happy Lift, Phoenix, MINT and Xtosis threads included:3

1. Swelling (35%)

2. Skin dimpling (10%)

3. Paraesthesia (6%)

4. Thread visibility/palpability (4%)

5. Thread extrusion (2%)

6. Infection (2%)

Absorbable threads were associated with a significantly lower risk of paraesthesia (3.1% vs. 11.7%) and thread extrusion (1.6% vs. 7.6%) than non-absorbable threads. Patients older than 50 had a higher risk of dimpling (16% vs. 5.6%) and infection (5.9% vs. 0.7%) than their younger counterparts. In addition, the long-term satisfaction rate decreased significantly compared to immediately after the thread lift (88% vs. 98%).3

Non-absorbable threads in older patients are associated with a higher risk of complications.6 PDO threads are effective in aged skin rejuvenation, soft tissue retraction and support, showing fewer complications.6 In addition, treatment with thicker thread could be more efficacious.6 Thread results may be limited to around

12 months, which can be an advantage as fillers have been observed up to 12 years post-procedure, but it is crucial to manage patients’ expectations regarding longevity.7 In our experience, combining therapy with fillers may prevent the overfilled, unnatural outcome observed with excess fillers. Significant facial rejuvenation can be achieved by using threads, with improvement seen through combination therapy including botulinum toxin, platelet-rich plasma and fillers.8 Additional studies are needed to evaluate the safety and long-term efficacy of combination procedures.9

Swelling

A recent study confirmed that swelling is the most common complication from thread lifting, which usually spontaneously resolves within two weeks.2 If swelling persists and fails to show signs of improvement, patients should have a face-to-face assessment to rule out further complications such as infection, abscess and misplacement. Swelling may compromise the lift due to unstable anchorage within the oedema tissue. Management of post-operative swelling includes compression and nonsteroidal anti-inflammatory drugs.2

Dimpling

The incidence of dimpling ranges from 1.7% to 34.5% in the literature, which highlights that older patients are at higher risk of dimpling.3 An effect of ageing skin is more sagging, requiring greater tension to lift and achieve aesthetic ideals. The extra tension risks compromise the biomechanics of

the anchorage, thus accelerating relapse with facial dynamism. The thickness of subcutaneous fat tissue exhibits selective atrophy in the ageing population, with a potential risk of superficial anchoring at the dermis during thread lifting.2

In Figure 1, each coloured area shows a different percentage of facial dimpling in 190 patients.2

Paraesthesia

Paraesthesia includes pain, numbness, tension, facial stiffness, hyperalgesia and tenderness, and usually presents itself immediately.11 In a study of 160 patients who received a facelift with barbed threads, 78% reported none or mild pain, with 22% reporting moderate pain immediately post-procedure.1 In the study, four out of five cases were resolved after two months, with all cases showing full recovery by month three to six.1

Paraesthesia may present in different ways depending on which branch of the facial nerve is affected, therefore, insertion depth is important to mitigate these potential side effects.

Visible threads and extrusion

Superficial placement produces thread visibility and/or palpability. This presents after the inflammatory process has passed within two to four weeks. Massage therapy is beneficial, and with time the resorbable threads will be hydrolysed. In general, this is not uncomfortable, but it can cause distress for the patient if they are aware of the visible thread. Removal of threads is usually carried out with surgical removal,

1. Cheek: 30 cases (39%)

2. Zygomatic buccal groove: 22 cases (28.6%)

3. Nasolabial sulcus region: 11 cases (14.3%)

4. Lateral sides: 8 cases (10.4%)

1-4. Multiple positions: 6 cases (8.8%)

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
1 2 3 4
Figure 1: Coloured areas highlighting facial dimpling.2

so many practitioners are unable to carry out this procedure. However, if the tip of the thread is palpable, it may be possible to extract and trim back the thread under sterile conditions, although the practitioner should be confident with their ability in this practice.12 As discussed above, superficial placement where a thread is not inserted deep enough can lead to thread exposure. This requires surgical removal and is a severe complication occurring within weeks after the procedure. Once the thread is removed, a full recovery can be seen within two to four weeks post-surgery.3 If you encounter a complication which you feel is beyond your sphere of experience, do not hesitate to refer your patient to an experienced colleague.

Infection

Infection following threads is a rare complication but is commonly caused by thread removal. Patients over the age of 50 have a significantly higher risk of infection.9 Signs of infection will include redness, tenderness, swelling with possible systemic involvement including pyrexia and feeling unwell. Symptoms may be unilateral or bilateral depending on the conditions in which they are treated. However, it’s recommended that patients are prescribed antibiotics to prophylactically avoid postoperative infection.4,10

Indications and contraindications

Patients suitable for non-surgical thread lifts are those with mild to moderate signs of skin ptosis ageing. A guide of this would be skin laxity of between 1-2cm; below 1cm would benefit from injectables, and above 2.5cm requires surgical intervention.4

Contraindications for thread lifting are

patients with a high BMI, unrealistic expectations, excessively loose and crepey skin and those with particularly heavy ptotic soft tissues where surgical facelift is the gold standard.5

Contraindications on patients’ medical history include:5

• Acute inflammatory processes or skin diseases

• Autoimmune and somatic diseases

• Haemophilia

• Keloid scars

• Allergy to PDO threads or to prescribed anaesthetics

• Anticoagulants or antiaggregant medication

• Mental and neurotic disorders

• Pregnancy or breastfeeding

• Previous non-biodegradable injection materials or permanent implant

• Immunologically compromising diseases

• Atopic patients (multiple allergies)

An alternative for facial rejuvenation

Aesthetic procedures using absorbable PDO threads are an alternative method for facial rejuvenation. Different threads and techniques can be used depending on the patient’s needs. The significant advantages of these techniques are low morbidity and downtime. In-depth training, knowledge of different thread techniques and adequate patient selection are crucial to obtaining good cosmetic results. Due to the complex vascularity involved, practitioners must be confident in their knowledge of anatomy before performing the procedure. Although patient satisfaction initially can be satisfactory and the complication rate low, more studies showing long-term results are necessary.

Dr Jeremy Isaac practises at Wish Skin Clinic in Port Talbot. He is a country expert and national trainer for Teoxane, international KOL for MINT PDO threads as well as a trainer for Aesthetic Medicine Pathways. He is on the JCCP training and education committee and is a founder of MAP-IQ.

Qual: BDS, MSc (CosMed), PGCert (MedEd)

Alex Henderson is an independent nurse prescriber with 12 years’ industry experience. She has successfully opened two clinics in the Southwest of England. Henderson has experience in training practitioners on foundation filler and toxin courses as well as foundation and advanced PDO threads on behalf of 4T Medical.

Qual: BSc, INP

REFERENCES

1. Bertossi D, Botti G, et al., ‘Effectiveness, longevity, and complications of facelift by barbed suture insertion’, Aesthetic surgery journal, 2019, p.241-247.

2. Li YL, Li ZH, et al., ‘Facial thread lifting complications in China: analysis and treatment’, Plastic and Reconstructive Surgery Global Open, 2021.

3. Niu Z, Zhang K, et al., ‘A meta-analysis and systematic review of the incidences of complications following facial thread-lifting’, Aesthetic Plastic Surgery, 2021, p. 2148-2158.

4. Moon HJ, Chang D, Lee W, ‘Short-term treatment outcomes of facial rejuvenation using the mint lift fine’, Plastic and Reconstructive Surgery Global Open, 2020.

5. Otto J, Mian I, Otto A, ‘The development of PDO thread lifting in the UK’, PMFA J, 2016.

6. Khan G, Ahn KH, et al., ‘Combined press cog type and cog PDO threads in comparison with the cog PDO threads in facial rejuvenation’, Journal of Cosmetic Dermatology, 2021, p.3294-3298.

7. Master M, ‘Hyaluronic acid filler longevity and localization: magnetic resonance imaging evidence’, Plastic and reconstructive surgery, 2021, p.50-53.

8. Ali YH, ‘Two years’ outcome of thread lifting with absorbable barbed PDO threads: innovative score for objective and subjective assessment’, Journal of Cosmetic and Laser Therapy, 2018, p.41-49.

9. Tong LX, Rieder EA, ‘Thread-lifts: a double-edged suture? A comprehensive review of the literature’, Dermatologic Surgery 2019, p.931-940.

10. Surowiak, P., ‘Barbed PDO Thread Face Lift: A Case Study of Bacterial Complication’, Plastic Reconstruction Surgery Glob Open, 2022, p. 1-3.

11. Mian, I., Factors involved in tissue – lifting threads. Journal of Aesthetic Nursing, 2021, Volume 10 (6).

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
Dr Jeremy Isaac will be speaking at ACE 2023 on March 11 at the Teoxane Conference. Scan the QR code to register for free.
Combining therapy with fillers may prevent the over-filled, unnatural outcome observed with excess fillers

A History of Dermal Filler

Dermal filler is a term that we as aesthetic practitioners are immediately comfortable with as mainstays of our practices. In recent years, the public has become increasingly familiar with it too, as it has taken off among celebrities and on social media. But what led to the treatment’s formation and how do today’s products differ to their forebears?

The foundations of filler

Looking at the ‘origin story’ of dermal fillers takes us back to the vehicle that allowed such treatments to take place – the syringe. This implement was first invented in 1853 by two separate doctors for different indications.1 Scottish physician Alexander Wood used it to administer morphine in small doses to treat neuralgia, whilst French surgeon Charles Pravaz used it for intra-arterial injections when treating aneurysms.1

The first reported ‘cosmetic’ use of a foreign substance injected into the body was in Vienna in 1899, when Austrian plastic surgeon Robert Gersuny used liquid paraffin as a testicular prosthesis in a patient who required castration due to tuberculous epididymitis.2

Over the next few years, multiple substances of a similar consistency began to be used as filler to volumise and restructure – namely vegetable oil, mineral oil, lanolin and bees wax.1 This is until the complications started stacking up. These products, despite being relatively inert, often migrated and triggered chronic inflammation, leading to granulomas and scarring.1

At the turn of the 20th century, autologous fat was also beginning to be used for facial augmentation. German surgeon Gustav Neuber described the injection of fat taken from the upper arms to help treat facial defects.3 Autologous fat is still used today and can be taken from fleshy areas like the stomach and thighs, but the longevity and predictability of long-term results, caused by the high variability in graft volume retention, is as variable as it always has been.4 This unpredictability is attributed to the various techniques used for the procuring, processing and placement stages of fat-grafting.4

The next iteration of fillers came a few decades later with liquid silicone, following disfiguring reactions to previously used foreign-body fillers. Silicone had been used in the 1940s for breast augmentation in Japan before becoming popular in the 1960s in the US (especially with Las Vegas showgirls).5 Silicone is similar to paraffin and unfortunately had similar consequences, triggering chronic and disfiguring inflammatory immune reactions.6

In 1981, the US Food and Drug Administration (FDA) formally approved bovine collagen under the trade name Zyderm (Allergan Inc) as the first filler of its kind approved for cosmetic use. This was followed four years later by Zyderm II (using different concentrations of collagen sub-types leading to a more viscous gel) and Zyplast (cross-linked bovine collagen to increase longevity). An allergy test against bovine collagen was required prior to any facial injections with these products.7

Due to concerns raised about the allergenicity of bovine collagen, work began on autologous human collagen in the 1990s, leading to the creation of Autologen (Autogenesis Technologies). This was a relatively expensive product to manufacture due to the necessary harvesting and purification of the autologous human collagen (via a surgical procedure), not to mention the difficulty in administering uniform concentrations of collagen. In addition to this, there was no lidocaine added, so injection of the product was often painful. Trying to address the logistical issues with Autologen led to the idea of using cadaveric donor tissue (from approved tissue banks) from which the human collagen matrix was harvested. This led to the creation of Dermalogen (Collagenesis Inc).8,9

The next real evolution came with the advent of hyaluronic acid (HA) based fillers, as society pushed for increased filler longevity without the need for a skin test. It was soon recognised that HA was a safer and more effective base ingredient for dermal filler.10 Two different methodologies were used to obtain the HA: one was from rooster combs (Hylaform by

INAMED Corp), and the other was bacterial fermentation (Restylane by Medicis Aesthetics Inc). Both worked well, but the animal product had a shorter longevity so was soon superseded by the bacterial fermentation method.10 Following FDA approval of Restylane (Galderma) in 2003, the floodgates opened for HA dermal filler manufacture by companies worldwide.11

Development over time

HA is composed of repeat disaccharide units of glucuronic acid and N-acetylglucosamine that form a glycosaminoglycan (GAG) polymer.12 It is naturally occurring, with 50% of the body’s HA found in the skin.12 It acts as a scaffold for the extra-cellular matrix, giving it structure and hydration while aiding cell movement and regeneration. It also helps protect against free radical damage from UV exposure. It is rapidly metabolised by endogenous hyaluronidase enzymes, with approximately one third of total body HA turned over daily.12

Due to this turnover rate, most HA dermal filler products are ‘cross-linked’ to increase their longevity and tweak their physical characteristics. The cross-linking reaction relies on a chemical called 1,4-butanedioldiglycidyl ether, commonly known as BDDE. This enables the formation of long HA chains suspended in a physiological solution.13 Various methods are used in the manufacture of HA filler products that have an impact on the degree of cross-linkage, HA concentration and particle size. These elements are key in determining the clinical performance of the filler, tissue integration, longevity and product rheology. Rheological properties encompass terms such as elasticity, viscosity and cohesivity. These properties, when matched with patient anatomy, tissue quality and expectations, guide filler selection. The complex modulus (G*) is a measure of

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
Dr Kam Lally provides an overview of the development of dermal filler in aesthetic medicine
It was soon recognised that HA was a safer and more effective base for dermal filler

100 MILLION

We have reached a significant milestone, the manufacturing of 100 million JUVÉDERM® syringes.1,*

While we are proud of this achievement, reaching this milestone means so much more than a number.

For us, it represents so many patient experiences, because we craft every JUVÉDERM® treatment to highlight our patients’ individuality. Since our launch in 2006, the JUVÉDERM® brand has experienced a remarkable evolution that is still ongoing today.

We couldn’t have reached this landmark without the collaboration between Allergan Aesthetics, the expert skill of practioners… and of course the JUVÉDERM® experience that you continue to share.

It is because of these partnerships that so many patients have been able to achieve their unique aesthetic goals.

Although 100 million syringes is a significant milestone for us, we recognise that our journey continues and there is so much more to come.

At JUVÉDERM®, we believe that with our holistic treatment approach to individual beauty, combined with strong partnerships between Allergan Aesthetics and physicians, we can go beyond 100 million syringes.

Adverse events should be reported. Reporting forms and information can be found at: UK adverse events reporting https://yellowcard.mhra.gov.uk/ Adverse events should also be reported to Allergan Ltd. UK_medinfo@allergan.com or 01628 494026

Irish adverse events reporting https://www.hpra.ie Adverse events should also be reported to Allergan Ltd. UK_medinfo@allergan.com or 01628 494026

©2023
UK-JUV-230029
2023
This content is intended for adult (>18 years) audiences only.
Allergan Aesthetics, an AbbVie company. All rights reserved. Produced and Funded by Allergan Aesthetics, an AbbVie company.
February
* 100 million JUVÉDERM® syringes manufactured worldwide from 2004 to April 2022.1 For internal use only. 1. Allergan Aesthetics. Data on File. REF-96563. FILLERS GLOBAL NUMBER OF SYRINGES. May 2022.

ACE 2023 is the perfect opportunity to find out more about the HA dermal fillers on the UK market, from top companies including:

• Allergan Aesthetics

• Burgeon

• Church Pharmacy

• Croma Pharma

• FILLMED

• Galderma

• HA-Derma

• Joonghun Pharmaceuticals

• Merz Aesthetics

• Neauvia

• Prollenium

• Teoxane

• VIVACY

• 4T Medical

firmness/hardness, or the energy needed to deform a filler. Low G* fillers are preferable for superficial filling, whereas high G* fillers are better suited for deep volumisation. The elastic (or storage) modulus, commonly known as G prime (G′), is a traditionally touted parameter; it is similar to G* and represents the measure of a material’s ability to resist compression. The viscous modulus (also known as the loss modulus) G double prime (G′′) represents dissipated energy during product flow, caused by friction.14-16

Cohesivity is an increasingly important parameter when the filler is in-situ. It describes the adhesion between cross-linked HA molecules. Low cohesivity fillers spread easily after being injected, making them ideal for superficial and highly dynamic areas, whereas high cohesivity fillers maintain their structure and projection, making them better suited for deeper tissue volumisation and restructuring.15 Without getting entrenched in the physics of rheology, HA fillers are impacted by multiple physicochemical properties. The trend for modern, 21st century HA fillers is to take a ‘tissuetailored’ approach whereby rheological parameters are engineered with the end-tissue in sight to give better integration and more natural results. Another reason HA fillers are most commonly used is due to them being

relatively easily reversible with the use of hyaluronidase in the case of emergencies or adverse cosmetic outcomes.

Alternative treatments

There is a category of products that we haven’t discussed yet, as they usually fall into the category of ‘biostimulators’. These stimulatory fillers are fundamentally constructed of different compounds. The first in this category to get FDA approval was Sculptra (Galderma) in 2004, which is made of poly-L-lactic acid (PLLA). This is a synthetic biodegradable compound that is eventually hydrolysed in carbon dioxide and water, stimulating fibroblasts to upregulate collagen production and deposition.17 Often, multiple treatments are required, but the effects can be seen up to 24 months after treatment.17 Radiesse – FDA approved for Merz Aesthetics in 2006 – is composed of calcium hydroxylapatite (CaHA) microspheres suspended in an aqueous gel. The concentration of CaHA is 30%, and it has a similar structure to the calcium complexes that form bone. The CaHA acts as a biostimulator and increases fibroblast activity, thus increasing collagen production. It has almost no immunogenicity and is enzymatically degraded within approximately 12 months.18 This also means that there is a much lower chance of injection-site reactions or adverse reactions to the product.18 Due to the nature of CaHA, there is very little product migration, but as with Sculptra, there is no ‘antidote’ to reverse or dissolve the filler if incorrectly placed or if intravascular injection occurs.18

These stimulatory fillers were both initially licensed for use in HIV patients with facial lipoatrophy.19,20 Sculptra is placed into the deep (reticular) dermis or the subcutaneous fat, whereas modern HA fillers can be placed at all depths (dependent on the indication of the filler used). Stimulatory fillers must not be placed too superficially as they have a higher chance of causing skin discolouration, nodules and granulomas.21

Various ‘biostimulators’ are emerging onto the market as they grow in popularity. Lanluma (Sinclair Pharma) is the latest iteration of PLLA, with specific indications for the face, hands and body. Ellansé (AQTIS Medical) is another biostimulator that has poly-caprolactone (PCL) microspheres suspended in a carboxymethylcellulose based gel-carrier. Gouri (Dexlevo Inc) is a recent modification of PCL in that it comes in a fully liquid form. HArmonyCa from

Allergan Aesthetics is a hybrid dermal filler combining hyaluronic acid (HA) and calcium hydroxyapatite (CaHA), intended for facial soft tissue augmentation.

Future of fillers

Looking towards the horizon, biostimulatory products are truly here to stay, as we can learn to harness pre-existing physiological pathways and give them a boost. Nonetheless, the familiarity and safety associated with the reversibility of HA will always draw us back to this ancient molecule that unites all animal kingdoms. Moving forward, we will increasingly see hybrid products that combine HA with other biostimulatory compounds to get the best of both worlds. Fillers have certainly evolved since their inception as the challenges of the aesthetic arena apply pressures to research and development units globally. This creates an element of competition between manufacturers to satisfy the increasing experience levels of injectors and the demands of their patients. Competition is always a good thing, and leads to further innovation. As such, it really is an exciting time to be at either end of the humble syringe that sparked what has become a multi-billion dollar industry almost 200 years on.

Dr Kam Lally graduated in medicine from the University of Oxford, went on to qualify as a GP and is the Royal College of General Practitioners national aesthetic medicine lead. He is a global KOL for Teoxane, HansBiomed International, AlumierMD and Novo Nordisk. In addition to being experienced in injectables, he runs a weight management service in his Aestheticology clinic in Coventry.

Qual: BMBCh (Oxon), BA (Hons), MRCGP (UK), PG Dip Aes Med

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
VIEW THE REFERENCES ONLINE! AESTHETICSJOURNAL.COM
Dr Kam Lally will be speaking in the Teoxane Conference at ACE 2023 on March 11. Scan the QR Code to register for free today.

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Increase Patient Loyalty and Passive Income with GetHarley

Dr Sindhu Siddiqi discusses the benefits of using GetHarley in her clinic and how it has increased her skincare sales tenfold in as little as three months

When did your passion for skincare start?

I started my aesthetics career in 2013, specialising in injectables, but I found myself always talking to patients about skincare. I have suffered with skin issues, particularly acne, so I could relate to my patients’ skin woes. The skincare posts on my social media always get more traction and engagement than the ones about aesthetics, so I started to focus on skincare for my patients more. I wasn’t offering any skin treatments at my clinic at the time, but I quickly changed this to meet patient demand. I realised that not everyone wants injectables, and I wanted to offer my patients a choice.

How did you sell skincare before joining GetHarley?

I didn’t really sell much skincare before working with GetHarley because it was too much of a faff. I had limited staff and logistically it was a mess. We would spend a disproportionate amount of time trying to sort out delivery issues, for instance We weren’t providing a good service for patients. I didn’t want to give my patients a bad service as then they wouldn’t come back and recommend us, so I realised I shouldn’t be trying to do skincare unless I can do it properly.

I also realised that if I don’t sell skincare to my patients, they will buy it from another clinic and could be tempted to have injectables elsewhere. But I didn’t want to invest in lots of inventory as I don’t have the space. It’s also hard to know what will sell, and it takes time to figure that out. I realised that I could work with GetHarley in a more efficient way.

How has working with GetHarley changed your skincare financials?

Before working with GetHarley, we would barely make £1,000 a month on skincare sales. Now, it’s averaging £10,000 a month and we’ve only been with GetHarley for a few months, so it shows how much we can grow this part of our business. Soon, we will start to see an increase in repeat sales – that’s passive income – and any business should be interested in generating this.

How are you finding the partnership?

The team at GetHarley are very proactive. They are passionate about what they do and are genuinely supportive. It’s a mutually beneficial partnership, so everyone is focused on the same goal. I wanted some products to be in clinic to inspire customers to focus on skincare. So, my account manager helped me source samples

to do that, and we developed cards for different skin conditions like acne. The patient can take the card to reception and my receptionist inputs the regime into GetHarley so the products can be sent to their homes. It works so seamlessly.

Which brands do you sell via GetHarley?

Our best-selling brands are Obagi and skinbetter science. We do sell some Medik8 and other ‘affordable’ cleansers. It’s nice to mix it up so patients get products that are clinic-only alongside some affordable products so the total regime cost is not too expensive – we don’t want to put them off! It’s a smart way to do it as you will get more repeat sales from a £250 regime than from a £500 regime. It makes the patient feel their regime is just for them.

Does working with GetHarley help people graduate to in-clinic treatments?

Definitely! Patients gain trust in you and see you as the expert. We have noticed an increase in patients booking in-clinic skin treatments since working with GetHarley. They start to see a change in their skin from the products they are using, and are enjoying having good skin. They want to take it to the next level and book in for microneedling, facials, laser and more. It really has made a difference.

Why do you think people should join GetHarley?

There are many reasons, but honestly, I think if you don’t do it, your patients will go somewhere else. You are filling a demand and offering a more complete service. If your customers are coming for injectables, they want to invest in good skincare. We don’t have passive income for anything else that we do in-clinic, so it’s worth getting on board. It’s important to diversify your business and protect yourself, especially over the next year or so when it could potentially be difficult due to the cost-of-living crisis.

Funnily enough, working with GetHarley has helped my skin. I would tackle one imperfection and then be onto the next, but because I am now consistent with my own regime, I am seeing great results and am able to sell skincare plans better as I have had a positive experience myself.

Book in a FOC virtual demo at www.getharley.com/clinicians and quote AESTHETICSJOURNAL to skip our waitlist and get priority onboarding.

60 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com Aesthetics | March 2023 Advertorial GetHarley
This advertorial was written and supplied by GetHarley

A summary of the latest clinical studies

Title: Making Sense of Late Tissue Nodules Associated With Hyaluronic Acid Injections

Authors: Goodman G, et al.

Published: Aesthetic Surgery Journal, February 2023

Keywords: Complication, Delayed Onset Tissue Nodules, HA Filler

Abstract: The pathogenesis of delayed onset tissue nodules (DTNs) due to hyaluronic acid (HA) injections is uncertain. The objective of this study was to formulate a rational theory for DTN development and their avoidance and treatment through a multi-disciplinary and multi-country DTN consensus panel with 20 questions posed. Consensus was set at 75% agreement and was reached in 16/20 questions. The group believe that filler, pathogens and inflammation are all involved in DTNs, and that DTNs are most likely infection initiated. Injected filler may incorporate surface bacteria if the skin barrier is altered. The initially high molecular weight HA (HMWHA) filler is degraded to low molecular weight HA (LMWHA) at the edge of the filler. Commensals positioned within the filler bolus may be well tolerated until the filler is degraded and the commensal becomes visible to the immune system. LMWHA is particularly inflammatory in the presence of any local bacteria. Commensals may still be tolerated unless the immune system is generally heightened by viraemia or vaccination. Systemic pathogenic bacteraemia may also interact with the filler peripheral LMWHA, potentially inducing DTN formation. Given this scenario, practitioner and patient hygiene and early systemic infection treatment deserve attention.

Title: Efficacy of Platelet-Rich Plasma Versus Autologous Fat Transfer with Nanofat in the Treatment of Infraorbital Dark Circles

Authors: Alkhalifah A, et al.

Published: Dermatologic Surgery, February 2023

Keywords: Autologous Fat Transfer, Dark Circles, Platelet-Rich Plasma

Abstract: Treating infraorbital dark circles is one of the commonest aesthetic demands worldwide. Autologous fat transfer is commonly used to treat dark circles by filling the grooves, without effect on skin quality. Platelet-rich plasma (PRP) has been reported to improve skin quality. Autologous fat can be emulsified and filtered to produce nanofat, which is then injected superficially in the dark circles to improve skin quality and discolouration. The objective of this study was to compare the efficacy of PRP versus combined fat transfer and nanofat in treating infraorbital dark circles. 30 patients with infraorbital dark circles of combined etiological factors were randomised into two equal groups: Group A was treated with PRP and Group B was treated with autologous fat transfer with emulsified fat injection. Excellent and moderate responses were observed in three (20%) and two (13%) patients in group A, versus seven (46.7%) and four (27%) in group B, respectively. Non-responders were eight (53.3%) in group A and only one patient (6.7%) in group B. The difference was statistically significant regarding improvement (p = .048) and patient satisfaction (p = .032). Autologous fat transfer with nanofat is significantly superior to PRP in improvement and satisfaction.

Title: A Survey, Review and Future Trends of Skin Lesion Segmentation and Classification

Authors: Ahamad A, et al.

Published: Computers in Biology and Medicine, February 2023

Keywords: Computer-Aided Diagnosis, Skin Cancer, Skin Lesions

Abstract: The Computer-aided Diagnosis or Detection (CAD) approach for skin lesion analysis is an emerging field of research that has the potential to alleviate the burden and cost of skin cancer screening. Researchers have recently indicated increasing interest in developing such CAD systems, with the intention of providing a user-friendly tool to reduce the challenges associated with manual skin inspection. This article aims to provide a comprehensive literature survey and review of a total of 594 publications published between 2011 and 2022. These articles are analysed and summarised to contribute vital information regarding the methods for the development of CAD systems. These ways include: relevant and essential definitions and theories, input data (dataset utilisation, pre-processing, augmentations and fixing imbalance problems), method configuration (techniques, architectures, module frameworks and losses), training tactics (hyperparameter settings) and evaluation criteria. We discuss these dimensions to reveal their current trends based on utilisation frequencies. In addition, we highlight the primary difficulties associated with evaluating skin lesion segmentation and classification systems using minimal datasets, as well as the potential solutions to these difficulties. Findings, recommendations and trends can inform future research on developing an automated and robust CAD system for skin lesion analysis.

Title: Simultaneous Free Flap and Forehead Flap for Nasal Reconstruction

Authors: Yen C, et al.

Published: Journal of Microsurgery, February 2023

Keywords: Nasal Reconstruction, Nasal Surgery, Rhinoplasty

Abstract: Reconstruction of total or near-total nasal defects is challenging and requires the re-creation of three nasal layers. Fasciocutaneous free flaps have been used effectively for restoring the vascularised nasal lining and staged forehead flap for nasal skin replacement, but it is a long process. The aim of this study is to share our experience of combination of preliminary free tissue transfer with paramedian forehead flap reconstruction in the same stage of complex nasal reconstruction. The study follows 10 patients who underwent nasal reconstruction with free flaps, including four medial sural artery perforator (MSAP) flaps, five anterolateral thigh (ALT) flaps and one radial forearm flap for lining and forehead flaps for skin coverage simultaneously for total or subtotal nasal defects. Nasal obstruction symptoms evaluation (NOSE) score was utilised to evaluate the functional outcome, while the aesthetic results were evaluated with the last follow-up photos with score 1-5 by five plastic surgeons and five laypersons. The study concluded that combination of preliminary free tissue transfer for nasal lining restoration with a paramedian forehead flap for nasal skin replacement in the same stage may shorten the long process and achieve satisfactory reconstruction in complex nasal reconstruction.

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com

Blogging to Boost Patient Numbers

Whether you’re a seasoned aesthetic professional or just starting out, there’s no reason why you shouldn’t consider publishing a blog. As well as reaching new patients, well-written blog posts can reinforce your status as an expert in your field and keep your existing patients loyal. You may ask, however, what do you write about? Here, I will share the main benefits of blogging, as well as top tips for creating content.

Top three reasons to blog

1. Increase your website traffic

As well as helping you to build trust with your audience by showcasing your knowledge and expertise, a blog will help drive traffic to your website and, hopefully, encourage potential patients to book with you.

In fact, a 2022 study of 1,531 websites by HubSpot found that those with blogs got 55% more traffic than those without.1

Ideally, I would recommend posting a blog at least once a month and aim to keep the date consistent each time so followers will know when to expect it. If you have more time and lots of content ideas, you could increase to bi-weekly or even weekly blog posts. By sharing snippets of your blog posts on social media or asking other sources to add

the link to their website, you will encourage what is known as ‘social’ or ‘referral’ traffic.2 Visitors will likely be people who already know a bit about you – they may be a regular patient or someone who’s heard about your clinic and followed you to learn more. This type of sharing is great as it reminds people that you’re still around and could give them an idea of other things you can help with. What’s particularly valuable about blogging, though, is that every post you add creates another indexed page on your website, which can increase ‘organic’ traffic.2 This means you’ll have more chance of being seen by search engines and pushed higher in the search results of people who are looking for your types of services.

For example, if someone types in ‘is salicylic acid good for acne’ and you’ve written a blog post detailing what salicylic is, how it can help acne and when it should be used, then you could gain not only a website visitor, but someone who appreciates that you know what you’re talking about and are someone worth booking with.

Crucially, you must ensure that you’re using the right search engine optimisation (SEO) tools to be seen. This involves using relevant key words, meta titles and meta descriptions. There’s lots of advice online about how to

do this well – I’d recommend articles by Semrush and Google to get started.3,4 Turn to p.73 to find out how to put together an SEO strategy. As a Forbes tech article described, ‘Search engines will identify your website as a key resource that is providing valuable information that needs to be found. Typically, websites that have a blog have 434% more indexed pages.’5

2. Better understand your audience

Having a blog can also allow you to gain insight into your target audience. If you allow readers to subscribe, comment and like posts, then you’ll gain an indication of the topics they find most interesting and be able to tailor future content, as well as your products and services, to these interests.

Most websites will have a section where you can view your analytics or you can sign up to Google Analytics for free – do this on a monthly basis and track things like:6

• Number of visitors: compare what type of posts get the most attention

• Bounce rates: find out how quickly a visitor leaves your blog post page – higher rates for certain posts may mean the content wasn’t as engaging

• Average time on page: gain a good indication of whether visitors have skipped, scanned or read your blog post properly

• Top traffic sources: learn where most of your visitors come from and consider posting there more often

There are loads of other things you can analyse, but these statistics are a great starting point to give you insight into your blog posts’ performance and ideas of what you can tweak to better serve your audience.

3. Expand your patient demographic

While Instagram Reels and TikToks may seem like the most popular forms of content at the moment, it’s important to remember that your marketing strategy shouldn’t solely rely on these videos alone. To ensure your business reaches a wide demographic of potential patients, you need to consider varying your output and tailoring it to different platforms. This may sound like a lot of work but, in reality, if you start with a simple blog post, you can translate this into multiple forms of content that appeals to a wide variety of people. For example, if you were to write a blog on your ‘top 10 skincare recommendations’ you could use the information to also:

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
Freelance writer and editor Chloé Gronow details the value of creating a blog and shares ideas that will drive traffic to your website

• Create a Reel/TikTok of your skincare routine that incorporates your recommendations – great for those who are short on time

• Post images of your recommended products on Instagram – perfect to grab attention of those who love a visual • Film a YouTube video of your recommendations – some people learn better from watching/listening compared to reading a blog

• Expand on your points further in a longer-form article and pitch it to a local magazine for publication – reach those who aren’t as internet-savvy

As well as sharing the link to your blog alongside these social media posts, you should link to it in your patient newsletter to drive traffic further too.

Choosing effective blog topics

It’s all well and good having a blog, but it’s useless if it doesn’t add value to the reader. The key point to remember is that a blog shouldn’t be used as your online diary, full of your thoughts and ramblings that mean nothing to those who visit it. Instead, it should make a positive difference to readers’ lives and encourage them to take action.

Here are some ideas that will help you achieve this:

Answer FAQs

Every business will have frequently-asked questions. For an aesthetic clinic, these may be things like ‘How does this treatment work?’, ‘What’s the clinical evidence behind it?’, ‘How long until I see results?’ and ‘Will it hurt?!’

If you’re struggling to think of FAQs, try websites like answerthepublic.com or semrush.com where you can gain insight into what people are typing in search engines, on any subject you choose.

For each treatment you offer, create a blog post that answers these questions and invite readers to book a consultation for more in-depth advice.

Link to news

See what people are saying about aesthetics, and associated products and treatments in the press. Has a celebrity undergone a procedure you offer? Educate your readers on what they likely experienced and how the treatment works.

Recent great examples I’ve seen of this

include Judy Murray and her Morpheus8 procedure, and Shirley Ballas following NeoGen plasma treatment.7,8 Multiple clinics who offered these treatments were able to share their insights and tell internet searchers that they could help patients achieve similar results.

Don’t forget trade press… this very journal is an excellent source of industry news and some of it can be translated to a consumer audience. Take the recent updates on regulation as an example. Aesthetics reported that ‘Government Delays Proposed Licensing Scheme’.9 For your blog you can:

• Briefly explain what the licensing scheme is

• Detail why it is relevant to those having aesthetic treatment

• Highlight the impact the delay will have on patients

• Give your take on the scheme and point out anything else you think that should be done to benefit patients

Doing so will demonstrate that you care about patient safety, understand the complexity of regulation and are passionate about positive change that will benefit your patients.

Expand on statistics

One of my favourite quotes when I was training to be a journalist was ‘facts tell, stories sell’. Essentially, this means that a fact (or stat) will grab readers’ attention, but a story around it is what will keep them engaged. Again, this journal is a great source for statistics. You’ll notice a stats column published in the news section each month, covering all sorts of topics related to aesthetic medicine. Keep an eye on other specialty organisations and publications for more too. So, how do you make a story out of a stat?

Let’s look at this one: ‘38% of women said they would take action when they begin to notice sagging of face contours in the cheekbones, jaw and neck areas’.10 Your blog post could:

• Explain why women begin to see these changes as they age

• Address that it’s ok to want to take action

• Outline the treatment options that could help this concern

• Detail how they work and expected results – for each option, cover pain, side effects, potential complications, when you will see results, how long results last

• Share a patient testimonial from someone who has taken action that highlights their positive experiences

Statistics are a great way to get people talking and, importantly, sharing; ask your readers to share their perspective on your stats too – this will generate further reach and positive engagement.

Don’t forget…

Whatever type of blog post you decide to write, always remember to include a ‘call to action’ at the end of each blog post – what you want a reader to do next – whether this is book a consultation, share with friends or visit another area of your site to learn more. You don’t want to lose them just after you’ve attracted them with your great content!

Getting started

Hopefully you now recognise how valuable starting a blog can be to you and your business. As well as building trust in you as an aesthetic professional, it will drive those all-important clicks to your website that will ultimately lead your target audience to book treatments with you. And if writing is not your forte or you simply don’t have time, get in touch with an experienced writer or marketer for support.

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
Chloé Gronow is an experienced writer, editor and content manager, specialising in aesthetic medicine. She supports individuals and businesses with copywriting, blogging, social media strategy, editing, ghost writing, awards entries and conference management. Gronow has a BA (Hons) in English and Contemporary Media, and an NCTJ Gold Standard Diploma in Journalism.
VIEW THE REFERENCES ONLINE! AESTHETICSJOURNAL.COM
Chloé Gronow will be speaking at ACE on March 11 all about the benefits of blogging. Scan the QR code to register NOW.
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Incentivising Your Team to Sell

‘To sell is human’ – a phrase coined by Daniel H Pink who wrote a best-selling book with the same title in 2018.1 Yet, many clinics fail to prioritise recruiting staff with sales skills as clinical expertise and knowledge are foremost in their mind. Although this is important, having the ability to sell products, treatments and packages in-clinic is also key to running a successful business. Whether you select a few team members to be sales-focused or you encourage the whole team to actively sell, it is vital you have people in-clinic who can and will sell.

So, how do you incentivise your staff so they seek out opportunities to ethically sell additional products, treatments or packages to patients? Why should you incentivise someone when it may be part of their job description anyway? This article will take you through the reasons why your staff may need motivating and incentivising, as well as exploring ways to effectively do this.

Motivational drivers

What motivates someone in the workplace? survey conducted in 2022 asked more than 200,000 employees across 500 organisations about a variety of management topics, including company culture, opportunities, motivation and growth.2 One question asked was, ‘What motivates you to excel and go the extra mile at your organisation?’, with a choice of 10 options to select from. Surprisingly, money was not number one. It fell in seventh place with the results shown in Figure 1

Incentivising your staff using bonuses, commission and money alone is not enough to engage and motivate most people. Yes, it plays an important part and ties in with many higher-ranking motivations surveyed, but the benefits of feeling part of a team, recognition, professional development and job satisfaction all play a larger role and should be considered when setting targets and creating effective incentives.

Know your team

Before you effectively create a desirable commission or rewards structure, you must understand what motivates people. We all have different drivers, and what fires up one person may leave another cold, or worst-case scenario, turned off completely. This is something to be aware of and, to an extent, accommodate by using different ‘types’ of incentives. Start (and maintain) the process with communication. An annual appraisal is useful for managing staff and their professional development, but it is not enough to build sales incentives. Speak with staff frequently and organise a one-to-one every three months to discuss the soft skills around their role and the workplace. Do they have the desire yet lack the skills and need sales training, so they feel confident? How do they feel about selling and are those feelings positive or negative? Their view of selling is important to know so you can help turn any negatives into positives.3 If you have staff who see selling as negative, you need to help change their mindset. Have they seen a bad sales experience which affected how they view selling? If so, ask them what could be done to have made it positive. Next, identify good sales experiences and discuss how they benefited from it. For those who insist selling is not part of their role, or refuse to sell, try to reframe things. Show them how selling can mean assisting a patient to discover what will get them the best outcome or helping them feel confident about themselves. Both groups may benefit from specialist sales training, so they feel comfortable adding these skills to their role.

It’s also important to ensure your team that you are selling valuable solutions to your patients that you know will work and help them. Otherwise, your team might feel that they are selling for the sake of it to reach a target, which is what we want to avoid.

Once you know what drives and motivates each team member, examine the top two to

three motivators and build incentives around these. Most fall into one or more of the categories listed below. It is not enough to just have one ‘type’ of incentive. By creating different types, you will cater to all of the team.

Camaraderie and team spirit

When you have staff who thrive on being part of a team, group sales targets work well. Nobody wants to let the team down or be the reason they lose a bonus, treat or praise, so staff will motivate each other.

Create smaller teams by role and have them compete against each other (for example, front of house, practitioners, admin and therapists), or for smaller clinics, have just one. Set weekly or monthly team sales targets and reward winners with lunch or their choice of playlist in-clinic if they hit target. An incentive can be almost anything, so finding what motivates people can help tailor the reward to ensure maximum numbers of the team are onboard. Ensure the competition remains friendly, explaining that everyone can benefit from the increase in motivation and team spirit whilst acknowledging positive behaviour from anyone who tries, even if they fail, at the next team meeting. Consider quarterly or six-monthly targets with greater rewards such as dinner at a fancy restaurant or a visit to a spa.

Job satisfaction and self-worth

Staff who enjoy providing the best service and have pride in their career can be encouraged to sell if goals are created that reward this. Key areas that are effective with this group and result in sales as a ‘side effect’ include going above and beyond with customer care, positive patient feedback and number of referrals generated. A monthly award for ‘Staff Member of the Month’ with flowers, champagne or gift tokens could be a way to motivate and encourage these members.

Recognition and praise

With success comes recognition, and team members who hit their sales targets could be praised during team meetings, causing a positive effect on future performance. Consider having a ‘Wall of Fame’ in the staff room where the top performers’ names are updated each week or month. Ask your top performers to share tips and techniques during monthly sales meetings so others can learn from their success.

Professional and career development

Lack of career progression is a significant and reoccurring reason why staff leave

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
Business consultant Vanessa Bird discusses how and why you should incentivise your team to sell ethically
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aesthetic clinics, much to the detriment of your business. Therefore, if you can incentivise sales performance with the promise of promotion, extra responsibilities or additional professional training, you may encourage them to stay. If you are a start-up or have limited funds or opportunities to progress staff careers, identify a future date when you anticipate being in a stronger position to be able to do so, then talk about this with your staff so they understand the mid- to long-term opportunities.

Set incentives that encourage and reward consistently high performance, such as 12 consecutive months of exceeding sales targets to receive a bonus plus promotion. Set a quarterly sales goal where the top performer gets to attend an aesthetic conference or go on a training course. To differentiate this from their professional development, add extra-curricular bonuses when attending, such as a better hotel room than usual or a ticket to The Aesthetics Awards.

You may not believe you have the space or budget for more senior roles, but the more successful salespeople your team are, the more revenue you generate, allowing you to create new roles to benefit all staff. Promotions should be decided on several things, including merit, skill, talent and attitude, yet the overall selling skills of the team can bankroll promotions for everyone. You can then grow your business and invest in a second clinic or take on additional staff, giving you the opportunity to provide career progression for those who want it from all roles, not just the customer-facing selling roles.

Add selling to future job descriptions and incorporate it into all roles in-clinic. You’re likely to attract sales-positive staff who

understand the importance of selling to provide the best experience for patients. You don’t necessarily have to include detailed sales targets with commissions in every job description. For more clinical roles, adding that they will be expected to be open to learning and implementing soft-selling skills as part of their day-today responsibilities should be enough to encourage this conversation during the recruitment process. You can then assess their existing capabilities and training. You should always prioritise medical experience and training over sales for some roles, but having the communication skills necessary to sell, whether formally or informally, is a positive trait in any staff member.

Money

Financial rewards can ensure your highperforming staff members are remunerated well for their efforts. As well as a sliding scale of commission, set additional short-term targets over one to three months. This would be when staff receive a higher percentage commission if they sell a particular course of treatment or link-sell a specified amount of skincare. These higher percentage commissions are useful to encourage your team to sell less popular treatments, promote expensive packages or boost sales during quieter months.

Adding vision boards

In addition to offering a variety of reward systems to drive sales, it’s worth looking at additional techniques that can have a positive effect on performance. Vision boards are something you can implement for everyone. A vision board – a physical or digital collage of photos, images and words – can be a useful aid to motivate, inspire and boost

productivity. Neuroscientist Dr Tara Swart states that, “The brain assigns a higher ‘value’ to images than written words on a ‘to-do’ list, and the more you look at those images, the more they move up in importance.”4 Encourage staff to create their own board of things which motivate them. It could be a mix of designer items, home improvements, quality time with family and friends, a wedding, holidays or cars. It should inspire the person to work harder, motivate them when they are stressed or low, and remind them how selling in-clinic will benefit them. Don’t forget, once something on the board has been achieved, it can be replaced with a new goal or motivation.

Encourage selling in your practice

Incentivise good intentions and effort. Some people stop trying if they feel they cannot hit a target, become disillusioned if sales fall through or take a step back if they perceive others are ‘better’ at selling. In this instance, we want to encourage the right behaviour and a strong work ethic. Be open to occasionally rewarding effort and good actions so people don’t lose motivation if they fail to hit target. This is great when you have a new starter and could be done monthly or quarterly. A coffee shop gift card or allowing the person to have an hour off work one day could be good rewards for effort.

Vanessa Bird is the founder of The Aesthetic Consultant. She has more than two decades of sales experience and 14 years in the aesthetics industry. She now works with companies, clinics and practitioners to help them increase sales and grow their businesses.

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
Camaraderie and peer motivation Intrinsic desire to do a good job Feeling encouraged and recognised Having a real impact Growing professionally Meeting client/customer needs Money and benefits Positive superiors/senior management Belief in the company/product Other 20 17 13 10 8 8 7 4 4 9
4% 4% 7% 8% 8% 10% 13% 17% 20% 9%
Figure
1: Results of a survey highlighting motivations to excel at an organisation2
VIEW THE REFERENCES ONLINE! AESTHETICSJOURNAL.COM
Vanessa Bird will be speaking at ACE on March 10 in the In Practice Theatre. Scan the QR code to register for free.

Networking in Aesthetics

Whether you’re a fan of it or not, networking is a crucial part of growing your knowledge and connections in the aesthetics specialty. For practitioners, clinic staff and company representatives alike, networking facilitates conversations around advanced techniques, clinical innovations and business advancement which can be beneficial for all.

Networking can take many forms, and various contexts can prompt different conversations. The aesthetics specialty provides a range of networking scenarios, including large conferences like ACE and CCR, awards ceremonies like The Aesthetics Awards, meetings of associations like BCAM and BACN, product launch events, masterclasses and training courses.

In this article, plastic surgery registrar and director of training provider Acquisition Aesthetics Miss Priya Chadha and country manager for Hydrafacial in the UK and Ireland Lauren Gibson share their tips on overcoming the nerves to network efficiently and build your connections.

Getting started

Introducing yourself and initiating conversations, especially with respected industry figures, does not come naturally to all. Introverts comprise an estimated 30-50% of the adult population.1 While being an introvert does not necessarily coincide with being shy, according to international networking speaker Andy Lopata, many introverted individuals will find networking more difficult than natural extroverts

because they may prefer intimate conversations to large, overwhelming gatherings.2 In fact, according to psychology writer Olivia Guy-Evans, even some extroverts will be faced with nerves when in new and unfamiliar situations like networking events.3 However, apprehension does not have to be a barrier to networking successfully.

Miss Chadha shares, “When I first started out, I disliked attending conferences. I felt so awkward and was really hesitant to even attend for the learning. Networking began to get easier for me when I went into conversations with clear intentions. Instead of just going over and having a conversation with no direction, I approach people with a specific comment about their work or a particular area of interest. You don’t need to do this with everyone –that can drain your energy. Stick to people whose advice you think could prove useful to you in your personal or professional journey.”

Gibson highlights that there’s no shame in building on your networking skills gradually if you struggle with it, saying, “If you’re nervous, my advice is to slowly build your confidence. At your next event, take small steps to building your networking skills, grab a drink and do a circuit of the room, introducing yourself to a couple of people as you make your way round.” She suggests you could plan questions or topics of conversation before arriving at events to set your intentions, as Miss Chadha also recommends. Some of Miss Chadha’s frequent options include ‘How long have you been in the industry?’, ‘How do you see the industry changing over the next few years?’ or ‘What excites you the most about your work right now?’ Open questions such as this will trigger more interesting discussions, rather than a simple ‘yes’ or ‘no’. You can even compliment someone’s outfit as a way to initiate a conversation.

Making an impression

Networking events can often be a whirlwind, especially in the case of a conference with hundreds or even thousands of attendees. One challenge when introducing yourself is not only making a good first impression, but one that sticks – you need to be memorable. Miss Chadha says the best way to get on someone’s good side instantly is by being polite and kind. In fact, displaying warmer behaviour upon first meeting someone can prompt them to treat you more favourably in turn.4 Gibson believes just ‘being a person’ is the key to this. “I think we’ve got into this culture of our career defining us,” she says, “but sometimes that’s not what people want to hear. They want to know you as a person and what your story is in the industry, versus the business you’re working for.”

Gibson says that eye contact is one of the most important elements of any networking conversation. In fact, a 2022 study by Caroline Di Bernardi Luft et al. showed that two brains’ gamma frequencies become more synchronised when eye contact is maintained.5

Gibson explains, “We’re all so busy connecting with other likeminded professionals digitally, that we sometimes forget how great it feels when somebody really listens to what you’re saying, looks you in the eye, smiles and doesn’t interrupt you.”

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
Miss Priya Chadha and business manager Lauren Gibson share their advice on making valuable connections in the aesthetics specialty

Adding value to a conversation is another skill Miss Chadha and Gibson both emphasise. Just as you can consider what types of questions you want to ask going into an event, you can consider what you want to present about yourself as well. Gibson suggests entering a conversation by commenting on something you’re particularly passionate about to get the other person’s opinion. For example, ‘I’m really passionate about mentoring young people in aesthetics. What are your thoughts on this?’ This will allow you to instantly find common ground with people who could be valuable connections, she explains. Miss Chadha suggests that being clear and specific makes it more likely that you will achieve tangible results from a networking conversation. “I remember the people who come to me with a purpose,” she says. “Unfortunately, I can’t mentor everyone, so if someone comes to me asking if they can reach out after the event, there’s no guarantee I’ll get back to them. But if they come up to me and say, ‘Priya, your talk was great, could I have 10 minutes of your time tomorrow over a coffee to hear more about how you juggle work and motherhood’ or something like that, I’ll probably say yes. It’s finding the common ground and ensuring a more human connection. It’s really important to me that I know exactly how I can help you, and that can often be established in the first few moments of meeting. It’s a little more direct, but I certainly prefer that.”

Gibson highlights that if you attend events on the behalf of a company, it’s crucial not to spend the entire time selling your products. She explains, “At the end of the day, people buy from people, so if you are authentic, listen to what they have to say and don’t just think about how you are going to close that sale, the more positive the outcome will be.”

She says she never attends events with a sales target because the focus should be on the conversations. She believes that if people chat to you and feel like they’ve been in a sales pitch, it’s unlikely you’ll be able to close any sales. She continues, “If you get somebody excited about your brand, you might see them at the next event and the conversation kicks off again. If they feel like you’ve been genuine and authentic with them, they’re more likely to continue to engage with you.”

Building your circle

Networking is not just about climbing a ladder of experience by talking to industry celebrities. Miss Chadha shares that in her experience, creating a close circle of people at your level is just as important. She says, “Networking has allowed me to build my own network: my safe space which I always fall back on and who always give me security to keep going. So, build your network at your level, as well as above and below. People always think networking is social or network climbing, but you must build your own tribe to keep growing.”

She always says that knowing people at the same point of their career helps with mutual confidence building when attending

events. “The absolute key is having a partner (or partners) in crime. Somebody with whom your confidence immediately goes up when you’re together. You get on, you’re at the same stage, you’re growing together, you’re learning from each other. Having people like that gives you the solidarity and assurance that you sometimes really need,” she explains.

Miss Chadha highlights training courses or masterclass days as particularly valuable opportunities to build this ‘tribe’. She explains that you have immediate common ground as you’re all learning, and you can further your knowledge as well as your social circle by staying in touch after the course. This network is also valuable if you ever need any advice from those going through similar processes. She says, “My tribe is my bar, and every time one of us ups our bar, the others do too.”

Becoming established

If networking still sounds intimidating, both Miss Chadha and Gibson emphasise that nailing the fundamentals is the key to success, many of which will come more naturally than you might think. There are basics to networking you shouldn’t forget, like remembering someone’s name, with Gibson saying, “We forget to appreciate people and say ‘Thank you so much for that conversation, it was really great to connect with you’. Those little things stick in somebody’s mind after they’ve met you.” She says that once you lay these foundations with connections, there will be more and more familiar faces at each networking event you attend, and it’ll get easier to immerse yourself in them each time. Miss Chadha emphasises, however, that networking need not be a huge cause of stress. Whilst attending events is hugely useful, sometimes your comfort area is going to be the most productive place for you to grow. She says, “Maybe you want to network from behind a screen – send an email or a comment on Instagram. Maybe that’s better for you, and that’s okay.” Indeed, research from Jennifer Pickett et al. found that if an introverted individual tried to display extroverted characteristics for an extended period, they experienced depleted levels of vitality soon afterwards, showing that trying to act like an extrovert will not necessarily be effective when networking.6 A slow and steady development of your networking skills is the way to go when building connections in the aesthetics specialty.

ACE 2023 is the perfect opportunity to grow your networking skills. Come along to the In Practice networking drinks at 4:30pm on March 10 and the Hydrafacial networking drinks at 5pm to build your connections! Scan the QR code to register for free.

REFERENCES

1. Stewart C. ‘Are There More Introverts Than What We Think There Are?’ (US: LinkedIn, 2021) <https:// www.linkedin.com/pulse/more-introverts-than-what-we-think-carol-stewart-msc-finstlm>

2. Lopata A. ‘Why Introverts Excel at Building Professional Relationships’ Psychology Today (US: Psychology Today, 2022) <https://www.psychologytoday.com/gb/blog/connectedleadership/202209/why-introverts-excel-building-professional-relationships>

3. Guy-Evans O. ‘Signs You’re an Extrovert with Social Anxiety’ Simply Psychology (2021) <https://www. simplypsychology.org/can-extroverts-have-social-anxiety.html>

4. Berscheid E, Snyder M, Tanke E. ‘Social perception and interpersonal behavior: On the self-fulfilling nature of social stereotypes’ Journal of Personality and Social Psychology (1977) <https://psycnet.apa. org/record/1979-26014-001>

5. Di Bernardi Luft C, et al. ‘Social synchronization of brain activity increases during eye-contact’ Communications Biology (2022) <https://www.nature.com/articles/s42003-022-03352-6>

6. Pickett J, et al. ‘Concurrent and lagged effects of counterdispositional extraversion on vitality’ Journal of Research in Personality (2020) <https://www.sciencedirect.com/science/article/abs/pii/ S0092656620300532?via%3Dihub>

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
Apprehension does not have to be a barrier to networking successfully

Time to Go Paperless

For many aesthetic practitioners, too much time is spent keeping on top of the admin and record-keeping that needs to be done. Does this sound familiar? Even in 2023, some practitioners have not ‘gone paperless’ because of worries that they’re not ‘tech savvy’ or their clinics are ‘too small to need software’. However, taking on Aesthetic Nurse Software (ANS) for your clinic will be like getting your own digital business partner, with an amazing team on hand to support you. At ANS, we understand that your time is valuable. That’s why we’ve created a software designed to support practitioners like you! Here’s how you can free up time and see more patients by utilising ANS…

Automatically send forms

ANS provides you with the forms you need, whenever you need them. You can completely automate forms to be sent to patients before their treatment, saving you hours in clinic! Medical history, consultation consent and aftercare forms can be completed securely by patients from home.

Bookings made easy!

A 24/7 online booking system means you’ll never miss another booking! Patients can book and reschedule appointments online, cutting out the back-and-forth to arrange appointments. ANS makes it easy for your patients to book via your website, social media and Google. You can also seamlessly collect a deposit to secure bookings.

Impress patients, keep them coming back and reduce no-shows

ANS will automatically take care of appointment reminders and follow-up messages, helping to reduce no-shows, collect online reviews and increase repeat bookings without lifting a finger!

Peace of mind for secure patient records

“My patient records are safe, confidential and protected.” Those are the words of one ANS practitioner. Do you have the same confidence that your patient data is as secure as it should be?

ANS uses secure sockets layer (SSL) security with end-to-end encryption to ensure patient records are completely secure, as well as making sure data is backed up so you can have peace of mind that sensitive records won’t be lost, whilst supporting you in complying with data protection requirements. Medical history, contact details, photos, sensitive notes and other patient information are organised against individual patient records.

Take the stress out of staying compliant

We all know the importance of maintaining you may have unintentional gaps if you store batch numbers, before and after photos, consent forms and medical questionnaires in separate places and on different devices.

ANS provides a clear clinical pathway to

follow for each treatment to ensure you complete all documentation required after patients leave your clinic. ANS supports you to comply with professional requirements for record keeping (NMC, GMC, and GDC) and GDPR, as well as insurance.

Dr Sharan Uppal – Owner of PegiDay Aesthetics

“I enjoy how versatile the software is. I can access the software with ease whether I’m on my mobile, iPad or laptop. It allows me to check my diary and make amendments on the go. The touch screen annotations on treatment diagrams are intuitive to use. It makes my note keeping easy and is brilliant when looking back at my treatment plans. There are so many great features, and even sending forms and reminders prior to appointments is easy for a technophobe like myself!”

If you’re still undecided, here are a few reasons why more than 1,500 clinics have partnered with ANS:

• Fantastic support – Our award-winning support team is praised by practitioners for going the extra mile. We’re not just a software solution – we’re real people who are just a phone call away.

• Simple to use – We designed ANS to be easy to use, even for technophobes! No more frustration with overcomplicated, clunky software. Just everything you need at the touch of a button.

• Affordable for any clinic – Whether you’re starting out or have a successful clinic, ANS will support you without breaking the bank.

This advertorial was written and supplied by Aesthetic Nurse Software.

For more information contact, www.aestheticnursesoftware.com or info@aestheticnursesoftware.com 0330 133 2122

Instagram: @aestheticnursesoftware

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Creating an SEO Content Strategy

Content planning for search engine optimisation (SEO) purposes is an essential aspect of digital marketing for every business, and aesthetic clinics are no different. However, no aesthetic practitioner wants to fill their already busy days even further. So, here, we’re going to simplify things a little with some clarity on the process you need to follow, and give you a head start with some techniques which will improve your marketing performance more rapidly.

First steps: definitions

First up, a few definitions. SEO stands for ‘search engine optimisation’. When you run a search on Google, something has to decide in what order the thousands of results are listed. That something is an algorithm – a set of rules. As a business owner, you want your website to appear near the top of the list, and SEO is the art of understanding the algorithm and abiding by its rules for the best exposure.

This causes content planning to matter because the ‘usefulness and relevancy’ of content is one of the key criteria by which the algorithm judges the strength of your website.1 An effective content plan will improve your search engine rankings and drive more traffic to your website.

The official process

There’s a relatively simple process for basic SEO optimisation – this will be our starting point and will give you the basic principles. However, as business (and SEO in particular) is intensely competitive, once we’ve got this baseline in place, we can look at some additional smart ways of reducing time and effort while raising the quality of our SEO performance. The below provides a standard SEO process.

Keyword research

Among other things, those algorithms look for keywords. It’s no surprise that someone who types ‘Aesthetic Practice’ or ‘Dermal Fillers’ is looking for someone like you. Keyword research will help you identify the keywords and phrases that your target audience is searching for

when looking for aesthetic services, so you can include them in your content. Google Keyword Planner and Semrush are some resources to help with this.2,3

Refine for your target audience

We all operate in different parts of the market. Look at the town or city you are based in. Which group/groups of people are you targeting? Mid-market? Mainly female? Or higher-end/high disposable income? Athletes? Working parents? Identify the demographic, interests and concerns of your target audience and tailor both your keywords and content to meet their needs. Drop the keywords they won’t use (for example, devices or products that you don’t offer or which don’t solve their problems) and keep the ones which do.

Create a content calendar

Plan and organise your content in advance, typically in three to four month blocks, and ensure that you are regularly publishing new and relevant content to your website. Your content, which you will ideally be publishing at least two to three times per month, should be simple, informative, include your keywords and provide value to your target audience – don’t just sell. Whatever you create or read, always watch it back. Ask yourself: would I be glad to read this as a customer? If you can’t say yes to that, go back and revise.

If this sounds like hell, don’t worry – we’re going to come back to this below.

Optimise your content for SEO

Adding your keywords was a good start. But SEO is incremental. The more ‘goodies’ you can add, the better.! Make sure that blogs, for example, have titles and descriptions (which helps Google tie your content to relevant searches). Include images and videos in your content if you can, as this will make it more engaging and shareable, as well as adding links to other websites. All of these have value to search engines. Don’t spend a lifetime looking for SEO bonus points, though – nobody can do everything.

Don’t forget to measure the results

Use tools like Google Analytics to track the traffic to your website, seeing which of your marketing channels are delivering traffic, and which of your blog articles are garnering the most engagement. Look at tools like Google Search Console or MOZ.com and keep an eye on those keywords as they can change at any time.4,5

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
Digital consultant Rick O’Neill discusses how to optimise your content with an SEO strategy

The black-belt approach

You’ll find variations of the above process in countless books and websites, and it works just fine. There are two shortcomings, though. First, it’s all good for a highly-resourced business, but most aesthetic practices are under-resourced (that’s not a criticism – it’s just the truth!). You don’t have the time to create acres of content on a scattergun basis and hope for the best. Second, in my view, it lacks ambition. Aesthetic patients seek education, comfort, expertise and nurturing and you can be the person to provide it.

With the right approach and the right content, you can become the respected practitioner for local customers seeking answers to their valued questions. Your website can become the ‘go to’ source of trusted insight. The above process is entirely valid and an important introduction to the field. But we now have an opportunity to turbo-charge it with a ‘black-belt’ approach to content planning.

Rock solid ideas

Answerthepublic is a great resource which assesses the questions which people type into Google, thereby giving you every possible question a potential patient could ask about every treatment that you offer, prioritised according to the frequency of search.6 For example, for dermal filler, key questions include:

• How do dermal fillers work?

• Are dermal fillers safe?

• Can dermal fillers be dissolved?

• Where can dermal fillers be used?

You can already see that just being able to answer these questions (in blogs, videos, podcasts) is an exceptional way to reach your customers with credibility, with the sure knowledge that you’re giving them information they respect and genuinely need.

Cross reference these terms with Google Trends and you can even discover which products, themes and questions are peaking in popularity for an even more laser-focused approach to content ideas. Tools like these will give you an endless source of questions which you now know will add value and be appreciated by your customers. Provided you can compete with existing resources to answer these questions by being more thorough, considered, targeted or local, you’re in great shape to create a world of respected

content which will move the needle on your customer acquisition.

The advice above from the core process still stands – a great article is around 1,500 words long and optimised for keywords, and you should bring it to life with imagery, video, storytelling, bullet lists and graphics.7

Produce once, reuse plenty

All that said, producing content still requires a little time and effort. A raft of artificial intelligence tools are coming to the fore which make producing text, audio and video easier than ever, but it’s still another job which needs to be done. It will therefore almost certainly make sense to outsource your production work, but whether you do that or handle it in-house, it makes both financial and marketing sense to maximise the value of the creative assets you produce by reusing and distributing them across all your channels. That means taking, say, a blog- and then re-purposing it as a video for your website, social and YouTube channels. You have an extraordinary range of reuse options:

• Try taking three key points or themes from the article and turning them into social posts which offer different perspectives on the theme or answers to it

• Create short excerpt versions of the article to post into your Google local business profile, to meet the needs of people searching for local providers

• Deliver them as part of an educational email campaign for your patients and potential newcomers, raising your credibility with each email and reminding them of your expertise so that when the time comes to make a purchase, you’re the first port of call

This, of course, works for other initial media, too. If you happen to be more comfortable in front of a camera than a pencil, that’s just fine. Produce video answers, but then repurpose them into text, snippets and social clips too. Again, there is an increasing list of automations to help you – rev.com, for example, is very good for transcribing video into text which can then be used as the basis of a blog (turn to p.62 to learn more about the benefits of blogging). Rev.com will also instantly create subtitles for your video – perfect for people browsing on social media without sound.8

Content planning for SEO success

SEO is a necessary evil of digital marketing. The sort of person who becomes an aesthetics specialist is not generally the sort of person who likes the repetitive precision of SEO research. We feel your pain. To make it easier and dramatically more effective, the ‘black belt approach’ – produce materials which can position you as an expert in every condition and treatment type you cover, and then distribute it with minimum effort across all channels – comes with a significant benefit. It positions you not only as the right local business owner, but also as the undisputed authority in your market. That’s got to be good for the soul as well as your business.

Rick O’Neill, is a digital consultant to the medical aesthetics, cosmetic surgery and pharma sectors. With more than 20 years’ experience in digital marketing, he is the founder and owner of the digital agency Look Touch & Feel based at Silverstone Race Circuit. O’Neill is a founding partner of The Aesthetic Entrepreneurs, investor and advisor to many other digital businesses. He is also currently digital consultant UK and Europe to a well-known aesthetics company.

Rick O’Neill will be speaking at ACE on March 10. Scan the QR code to register now.

REFERENCES

1. Julia McCoy, “Why Content Is Important for SEO”, Search Engine Journal, 2021 <https://www.searchenginejournal.com/ seo-guide/content-important-seo/>

2. Google Keyword Planner, Choose the Right Key Words, <https://ads.google.com/home/tools/keyword-planner/>

3. Semrush, Captivate Your Audience, <https://www.semrush.com/ lp/sem-aeoy/en/?kw=semrush&cmp=UK_SRCH_Brand_Semrush_Exact_BING&label=brand_semrush&Network=o&Device=c&utm_content=&kwid=kwd-81638924210645:loc-188&cmpid=412439686&agpid=1306220117253722&BU=Brand_ Semrush&extid=&adpos=&msclkid=4db7524e452a12bbed293196a8ff57db&utm_source=bing&utm_medium=cpc&utm_ campaign=UK_SRCH_Brand_Semrush_Exact_BING&utm_term=semrush>

4. Google Search Console, Improve Your Performance on Google Search, <https://www.bing.com/>

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
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In The Life Of Dr Catherine Fairris

Dr Catherine Fairris shares a typical day in-clinic and how she juggles her role as BCAM president

A typical working day…

I’m not a morning person, but I’m a mother of two so I normally get up around 6:15am-6:30am because my mornings are quite hectic! Before sorting out breakfast and the school run, I take about 15 minutes for myself to go through emails and put together a mental to-do list before heading to clinic. I get into my clinic Wessex Skin Clinic in Winchester at about 8:30am, with my first patient at 9:20am, so there’s plenty of time to prepare my treatment room, change into my scrubs and have a huddle with my team to plan the day ahead. Some days the huddle will be discussing any supply issues or how to navigate a difficult patient who’s coming in, but sometimes it is just a nice chance to chat with my team and answer any questions. I perform a wide variety of treatments throughout my day. Patient demand used to be firmly on the classic Botox from Allergan and Teosyal dermal filler from Teoxane, but recently I’ve noticed body treatments coming more into focus. I’m providing more procedures like CoolSculpting and radiofrequency microneedling nowadays, as my patients are looking for solutions to issues like loose skin, excess fat and stretch marks. Medical-grade skincare has become more of a priority, and my patients have been loving Obagi and skinbetter science. I also offer personalised skincare packages through GetHarley which works well for patients who want a convenient and cost-effective option. When choosing new products or devices, I examine the evidence-based data before opting for them, and I always look for US Food and Drug Administration (FDA) approval because I think it indicates a high standard of efficacy and safety.

I know it doesn’t sound great, but I don’t take a lunch break during a day in my practice. Because of my other commitments and because I want to ring-fence time for my family life, I’m only in-clinic three days a week so I want to optimise my time with my patients while I’m there. I’ll grab a couple of proteinrich snacks or pieces of fruit during the day, but I typically work straight through from 9am to about 4:30pm.

Career if you weren’t a practitioner…

I’d own a café. I’d bake cakes and chat to my customers, and maybe get a little van to sell coffee at festivals.

Favourite thing to watch or listen to right now…

I binged White Lotus over Christmas which was brilliant, and my family is loving the Harry Potter audio books.

Ideal holiday destination…

I’d love to island hop around Asia to explore places like Hong Kong, Thailand and Singapore.

After work, I usually manage to do the school run, and then in the evening I can make some time for myself. Staying active is a big priority, both for my physical and mental health. I recently got a Peloton and it’s revolutionised my life, so I might do a 45-minute spin or some pilates or yoga. I’m also doing my dermatology diploma with University College Dublin at the moment on top of everything else, so I have to make time to study too. Sometimes I’ll go out for a dinner with colleagues or my girlfriends to wind down and make sure I stay sane!

Other work commitments…

I am the president of the British College of Aesthetic Medicine (BCAM), so a few hours every week is dedicated to my responsibilities there. Once a week, I’ll touch base with the BCAM team to address anything like media requests, questions from members or educational queries. Some weeks there are more significant commitments like board meetings with other associations such as the British Association of Cosmetic Nurses (BACN), which are particularly important now as we’re providing contributary evidence to the UK Government’s plans for a proposed licensing scheme for non-surgical cosmetic procedures in England.

I really value my work with BCAM because I think it’s crucial for aesthetic practitioners to have a source of support and learning that’s focused on clinical evidence and safety. I’m a bit of a geek and I love learning so it’s the perfect responsibility for me, and it is such an honour to be president! We recently announced that the BCAM Conference will return on September 30 at Church House, Westminster, so I’m looking forward to that already!

Most memorable day…

I think it would have to be the BCAM Conference 2022, because it was my first conference as president and I also organised the day. It was very hectic, but I was so proud because of the part I’d played in putting together the clinical agenda and inviting the incredible pioneer of botulinum toxin Dr Jean Carruthers to join us from Canada. As I stood on the stage during my opening speech and saw so many people who had come from around the world to attend, I felt an immense sense of accomplishment.

But really, any day when a patient leaves my clinic with happy tears in their eyes because I’ve made them feel good always sticks in my mind – that’s what I do it for!

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com

The Last Word

Mr Dalvi Humzah and aesthetic nurse Telisha Jenkinson debate the pros and cons of opening a clinic with a business partner

The prospect of setting up an aesthetic clinic can be an exciting but daunting venture. Knowing where to start and navigating through the clinical and business aspects can be a challenge. You may contemplate whether it is best to go at this alone or with a business partner. Some argue there is little benefit in having a partner, only causing frustrations with shared authority, conflict over decisions and different approaches to work, practice and business.1 However, after recently going into business together alongside two other non-clinical partners, we believe this approach can and should be considered.

The pros of partnership

One of the most obvious reasons to open a clinic with a business partner is that the financial burden can be spread between one or more parties. This allows for lower start-up costs and you might even be able to invest more money into the business which you might not have been able to do on your own. For example, buying a bigger space for your clinic, investing in an additional device or employing an extra staff member.

Alongside this, you are able to develop strong, trusting relationships with your colleague and build a foundation whereby you can learn from, and support, one another; this is crucial in aesthetics. Every practitioner has a plethora of unique experiences, knowledge, skills and expertise, and by collaborating, practitioners can identify individual and collective strengths and weaknesses. For example, when forming our partnership, we were able to bring both surgical and nursing aspects into the practice. Our backgrounds allowed us to plan a holistic patient pathway from non-surgical, energy-based treatments to surgical options. By starting a partnership, we could offer patients both entities of aesthetics as well as joint skills and knowledge. Also, by having the support of two non-clinical partners, all aspects of the business were effectively managed. Therefore, going into business with a partner(s) can introduce support and structure to a clinic, instead of responsibilities all falling onto one person.

Partnerships are not for everyone

We are fortunate to have a successful four-way partnership at Beechwood, but we appreciate this structure is not for everyone. As someone with your own ideas, level of expertise and vision for business, bringing these together with another individual can be tricky if they don’t merge well. Entering a partnership can be difficult – instead of having just one boss, there are two or more. You might prefer to make your own decisions, have different ways you think the clinic should be run or have conflicts over who to hire. Therefore, it’s important that whoever you go into business with has similar morals and ethics to yourself and that you carefully consider if this option will work for you long-term.

Tips for success

For a successful partnership, we believe it’s important your partner(s) fit comfortably together. You need to ensure you agree on crucial factors such as the clinical environment and standards,

your plan for business growth, the clinic location and business goals, among other factors. Business partners don’t necessarily need to have the same skills and attitudes, but the clinic will need both clinical and administrative input and it’s important to consider how this will be dealt with. Some questions we asked ourselves before going into business were: do we agree on how we see the business developing? How do we complement one another? Are we in agreement on the level and quality of training and education we must bring and work towards? Are we comfortable sharing finances? Do we agree on what this partnership means and are we able to communicate effectively? The questions were endless, but it was important that we could answer them during a sit-down meeting and feel reassured with our responses.

From the outset, ensure you agree on the type of legal entity you are developing. All partners need to feel secure, as well as having the reassurance that your patients will be safe and not impacted negatively by any outcome. Confirm how decisions will be made, and how you will agree on proposed changes, implementations or developments within the business. By entering a partnership, you need to ensure you have trust, especially if one of you decides to leave.

Collaboration is key

No matter what you decide, we believe a business in medical aesthetics cannot grow without the support of others, whether that is suppliers, patients or business partners. Maintain your focus on ensuring the best service for your patients, providing innovative treatments and accessing high-quality training from industry-leading professionals. Whether you decide to become part of a partnership or start a business on your own, effective relationship-building is vital to the success of your business.

Mr Dalvi Humzah is a consultant plastic surgeon and delivers his clinical practice through PD Surgery and Training Ltd. He has recently opened Beechwood House Healthcare and Aesthetics Clinic. He is also director of the award-winning Dalvi Humzah Aesthetic Training and clinical director of Derma-Seal Ltd.

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

Telisha Jenkinson worked as a registered nurse for 14 years with a background in gynaecology and sexual health. She has been an aesthetic nurse since 2018 and is the lead clinical nurse at Beechwood House Healthcare and Aesthetics Clinic in Wolverhampton.

Qual: RN, SCPHN (HV), FNE, MSc

Telisha Jenkinson will be speaking at ACE on March 10 in the In Practice Theatre. Scan the QR code to register for free.

REFERENCES

1. Duncan S, ‘The Advantages & Disadvantages of Business Partnerships’, Real Business, 2022, <https://realbusiness.co.uk/advantages-disadvantages-business-partnerships>

2. Sines D, ‘Standardising Aesthetic Care’, Consulting Room: Your Aesthetic Partner, 2022, p. 16-17.

3. Adams A, ‘Building The Mindset of a Successful Clinic Owner’, Aesthetics Journal, 2022 <https:// aestheticsjournal.com/feature/building-the-mindset-of-a-successful-clinic-owner>

Reproduced from Aesthetics | Volume 10/Issue 4 - March 2023 @aestheticsjournaluk Aesthetics Aesthetics aestheticsjournal.com
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