MARCH 2022: The Business Issue

Clare Amrani explores the use of botulinum toxin for migraines

Working Around Business Pitfalls

Four specialists explain how to keep your clinic moving

Anna Baker discusses considerations for LED phototherapy

Managing Staff Recruitment in Your Clinic

Anna Gunning examines maintaining relationships with staff

BEFORE 4 WEEKS AFTER 1 TREATMENT

Photos courtesy of A. Renta, MD

BEFORE 12 WEEKS AFTER 1 TREATMENT

Photos courtesy of Dr. Tatiana & Dr. Rishi Mandavia

With the Aesthetics Conference & Exhibition and The Aesthetics Awards taking place on March 11&12, it’s going to be a busy month! ACE is going to be the first opportunity this year for the whole aesthetic specialty to get back together again for two days of learning, networking and connecting with key industry suppliers, so it’s not to be missed! You can learn more about the free incredible content and expert speakers on p.18 We have sold out of Aesthetics Awards tables! We have almost 800 people from across the industry attending the first ceremony since before the pandemic and I can’t wait to see you all for an evening of recognition and celebration. Good luck to all Finalists! In the journal this month, we focus on growing your aesthetic practice and have some excellent business articles. You can learn about common business mistakes and how to avoid them (p.21), recruiting successfully (p.60), business outsourcing (p.65), and how to become more environmentally sustainable (p.71). If you are an Aesthetics

Shannon Kilgariff Editor & Content Manager @shannonkilgariff

journal Full Member you will have also received the Spring issue of Beauty Uncovered magazine featuring Karren Brady! We hope your patients love it. Remember if you would like to share this great resource with your patients to get in touch –hello@beautyuncovered.com. Finally, I would also like to announce that Chloé Gronow will be stepping down as Editor of the journal. I am sure everyone in the industry will greatly miss Chloé (myself included) but I’m excited to say that she will still be working with us on a freelance basis, and I look forward to our future collaborations together. With Chloé stepping down, I have been appointed full-time editor and content manager! It’s a challenge I am delighted to accept, and I am very excited to work with our amazing team, as well as our expert Clinical Advisory Board, contributors, clients, and other key industry stakeholders to deliver world-class content for the Aesthetics, Beauty Uncovered and CCR portfolios. If you see myself or the team at ACE or the Aesthetics Awards on March 11&12, be sure to come and say hello! You should also pop into our Aesthetics, Beauty Uncovered and CCR exhibition stands to learn more about writing, subscribing and our events portfolio. See you soon!

Clinical Advisory Board

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

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.

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

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.

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.

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.

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 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.

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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.

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Sharon Bennett, Clinical Lead

Injecting the Male Mid-face

Three practitioners provide techniques for treating the male mid-face

Dr Kim Booysen discusses whether ultrasound is something you should consider

Exploring Skin of Colour and Laser Hair Removal

Dr Baldeep Farmah details how laser hair removal can be accessible for SOC

Rosey Drewitt-Staples provides her approach to rejuvenating the perioral area

Anna Baker discusses the considerations around LED phototherapy

Lucy Williams outlines the potential causes of botulinum toxin resistance

Growing Your Practice Integrating skincare into your patient’s treatment journey

Dr Mayoni Gooneratne discusses feelings of guilt and shame among patients

Mr Benji Dhillon reflects on his career and presents tips for success

The Last Word: Treatment Room Mirrors

Nina Prisk presents her thoughts on having mirrors in treatment rooms

Special Feature: Working Around Common Business Pitfalls

Page 21

Clinical Contributors

Clare Amrani is an independent nurse prescriber and director for Luvenis Aesthetics. She is a board member for the BACN and is a technical expert marker for VTCT for Level 7 in Aesthetic Medicine. Amrani is completing an MSc in Cosmetic Medicine.

Anna Baker is an aesthetic nurse prescriber, trainer and qualified educator. She is a key opinion leader, BACN Board member and jointly leads on the BACN Education and Training Committee. Baker is the owner of Anna Baker Aesthetics.

Dr Raul Cetto practises at Clinic 1.6 London, specialising in aesthetic medicine and has been awarded a Diploma in Otolaryngology and Head and Neck Surgery from the Royal College of Surgeons of England as well as completing the College’s membership examinations.

Dr Lee Walker is an aesthetic dental surgeon, director and clinical lead at BCity clinics, with more than 20 years’ experience in aesthetics. He is the a visiting professor of Aesthetic Medicine at the Andres Bello University Santiago, Chile and is chairman of CMAC.

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

Dr Baldeep Farmah is the medical director of Dr Aesthetica. His aesthetic skills are combined with years of experience as a psychiatric consultant. He specialises in offering patients results which leave a positive impact on their mental and emotional wellbeing.

Lucy Williams is an independent nurse prescriber with more than 10 years’ experience. She is the owner of Aurielle Aesthetics. Williams completed Lee Walker Aesthetics Academy and continues to educate and evolve her skills and profession within the industry.

Talk #Aesthetics

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Thank you to @aestheticsjournaluk for the feature discussing this great topic in the February edition!

Statistics

Report shows plastic surgery procedures declined in 2020

Recent statistics released by the International Society of Aesthetic Plastic Surgery (ISAPS) have highlighted the impact COVID-19 has had on plastic surgery throughout 2020.

#Filming

Dr Lee Walker

@leewalker_academy

Had fun today filming with @teoxane_uk.pro safe to say that filming is not my thing!

#Education

Dr Joshua Van der Aa @drjoshualondon

Last week I was honoured to be invited to shadow the incredibly talented @drdominicbray while he performed a face and neck lift #education

The report was sent to approximately 25,000 plastic surgeons in the ISAPS database. Data from 1,081 surgeons was compiled for the survey. According to the report, plastic surgery procedures decreased by 10.9% in 2020, with 77.8% of surgeons globally experiencing temporary practice closures during the pandemic. Despite this, non-surgical procedures, primarily dermal fillers and hair removal treatments, continued to increase, but by lower proportions than previous years (5.7% in 2020, compared to 7.6% in 2019). The most common surgical procedures worldwide remained the same during 2020, with breast augmentation resulting in 16%, liposuction 15.1%, eyelid surgery 12.1%, rhinoplasty 8.4% and abdominoplasty 7.6%. The top five non-surgical procedures also remained consistent with botulinum toxin at 43.2%, hyaluronic acid at 28.1%, hair removal at 12.8%, non-surgical fat reduction at 3.9% and photorejuvenation at 3.6%. Around 85% of non-surgical procedures were performed on women. The age distribution for different procedures showed that 19-34-year-olds made up the highest proportion undergoing rhinoplasty (67.9%), whilst 35-50-year-olds accounted for a majority of botulinum toxin procedures (50.2%).

Expansion

BCAM appoints new management team

#Skin

Dr Ifeoma Ejikeme

@dr_ifeoma_ejikeme

I did a thing today! Had a blast chatting to @stephlunch on @packedlunchc4 on how to build a skincare regime using my signature five steps with products

#Business

Dr Simon Zokaie

@drsimonzokaie

Thank you @jayneproson and John for a great meeting. We had a day brainstorming and doing a deep dive into our business

The British College of Aesthetic Medicine (BCAM) has appointed a new Board of Trustees member and vice president. Aesthetic practitioner Dr Catherine Fairris has been appointed vice president to work alongside president Dr Uliana Gout. Her role involves increasing public outreach, working with stakeholders on regulation and expanding events such as the annual conference and members’ educational brunch sessions.

Dr Fairris said, “I feel privileged to have been given the opportunity to take on this role. I look forward to working with the rest of the Board to accomplish more great things for BCAM.”

The BCAM Board of Trustees has also expanded with the addition of aesthetic practitioner Dr Rupert Critchley. He commented, “It’s a privilege to be selected as a trustee for BCAM. I am passionate about creating change in the UK aesthetics sector and I believe in improving safety standards and regulations, standardising training pathways and educating responsible injectors to help this industry evolve.”

The BCAM will be exhibiting at the Aesthetics Conference & Exhibition (ACE). Register free on p.19.

Aesthetics Awards tickets sell out

Tickets for the Aesthetics Awards are officially sold out! The Awards ceremony will take place at the Royal Lancaster Hotel in London on the evening of March 12, after the Aesthetics Conference & Exhibition. The evening will involve a drinks reception, a delicious three-course dinner, the exciting Awards ceremony with celebrity host Cherry Healey, followed by dancing and live music. Editor and content manager of Aesthetics, Shannon Kilgariff said, “We are so excited to bring the industry together and hold a live Aesthetics Awards ceremony! Good luck to all our Finalists.”

Galderma releases Restylane Eyelight

Pharmaceutical company Galderma has launched hyaluronic acid filler Restylane Eyelight in the UK. According to the company, the Restylane Eyelight aims to reduce undereye shadows caused by a lack of volume in the area. The product contains hyaluronic acid, which is part of Galderma’s NASHA gel technology, combined with lidocaine. A clinical study demonstrated that six and half months after the first treatment, 88.6% of people reported looking less tired, 91.4% felt attractive due to the improvement in their dark circles and 94.3% who tried Restylane Eyelight said they would recommend it to a friend and repeat treatment. Galderma will be exhibiting at the ACE on March 11-12. Turn to p.19 to register now!

Botulinum toxin

Croma-Pharma unveils new toxin

On January 25, aesthetic manufacturer Croma-Pharma confirmed completion of the decentralised procedure for its new botulinum toxin. According to the company, market authorisation has also been received in France and Austria with the next step being to gain market authorisation for Letybo Europe across all territories. The toxin has been indicated for the treatment of moderate to severe glabellar lines. The submission in Europe is based on the data of three completed, randomised, placebo-controlled phase three trials which enrolled a total of more than 1,000 subjects in Europe and the US. Croma has licensed the product from the Korean toxin producer Hugel Inc and established a joint venture company. This is to develop and commercialise its hyaluronic acid dermal filler products with Hugel’s botulinum toxin products. Andreas Prinz, managing director at Croma-Pharma, said, “We are pleased to announce that our toxin has completed the decentralised procedure in Europe and will continue with the market authorisation in major European countries in the next few months.” Croma-Pharma will be exhibiting at ACE on March 11-12. Register free on p.19.

Vital Statistics

In a survey of 204,493 internet users, 77% used social media to search for more information on brands (GWI, 2022)

The top aesthetic treatments in 2021 were dermal fillers, scar removal, mole removal and thread lifts (WhatClinic, 2022)

In a survey of 3,800 women in the UK, 99% felt their perimenopausal or menopausal symptoms led to a negative impact on their careers (Newson Health Research and Education, 2021)

Customers are around four times more loyal to eco-friendly businesses (Net0, 2021)

Eczema sufferers spend an average of £300 per year to ease physical and emotional pain from the condition (Gladskin, 2021)

In a survey of 723 adults with mild acne scars, 19.3% considered them a ‘very large’ or ‘extremely large’ concern (American Journal of Clinical Dermatology, 2021)

Dermal filler

Events Diary

11th-12th March

Aesthetics Conference and Exhibition aestheticsconference.com

12th March

Aesthetics Awards aestheticsawards.com

7th-8th May Beauty Uncovered Live beautyuncovered.com

15th-16th September

The BACN Autumn Aesthetic Conference bacn.org.uk

13th-14th October CCR ccrlondon.com

Education

BACN to hold Symposium Event in April

Dermatology

New programme on skin conditions to air

UK charity British Skin Foundation (BSF) and ITN Productions Industry News are co-producing a new programme on skin. The news-style programme ‘The Ages of our Skin’ aims to raise awareness and understanding of different skin conditions and the importance of skincare across all ages. It will address the myths and misconceptions with science-based advice from industry professionals, explore new developments in dermatology and highlight the BSF’s role in funding research into advancements of treatment and cures. According to the BSF, the programme will combine interviews with professionals, news-style reports and sponsored editorial profiles from organisations and industry innovators in studio and on location.

Matthew Patey, CEO of BSF, said, “Following a successful campaign with ITN Productions Industry News in 2021, the BSF are excited to be collaborating again on a brand-new project. The skin is the body’s largest organ and it’s important to take care of it throughout our entire lives. We’re looking forward to exploring ‘The Ages of our Skin’ alongside our experts in 2022.” The programme will launch at the British Association of Dermatologists’ Annual Conference on July 5 at the Scottish Event Campus, Glasgow.

Collaboration

Lumenis partners with Children’s Burns Trust

Aesthetic device company Lumenis has partnered with Children’s Burns Trust as its charity for 2022. The Lumenis team hope to raise money for the charity through a series of fundraising events which include a social event and several sponsored sporting events to be announced throughout the year. Research released by the Children’s Burns Trust as part of its National Burn Awareness Day campaign revealed that more than 8,000 children in the UK were burned or scalded in 2020 alone. The charity provides rehabilitation support for burned and scald injured children and their families as well as prevention and awareness campaigns.

Currently Lumenis is committed to benefitting the lives of scar patients globally through its Lumenis Care Foundation, founded in 2019 by associate director of marketing for Lumenis, Laure Boisseux.

The British Association of Cosmetic Nurses (BACN) is holding its first Spring Symposium in April. The event will feature a range of speakers as well as networking opportunities with a drinks reception and canapes post-event. The symposiums Headline Sponsor will be pharmaceutical company Galderma. Sharon Bennett, chair of the BACN and clinical lead of the Aesthetics Clinical Advisory Board, said, “I am really looking forward to our first face-to-face conference since 2019 and thrilled to have such exceptional speakers who are so generously sharing their knowledge with us at this prestigious venue of the Royal College of Physicians.” The event will take place on April 29 and the official agenda is yet to be announced. The BACN will be exhibiting at ACE on March 11-12. Register on p.19.

Boisseux commented, “We’re delighted that the Children’s Burns Trust will be Lumenis UK’s charity of choice for 2022. As a global leader in laser scar treatment, this partnership highlights our commitment to making a difference to the lives of countless children who have suffered scarring from burns across the UK.”

Development

John Bannon Pharmacy expands

Medical aesthetic supplier John Bannon Pharmacy has been granted regulatory approval to open a new pharmacy in Newry, Northern Ireland.

The company explains that the new pharmacy complements the existing bases in Tamworth, UK and the headquarters in Dublin, Ireland. The new pharmacy expands the capacity and ability to deliver customer focus and commitment to aesthetic partners across the region and locally in Northern Ireland. As part of the expansion, the company has also recruited Rosemary Hutchinson as pharmacy manager. Suzanne Bannon, managing director, said, “I could not be prouder of the entire John Bannon team in bringing this added capacity to fruition. I am equally excited to welcome Hutchinson to the team and look forward to building upon our successes in the UK, and long-standing reputation for customer service excellence in Dublin over the coming months and years.”

John Bannon Pharmacy will be exhibiting at ACE on March 11-12. Register free on p.19.

Live injectables to take place at ACE

The Aesthetics Conference & Exhibition (ACE) returns on March 11-12 at the Business Design Centre, London, with live injectable demonstrations from Headline Sponsor Teoxane, as well as Galderma and Prollenium. All treatments will take place in a clinically sanitised room with a complications regulatory process to ensure patient safety and complication risks are minimised. Event manager Courtney Baldwin said, “We are so pleased that live injectable demonstrations will be returning to ACE! Delegates can see injectable techniques and learn from industry professionals. Hygiene, sanitation, and patient safety are super important to us so all demonstrations will take place in a specified room with the correct protocols in place.” Turn to p.19 to register free for ACE.

Teoxane appoints new team members

Aesthetic manufacturer Teoxane has recruited four new team members. According to the company, Vinn Kaur who looked after the business in East London will be joining product specialist Sifa Veli in the West London area from February 1. The Teoxane sales team has also expanded with the addition of regional sales manager for South England Greg Parker and product specialists Jodie Wood and Hannah Miller, covering Greater North London, Central London and Home Counties. Hannah Nolan, national sales manager, said, “We are delighted to be expanding our sales team here at Teoxane UK in order to further support our much valued customers. Our focus has always been to deliver excellent service to complement our award-winning product portfolio.” Teoxane will be Headline Sponsor at ACE on March 11-12. Register free on p.19 to attend.

AestheticSource celebrates 10-year anniversary at ACE

Clinical distributor AestheticSource will be celebrating its 10-year anniversary at the Aesthetics Conference & Exhibition (ACE).

AestheticSource has a series of activities planned for its anniversary throughout 2022, commencing with a champagne reception hosted at their exhibition stand at ACE on March 11. They will be releasing information on events, promotions and offers throughout the year, available to both existing and new customers starting from March with show exclusives for ACE attendees.

Lorna Bowes, CEO of AestheticSource, commented, “AestheticSource is a true team collaboration. The company started out 10 years ago with the heritage of my 25 previous years in aesthetics and dermatology nursing experience before that. It is a joy to watch it grow into the company it is now, with a cohesive team determined to provide the best service and support to accompany the global brands we all love working with.” Register for ACE on p.19.

BACN UPDATES

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

REGIONAL EVENTS

Thank you so much to all members who attended the BACN regional meetings across the UK in February. The BACN offered networking opportunities across five different cities where there were a range of speakers, demonstrations, and educational content made available to BACN members.

After such a long time apart, it was wonderful to see so many longstanding members back together and reunited, and it was also really encouraging to get to know some brand-new members who have yet to take part in any BACN events. There are several regional events that have yet to take place which BACN members are able to come along to. Many also include BLS training and peer-to-peer networking, and all come with CPD points to use.

Leeds – 3rd March Newcastle – 18th March Glasgow – 21st March

ACE 2022

London – 25th March Belfast – 28th March Manchester – 1st April

The BACN is really excited to be exhibiting at the Aesthetics Conference and Exhibition (ACE) 2022. The BACN team will be on hand to help with any issues or queries that current members may have, along with simply saying hello! The team is also available to have a chat to any aesthetic nurse who would like more information about what the BACN does and how it could help them. The BACN will be on Stand G6!

SPRING SYMPOSIUM UPDATE

A full list of speakers has been announced for the Spring Symposium 2022 taking place at the Royal College of Physicians on Friday 29th April 2022. More details can be found on the events page of the BACN website.

This column is written and supported by the BACN

Recruitment

Pharmacy

Who are John Bannon Pharmacy?

The company was founded by John Bannon in 1985 in Dublin as a supplier of surgical products to healthcare providers. In 2010, the company expanded and diversified into the medical aesthetics field, becoming one of the largest suppliers in the Republic of Ireland. The first UK operation was established in Tamworth, Staffordshire with the opening of the first John Bannon Pharmacy. Since then, we have partnered with most of the leading aesthetic manufacturers.

What’s new at John Bannon Pharmacy?

In January we received approval for the opening of our new pharmacy in Northern Ireland, which is situated at the site of the John Bannon Training Academy in Newry, enabling easy access from both sides of the Irish border. Rosemary Hutchinson has been appointed as the pharmacist in charge who has a wealth of knowledge and experience in the pharmaceutical and aesthetic industry. The pharmacy is open, and Rosemary is excited to meet with existing and new customers.

Why did you choose Northern Ireland?

It was a natural progression as a business as the offering brings our renowned customer focus and commitment to practitioners across the region. Since leaving the EU some of our Irish customers have experienced difficulties because of the increased regulatory burdens. The Newry pharmacy will facilitate a smoother customer journey for existing and new accounts and shows commitment to our partners that we are prepared to invest in distributing their products to all areas of the UK and ROI.

Are there any upcoming developments?

The next development is the launch of our website which includes our electronic prescribing module called ReX. We will be continuing to expand our product portfolio as well as the list of partners we work with. After two years of disruption due to the pandemic, we are excited to meet practitioners again this year at the various trade events. It has been a challenging time for everyone in the aesthetics industry, but we are optimistic about the future!

This column is written and supported by

Marketing

Totally Derma unveils new branding at ACE

Nutraceutical collagen drink company Totally Derma has updated its branding as part of its five-year anniversary. According to the company, the branding highlights health, regenerative wellbeing and lifestyle elements, which defines the brand’s ethos. The new branding elements include a new website, lifestyle video, product label, logo, colour palette, typography, imaging, cohesive messaging, social media campaigns, marketing collateral such as brochures, leaflets and gift bags, explains Totally Derma. Anita Eyles, director of Boley Nutraceuticals which are the brand owners of Totally Derma, said, “Totally Derma has enjoyed significant growth throughout the last five years in tackling the root causes of ageing and delivering expert holistic solutions to age management. We can’t wait to share new clinical data with the medical aesthetic community at ACE in March!” Totally Derma will be exhibiting at ACE on March 11-12. Register for free on p.19.

Event

Launch of the first global conference for SkinPen

Medical aesthetic manufacturer Crown Aesthetics is hosting its first global education conference in March. The manufacturer of the FDA-cleared microneedling SkinPen Precision device will be holding the event for its customers, with training and discussion on clinical education and business development. Reena Sandhu, head of marketing and operations in the UK and Ireland, commented, “We are excited to bring the company’s first global education conference to London. We have customers and partners flying in for the conference, and for those that cannot make it in-person, we will be live streaming the whole event to all over the world.” The event will be taking place on March 19 at the Cavendish Conference Centre, London, from 9am-5:30pm GMT.

Skin

skinbetter science introduces new neck cream

Distributor AestheticSource has launched the skinbetter science Techno Neck Perfecting Cream. According to the company, the cream has been created to specifically treat the skin on the neck, which often shows a more severe ageing pattern than skin on the face. The NOw Complex is composed of protein which harnesses the body’s natural process of nitric oxide. This aims to improve the appearance of ageing skin on the neck and décolletage leaving it firmer and more resilient, explains the company.

AestheticSource will be exhibiting at ACE on March 11-12. Turn to p.19 to register now.

Superintendent pharmacist Andy Pickin at John Bannon

Collagen

Skinade partners with Beauty Uncovered Live

Health supplement brand Skinade will be partnering with consumer facing aesthetic event Beauty Uncovered Live.

At the event, all ticket holders will be given a free Skinade collagen drink as well as access to the Collagen Bar in which Skinade drinks are available. Each bottle has been customised to display the Beauty Uncovered logo. Courtney Baldwin, event manager, said, “We are super excited to have partnered with Skinade for Beauty Uncovered Live! All attendees will receive a free collagen drink with their ticket, giving an instant boost of collagen to your skin whilst attending the event. The Collagen Bar is a great opportunity to socialise and learn more about the benefits of Skinade for your skin!” Piers Raper, CEO at Skinade, said, “Skinade has been deeply involved with CCR and the Aesthetics Conference and Exhibition since launching in 2013, so working closely with the same team on Beauty Uncovered Live is both an interesting and logical opportunity. We are excited that Skinade will be collaborating with Beauty Uncovered on their new venture designed to bring the patient and end user into the professional aesthetics space like never before.” Beauty Uncovered Live will take place on May 7-8 at the Business Design Centre, London. Turn to p.79 to find out how you and your patients can attend. Education

VIVACY unveils new S.A.F.E programme

Aesthetic product manufacturer VIVACY has launched the S.A.F.E international training programme. The Stylage and Anatomy Facial Experience (S.A.F.E) has been designed to deliver an exclusive masterclass on the interconnection between the rheology of Stylage and the results expected by practitioners. Small groups rotate to analyse different areas of the face. Practitioners are invited to perform a drawing evaluation, and an assessment of the anatomy is carried out to find an optimal treatment plan. A hands-on injection practice with Stylage products is performed. The training also uses the iFace simulator which is an identical replica of the human face with different skin layers, vessels and arteries, muscles, fat pads and bones. The company has also replaced its VIVACY Learn with VIVACY Academy. The free learning platform is dedicated to medical professionals interested in Stylage dermal fillers and Desirial injectable intimate gels. The VIVACY Academy includes features such as a personalised platform in which an algorithm suggests content matching your preferences as well as developmental opportunities and all scientific literature on VIVACY products being accessible for free. Dates for the S.A.F.E trainings are to be confirmed for March, June and September. Vivacy will be exhibiting at ACE on March 11-12. Turn to p.19 to register for free.

ACE 2022 – GET YOUR FREE PASS NOW!

Highlights of the Aesthetics Conference and Exhibition on March 11 & 12

We cannot believe it! ACE, the leading clinical conference and your next aesthetic event, is finally here. With new and exciting speakers, products and launches confirmed every day, the offering at ACE keeps growing, and is an event that all aesthetic professionals simply cannot afford to miss. ACE event manager, Courtney Baldwin, says, “It has been amazing to see our industry go from strength to strength, and the support, excitement and anticipation building for ACE is unmatched. It is the must-attend aesthetics event of the spring, the education led by the UK’s most respected brands is truly unrivalled and we cannot wait to host an incredible event!”

For our loyal journal readers, we have an extra special ACE focused edition this month, packed with all you need to prepare for a productive and exciting event! With our full agenda across five theatres confirmed, make sure you keep hold of your copy of the Agenda at a Glance, inserted into this month’s issue, to bring with you to the event, filled with all the must-see sessions!

• Main Auditorium: Headline Sponsor TEOXANE will deliver learning on dynamic filler, achieving natural outcomes, anatomical mapping and live injections

• Symposiums: Live demos, including injections

• Expert Clinics: 30-minute talks to develop your clinic offering

• Masterclasses: 60-minute in depth clinical education

• In Practice: Bringing success for your clinic, sponsored by Enhance Insurance

Secure your FREE spot at ACE 2022

As well as the incredible, free, educational offering at ACE, there is also extended networking opportunities, product launches from leading brands, and great deals on new products from top suppliers. Attend sessions, connect with your community and earn CPD points, all while contributing to your clinical and business development. There are limited places available for the clinical sessions from aesthetics giants TEOXANE, Prollenium, Galderma and Merz so be sure to register FREE now before all sessions become fully booked.

Research Study highlights the effectiveness of glutathione

Vitamin and supplement manufacturer HINNAO has unveiled a new clinical study on glutathione. HINNAO Glutathione is liquid drops taken under the tongue which use high-stability lipid particles which can be absorbed into the bloodstream through small blood vessels in the mouth. The company tests all products using independent third-party certified laboratories to verify the percentage of drug permeation at specific time intervals. The study showed that 54% of the HINNAO Glutathione was delivered into the bloodstream within 40 seconds; 80% by 60 seconds and 83% by 90 seconds. Tania Malan, clinical director at Uniskin, said, “Glutathione has many favourable properties that impact patients’ skin and wellbeing. It is crucial to the immune system, protects the body against oxidative stress while providing immunity to the body. Glutathione has low bioavailability in the body, and the preferred method of supplementation used to be through IV. HINNAO has developed a superior supplementation with a delivery mechanism that equals an infusion. It is less invasive and more cost-effective for patients and clinics, especially those who do not provide infusions.”

NeoStrata launches new moisturiser

Clinical distributor AestheticSource has unveiled the new NeoStrata PHA Daily Moisturiser. The moisturiser contains polyhydroxy acids to support the skin’s collagen production, provide skin texture and firming benefits whilst also helping to balance the skin’s overall visible undertones, explains NeoStrata. The product includes antioxidants, lilac plant cell extract and vitamin E to help protect against the visible effects of oxidative damage due to everyday exposure to environmental aggressors, adds the company. Claire Foster, brand marketing manager at AestheticSource, said, “We are delighted to launch the PHA Daily Moisturiser to the UK skincare market as a new addition to the NeoStrata Restore collection. PHA Daily Moisturiser makes an excellent addition and perfectly complements the existing products in the collection.” AestheticSource will be exhibiting at ACE. Register free on p.19.

Anatomy

New technology allows arteries

to be seen through a phone

Belgian start-up company

Augmented Anatomy will be launching its ARtery3D technology to the UK at ACE on March 11-12. According to the company, the technology brings the hypercomplex network of facial arteries into focus and allows practitioners to inject fillers with accuracy, exacting safety standards to avoid the risks of arterial complications. The procedure starts with an MRI of the face, without the use of harmful radiation. Based on the MRI image, a 3D model of the superficial arteries between skin and skull is made. The 3D model is processed by specially developed software into an augmented reality image which can be retrieved and visualised through the ARtery3D app. By opening the app and pointing the phone at the patient, the entire complex artery network is displayed in augmented reality on the patient’s face.

A medical validation study performed by two independent radiologists showed that the arteries were located within a margin of 1mm of the marked location. The technology can create a 3D digital patient record allowing the practitioner to track changes and any evolutions for repeat treatments in the future. Register free for ACE on p.19.

Charity

The AUCC returns in autumn

The Aesthetics United Charity Conference (AUCC) will return in November. The one-day event founded by aesthetic practitioners Miss Priyanka Chadha and Miss Lara Watson, hosts 400 practitioners, supporting the organisation’s two charities, Refuge UK and NHS Charities Together. The conference raised more than £31,104 in total last year. The AUCC will also be continuing the Rising Star Scheme after its success in 2021. The scheme aims to spot new talent within the industry and provide a platform for growth and development. The successful Rising Star candidates will benefit from the initiative with recognition on the AUCC website and the opportunity to gain mentorship from an accomplished aesthetics professional. Unrestricted exposure to industry leaders and suppliers will also provide an advantage to candidates for the purpose of recruitment and collaboration, adds the AUCC.

Applications for 2022 Rising Star status is now open and can be submitted through the AUCC website. The event will take place at the Hotel Sofitel London on November 19.

Conference

HA-Derma announced as VIP sponsor at ACE

Distributor and training provider of the IBSA Derma portfolio in the UK and Ireland, HA-Derma, will be the VIP sponsor at the Aesthetics Conference & Exhibition (ACE).

At the conference, HA-Derma will be showcasing Profhilo Body to delegates and the VIP lounge will be themed around the new launch. Iveta Vinkler, director of HA-Derma, commented, “We are very excited to be a VIP sponsor at the forthcoming ACE conference as we have a long-standing relationship with the event. We will be presenting our latest launch, Profhilo Body, a very special and innovative product from IBSA. We look forward to welcoming delegates to the VIP lounge which has been conceived in the theme of Profhilo Body.” Turn to p.19 to register free for ACE!

Development

Aesthetics appoints new Editor

Shannon Kilgariff has been appointed as Editor and Content Manager of the Aesthetics portfolio. Kilgariff joined the Aesthetics journal six years ago in a journalist role, before being promoted to senior journalist in 2017 and then deputy editor in 2019. Kilgariff has been working as Acting Editor since May 2021 after previous Editor Chloé Gronow went on maternity leave. Kilgariff commented, “It’s an honour to take over the editorship from Chloé. I learnt so much about the aesthetics specialty from her, and our previous editor Amanda Cameron, and I know Chloé will be greatly missed. I have huge shoes to fill but I am extremely excited by the challenge and look forward to continuing to develop the portfolios.” Gronow added, “After eight years, it is with a heavy heart that I am leaving the Aesthetics team. I am privileged to have been welcomed into so many clinics and businesses, and have enjoyed learning about and championing the work being done to improve patient safety. I know this will be continued when my wonderful friend and colleague, Shannon Kilgariff, takes over.”

On the Scene

ICAN holds second virtual conference

The International College of Aesthetic Nurses (ICAN) held its second virtual conference in January. The conference opened with independent nurse prescriber and founder of ICAN Amanda Wilson, who introduced the speakers of the event. Nurse prescriber Natalie Haswell then discussed consultation and assessment skills in aesthetic nursing. Haswell outlined a definition of what a consultation is, why they are important, and the barriers to a good consultation. Next, nurse prescriber Shannon Lister spoke on the benefits of chemical peels and the perils of at-home peels. She commented, “One peel agent for all ageing is not going to work. Constant daily intervention with topicals is a must! It’s not about a specific brand, it’s about getting the desired results.”

The conference continued with nurse prescriber Anna Kremerov introducing the hyaluronic acid filler MaiLi, and then weight management for aesthetic patients was discussed by nurse prescriber Fiona Wondergem.

News in Brief

Merz releases educational platforms

Global pharmaceutical company Merz Aesthetics has added two new learning platforms to help the education of healthcare professionals. The first platform, ECADEMY, is an advanced clinical e-learning platform with access to more than 100 injection techniques, facial assessment and treatment planning video modules. The second platform named EVENTS provides professionals with access to both online and real-world medical aesthetics events and content with business and clinical topics available.

BCAM search for new scientific papers

The British College of Aesthetic Medicine (BCAM) is searching for new evidence-based studies and research to be presented to members at its Annual Conference in September. Contributors will have the opportunity to present live at Church House, Westminster, on September 10 to an audience of doctors and dentists practising aesthetic medicine. Papers should be submitted to BCAM events and partnership coordinator Dawn Larcombe by March 31.

Cosmeditech launches Exciplex device

Aesthetic supplier Cosmeditech has a new device designed to treat autoimmune skin conditions. According to the company, the Exciplex is approved by the Food and Drug Administration and is CE marked. It can be used to treat vitiligo, psoriasis, alopecia areata, mycosis fungoides and atopic dermatitis, and emits a monochromatic excimer light at 308 nm, explains the company.

Nina Prisk releases new lip product

Aesthetic prescriber Nina Prisk has launched an aftercare product for lips. Muse is designed to complement lip fillers to help minor wounds to heal, prevent transepidermal water loss and restore a supple feel and look to the lips. The product also helps prevent lip ageing with antioxidant and anti-enzymatic properties. Prisk commented, “Muse began after searching for a product to apply to the lips immediately post-treatment but also to recommend to patients to care for their lips during the healing stage.” The product is available in selected clinics, and online with the opportunity for clinics to become a stockist.

Administering Unlicensed Botulinum Toxin

Within the UK, botulinum toxin undergoes strict regulatory protocols to be prescribed and administered to patients. Despite this, ‘black market’ toxin and medicines being bought online and transported from overseas is a common and dangerous act, leaving patients with complications and practitioners with no accountability, according to key aesthetic associations.

Last month, an investigation by The Times found practitioners with no professional medical qualifications used social media to target women and girls for injectable treatments, suggesting the treatments were safe and would enhance their looks.1 Many had been using prescription-only products which had not undergone the safety checks and approvals from the Medicines and Healthcare products Regulatory Agency (MHRA), a legal requirement in the UK.

At one beauty clinic in Wakefield, West Yorkshire, it was reported that a man presented himself as a doctor but was not registered with the General Medical Council. He allegedly tried to convince a female reporter to have 25 injections of an unlicensed toxin product in her face. The investigation also highlighted that non-medical practitioners were using unlicensed brands.1 The current products which are licensed and available in the UK are Azzalure, Bocouture and Botox, with more expected to be available later this year. Many industry associations have voiced opinions on the investigation and called for the Government to take serious action with regulation in the aesthetics specialty.2 We spoke to some of the key industry associations to find out what more needs to be done to keep patients safe.

A continuing problem

In December, Aesthetics reported on remote prescribing after an investigation exposed four medical professionals running side-line businesses in which they prescribed botulinum toxin for patients they’d never met.3 Two months later, further reports suggest unlicensed botulinum toxin

is being purchased and used on patients, so how has this been allowed? Professor David Sines, executive chair and registrar of the Joint Council of Cosmetic Practitioners (JCCP), explains, “As we know, unlike other countries, the aesthetic industry in the UK is completely unregulated, which is why such reports are rife. One of the key activities that the JCCP has engaged with has been the publication of best practice guidelines for prescribing practitioners in 2019.4 A major issue highlighted in The Times report is that a significant number of people are obtaining medicines online in the form of parallel imports which have bypassed the MHRA licensing requirements or are using products which have been prescribed by a third party which goes against prescribing regulations.” Dr Uliana Gout, president of the British College of Aesthetic Medicine (BCAM), agrees with Professor Sines, commenting, “The College strongly feels that this investigation has exposed a practice that we know is going unchecked and is putting members of the public at risk. Immediate government action is needed in this virtually unregulated sector to protect the public from serious harm by limiting the use of these products exclusively to regulated healthcare professionals.” Sharon Bennett, the chair of the British Association of Cosmetic Nurses (BACN) and Clinical Lead of the Aesthetics Clinical Advisory Board, welcomes the undercover report exposing unlicensed botulinum toxin being administered. However, she doesn’t believe it is enough. She adds, “The undercover reports are welcomed because they again highlight the dangerous lack of regulation, but unless the practitioners are held to account, which they often aren’t, reports like this won’t stop them continuing this terrible practice.”

Will the new Health and Care Bill help?

Currently, a Health and Care Bill is progressing through the House of Lords supported by Secretary of State for Health

and Social Care Sajid Javid and member of the House of Lords Syed Kamall.5 The Bill details the future of the NHS within the UK with the final Royal Assent stage to take place in July. The JCCP has partnered with a range of organisations including the Chartered Institute for Environmental Health, the Royal Society of Public Health, and the Institute of Licensing with the aim of reaching an agreement on how to introduce a new system of regulation for the aesthetics sector.

Professor Sines expands, “In our 10-Point Plan and the recent All-Party Parliamentary Group report published in July 2021, we said that a new system of licensing should be introduced in the UK for all invasive aesthetic treatments that carry the possibility of risk to members of the public.6,7 For example, injectables such as botulinum toxin and dermal fillers, invasive lasers, platelet-rich plasma, vitamin infusions and cryolipolysis.” Working alongside a range of professional associations, the JCCP saw the Health and Care Bill as presenting a pivotal opportunity to address the need for regulation in the aesthetic sector, particularly with its emphasis on patient safety and regulation. “Together we formulated and proposed Amendment 2660 to this Bill last year and requested the Government and both Houses of Parliament to consider this with the aim of embedding an enforceable system of licensing within the Health and Care Act. Within the Amendment, we have called for a national system of licensing for invasive cosmetic treatments, underpinned by mandatory standards for education and training, qualifications and competency requirements for the practitioners relative and proportionate to risks involved with the procedure being performed, as well as to provide clarity on the regulation of mobile or home-based practitioners. Other requests were to ensure that all practitioners possess appropriate levels of medical indemnity insurance and access to redress schemes for members of the public, ensure all medicines, devices and products used are appropriately and legally sourced, periodic checks of premises and evidence that practitioners engage in continuous professional development.”

Professor Sines says the Amendment will be voted on before Easter. He adds, “If it is approved, we expect it to be a legal requirement for all aesthetic practitioners to be licensed within two to three years of the implementation of the new Act. We need a few years for the standards to be written and for people to have the chance to achieve

Aesthetics puts a spotlight on the recent undercover report on black market botulinum toxin and asks what this means for regulation in the UK

them. We hope this can be accomplished in 2025.” Bennett highlights that a duty of care should be upheld among regulators, and this has not been achieved thus far. She comments, “I think the requests by the JCCP are essential, especially in that the invasive treatments should be only delivered by healthcare practitioners. However this is only a recommendation. My view is that regulators must be seen to take ownership of their registrants who are delivering aesthetic medical treatments in private practice, and this should be extended to define or signpost to aesthetic practice standards, competence, additional qualifications and training in medical aesthetic treatments. If this happened, alongside the JCCP recommendation, there would be little need for the Bill.”

Bennett also believes that one limitation to the Health and Care Bill is that there are few representatives who understand the aesthetics specialty and therefore the requirements in aesthetics. She notes, “I welcome the fact that at last the Government have recognised the importance of legislating in the area of non-surgical aesthetic treatments. However, this is a highly complex area and I would encourage the Government to involve directly the full range of medical aesthetic specialists in the design and implementation of any licensing system. The importance of consulting with medically relevant specialists cannot be underestimated with a true understanding of what is required to deliver a full and safe medical treatment. I would accept a licensing scheme only if the high-risk injectable treatments are recognised to be the medical treatment they are, but then the argument might be that a licensing scheme shouldn’t be necessary. The British Standards Institute produced a non-surgical aesthetic standard. Within this standard it has a risk table for all procedures.8 The administration of injectable fillers is considered risk level D (with risk level E being death!). I believe this document should not be ignored by those trying to legislate in an area they have no depth of knowledge in.”

A slow progression

Despite the Health and Care Bill progressing through Parliament, regulation and standards might not be achieved soon, and could take a few years to be consolidated. Bennett concludes, “The aesthetics specialty has got a long way to go in terms of patient safety and regulation in the UK. In the meantime, if you are aware of unlicensed products being used, then the MHRA should be notified either through a phone call or via the Yellow Card Scheme. If it is a medically-qualified practitioner, then the appropriate regulatory council should also be made aware. I understand that there can be limited concrete evidence, but it is important and they have a duty to act. Another option is to contact the JCCP or Save Face who can collect data and contact the practitioner’s regulator for you.” VIEW THE REFERENCES ONLINE! WWW.AESTHETICSJOURNAL.COM

ACE 2022 is Finally Here

Join your industry for the ultimate medical aesthetic learning experience

The month of March is finally upon us, and with it brings the aesthetic event we have all be waiting for. ACE 2022 is finally happening, and this year, nothing will stop us! We are delighted that with restrictions lifted, and our speakers and brands prepped and raring to go, this year promises an aesthetics gathering like no other. With a packed agenda across five theatres confirmed, make sure you keep hold of your copy of the Agenda at a Glance inserted into this month’s journal to bring with you to the event, filled with all the must-see sessions! Planning your time at ACE is key, so check out the below summary for a whistle-stop tour of what’s on across the two incredible days!

TEOXANE delivers learning on dynamic filler, achieving natural outcomes and anatomical mapping

Our Headline Sponsor TEOXANE is taking over the Main Auditorium to host two days of free educational content. In partnership with its international faculty, this impressive agenda reinforces the company’s dedication to providing exceptional world-class clinical education to aesthetic practitioners. The experts at TEOXANE are delivering essential learning and practice styles with demonstrations for delegates to witness, each followed by a case and outcome analysis.

Live demos in the Symposium agenda

What better way to learn about the latest treatment styles than through up close and personal live demos? On Friday, the experts from Prollenium will give a full-face masterclass featuring Mr Mark Devlin, Dr Jo Ward and nurse prescriber Sharon Bennett. Galderma will then deliver insights into treating the eyes with Dr Munir Somji. Saturday will see Merz KOLs Mr Dalvi Humzah, Dr Simon and Emma Ravichandran, and Dr Paula Mann exploring key regions using ultrasound as the foundation of their treatment protocol.

Masterclass agenda – the best clinical education

As if the previous two theatres weren’t enough, we have more live demonstrations from leading brands Allergan, Church Pharmacy, Croma, HA-Derma and SkinCeuticals in the Masterclass Agenda. Delegates will hear from expert KOLs on how to maximise

Dr Lee Walker

Dr Wassim Taktouk

results with the products and devices on offer, while enhancing the patient treatment experience from start to finish. Live demonstrations and interactive presentations will take place, covering topics that include chemical peels, microneedling, skin bioremodelling, polydeoxyribonucleotide injections and PRP. Speakers include aesthetic nurse prescriber Susan Young, Dr Rehanna Beckhurst, Dr Tracy Mountford, Dr Amiee Vyas, Dr Mayoni Gooneratne, Dr Daniel Sister and more.

Develop your clinic offering with the Expert Clinic agenda

Join your aesthetic peers for engaging workshops led by top clinicians at the Expert Clinic. The agenda will feature specialist guidance on a huge range of aesthetic treatments, including dermal fillers, chemical peels, energy devices, skincare and more. Expect 30-minute sessions of live demonstrations and best practice advice on everything you need to know to develop your clinical offering. Aesthetic companies supporting the Expert Clinic include: AesthetiCare, AestheticSource, AnteAge, BTL Aesthetics, Celluma, Cutera, Erchonia Lasers, HA-Derma, Lynton Lasers, Neauvia, Venus Concept and Vivacy.

In Practice agenda – success for your clinic

The new In Practice agenda, sponsored and supported by Enhance Insurance, will feature the latest business insights, tips and advice from experts across the field of aesthetic medicine. The key destination for all your business support requirements,

this new channel educates via a dedicated conference, as well as through specific exhibitors at ACE and CCR to provide solutions and services. From social media, marketing, and diversifying your patient base, to launching new devices, enhancing your clinic and patient safety, there will be something for everyone to learn and discover.

Secure your FREE spot at ACE 2022

Attend the sessions that suit your learning needs the most and contribute to your clinical and business development. There are limited spaces available in both the TEOXANE and Symposium agendas so practitioners must pre-register for free online and arrive five minutes prior to the session start time.

Working Around Common Business Pitfalls

Four business specialists explain how to keep your clinic moving at every stage of your career

Whether you’re a new clinic owner, have been around the block, or you’re well established, with hectic schedules in a constantly evolving industry, situations can take you by surprise and important things to remember can go on the back burner. Aesthetics spoke to communications and business strategy consultant Julia Kendrick, finance and VAT advisor Veronica Donnelly and recruitment and business strategists Sue Thomson and Jean Johnston to get an overview of common mistakes at every stage of your career, from not neglecting your social media, to ensuring you’ve got a solid succession plan in place.

Starting out…

Public relations results with Julia Kendrick

When you’re starting out, it’s essential that you set the initial foundation for your business. This includes your logo, your values and beliefs, your marketing images, your staff, suppliers and even your décor. I see so many people rush in and put all their effort into the launch of their clinics without thinking about longevity and consistency. I know it is very tempting to just think about the launch, but you should be building your brand for where you want it to be in the future, not just for now. You might be working from a small unit, doing all your own social media with a very small team, but you should be marketing your business in an aspirational way. Build your brand with a solid foundation and room to grow, this way when you find yourself in the place you want to be, you won’t need to change your branding or message. Having a solid brand identity from the start will also mean that in the future if you want to involve a PR agency to do the work for you, you’ll be able to hand them over very detailed and comprehensive instructions about how you want to be represented. Another big oversight I see new clinic owners make is not researching their competitors early on. You might think you’re doing something new and exciting, but in this oversaturated market it’s essential that you find out whether the clinic around the corner has had the same brainwave. Everyone is using the same marketing tools and offering the same treatments so it’s your individual approach that will make you stand out. Whether that’s a focus on sustainability, (read more about this on p.71), adding wellness services to your clinic, or collaborating with other businesses, it’s important that you find your unique selling point at the beginning of your journey so as to build those patient relationships and ensure long-term repeat business.

Finance finesse with Veronica Donnelly

Aesthetics can feel like a minefield. Throw in everything you need to know about running a business and becoming an expert in finance, and it’s a miracle anyone takes the plunge! It’s impossible to master all three but something I see a lot of first-time clinic

owners stumble over is not getting the right advice. Do not go straight to your friend’s accountant! Check their expertise. From the very start you will need an experienced accountant who has a firm knowledge of aesthetics and all the nuances the industry entails. They’ll need to know whether you want to be a limited company or a sole trader, and any other essential details about how you want your business to grow and progress.1 Some of my clients have a training business as well as a clinic. Their accountants put them together in the same company, making it a really difficult business to sell when they wanted to, and denying them the possible tax relief on both businesses separately. Good advice will save you money in the long run.

Recruitment respect with Jean Johnston and Sue Thomson

It can be tempting when starting out to focus on the way your clinic looks, pricing, purchasing devices and dealing with suppliers, and just hire the first people that meet your criteria or rely on previous connections. You might want to skip the recruitment process and just hire a ‘friend’, but this can end up in tears unless you have a unique relationship and can have very honest discussions in high pressure situations if everything goes wrong. There is so much to think about when launching your clinic and underestimating the roles and tasks ahead of you and believing that you can do everything yourself is a common slip up. Consider outsourcing options for roles such as finance, regulation, HR, and receptionists. This way all staff are on contracts, and if things don’t work out you can choose not to renew the contract while you’re still building your brand. Read more about outsourcing practices on p.65 You might want to drop some of the formalities when hiring staff, meet potential candidates for a ‘coffee’ and really hit it off, only to find out once they start that they are not suitable. Having a robust recruitment process in place which includes a detailed job specification, multiple interview stages, a practical task, and a probationary period will give you the best chance of hiring the right person. An aesthetic practitioner talks us through this on p.60

Redefining the science and aesthetic of facial anatomy

KYSENSE® is a new CE marked HA dermal filler launched globally in 2021. KYSENSE® is manufactured using advanced technology resulting in unique rheological properties that improve injection precision, projection and patient satisfaction.

KYSENSE® has been developed by scientists in collaboration with doctors with decades of experience in the HA dermal filler market and who contribute to peer reviewed publications in HA dermal filler technology and in facial aesthetics.

KYSENSE® is only available to medical professionals

Register at: www.kysense.com

I love using KYSENSE® because of its natural results. My patients love the minimal swelling and are amazed they cannot even feel the products in the lips like other fillers they have tried.

Caterina Alvarez Independent Nurse Practitioner

Public relations results with Julia Kendrick

Once you’ve got your feet under the table, constant evaluation of your business is key to ensure consistency and maintaining the high standards you started with. It’s easy to get carried away spending lots of time and money on the launch phase and slip into a little bit of complacency after a year or so, but you need to maintain that momentum and upwards thinking.

Ask yourself:

• What went well at the beginning?

• How can I expand on that success and update it?

• How have trends changed since I launched?

• What’s new on the market?

These are all questions you should be asking yourself on a monthly basis to really make sure you’re always at the top of your game. It sounds like a massive chore to be that aware all the time, but if you keep adapting little and often, it will mean you won’t have to make massive changes and overhaul your business model later down the line.

Encouraging customer feedback is a really great way to gather the data you need to improve, especially once you have built up those relationships after a year or two. This can be done through surveys, feedback forms, hosting networking events or even on social media with a post asking followers to comment below about what new treatments they would like to see in your clinic. This is also a great way of showing new customers you will value their feedback and really want to know what they think, using that to tailor your business to your customers.

Finance finesse with Veronica Donnelly

After a couple of years, it’s really time to take a step back and look at how you’re financially running your business and ask yourself how you can make it better and easier for yourself. Get your accountant to do a comprehensive overview of your incomings and outgoings so you can really assess where you might need to cut costs, and where you can afford to expand the business.

If things are going well, you might want to think about moving to a bigger or more central location and with all the financial information in front of you, you can make informed decisions and take the fear factor out of spending your hard earned profits!

Another thing I would say is essential is to educate yourself and seek professional help in all the aspects of your business that you’re not an expert in. This is important at the beginning, but it can be difficult to find the time when you’re starting out. Take value added tax (VAT) for example. Very few people know enough about VAT and it can cause some serious issues down the line. Medical health treatments and health services are exempt from VAT however, there is often confusion over whether aesthetic treatments can be considered medical and therefore

be exempt from tax. Seek professional advice about all areas of your expanding business that you are not an expert in. Insurance is another tricky area. Shop around, make sure you’re going to a specific medical and aesthetics insurer, and be aware of what you are paying for. For example, a drop in premium price might also mean a reduction in what you’re covered for.

Recruitment respect with Jean Johnston and Sue Thomson

The two-year mark can be a very interesting time for a new clinic. It can be a make or break period for some, or it can be a time where you need to have the confidence to invest or grow. It can be tempting after a couple of years to rush in to expanding your team. If you do this without really thinking about the progression and direction of your clinic, you can end up hiring the wrong person and hinder all that progress you’ve made, or even worse you could create an entirely new role that doesn’t actually fit in your business, costing you time, money and existing staff satisfaction. This period is a great time for reflection and reviewing your current structure against your takings and profits. If there is a role within your business that seems to be surplus, then you can explore whether you still need this role, equally if there is a role that has expanded, such as front-of-house staff as they begin to excel at the role, you could think about hiring in a support role.

Established for a year or two

E IS FOR ETHICS

Felicity Jagger Midwife, Glow Up

Sally Wagstaff Nurse, Sally Wagstaff Aesthetics

Rachel McDermott Dental Hygienist, Boldmere Dental Practice

Dr Ben Coyle Doctor, YOU Beauty Clinic and Independent

Sam Eidukas Independent Nurse Prescriber – S Aesthetics

Sponsoring Aesthetic Nurse Practitioner

of

When you are well established

Public relations results with Julia Kendrick

Once you’ve had your clinic running smoothly for about five years or more, your long-standing patient base is thriving and you’re feeling good, it can be easy to become a bit complacent on your marketing assets like social media, and think less about how you can attract a new demographic to your clinic. Never go into radio silence! You will always need to be able to communicate with new audiences as the already oversaturated market is always changing. Now that you have the reputation, you can become a leading educational resource for new and old patients on social media. The consumer doesn’t just want to see sales posts so why not try making videos explaining the best treatment for crow’s feet, what a vascular occlusion is, or what causes rosacea and how to treat it? This will maintain the trust you have built up over many years with current patients, and add a big trust factor with potential patients, as well as keeping you and your business relevant by putting you slap bang in the middle of all the important conversations.

this effectively and you can ease into your sale or retirement easily. Planning this far in advance might mean you can slowly introduce another member of staff into your business whom patients can become familiar with, meaning you will actually have a patient base to sell along with the rest of your business assets. This may also allow you to gradually step back from the business as customers loyal to you will be happy to see these other members of staff. You can say they are ‘specially selected by you’, and cascade down the trust, even offering a premium pricing strategy i.e. charging more for your services as you step away from the business – you might find patients are less demanding of your time!

Recruitment respect with Jean Johnston and Sue Thomson

Finance finesse with Veronica Donnelly

This is the time when you need to start to future proof your business and think about a retirement or succession plan. I would recommend planning this at least 10 years in advance so you can achieve

Keep on planning…

So, you’ve made it to five years. Time to celebrate! However, this milestone is also a time when clinic owners need to put in to action a plan to retain the best of the best. Gone are the days of working with an employer for 40 years and receiving a golden handshake on your retirement. Recent data demonstrates that the average tenure for employees aged 25-34 is 2.8 years while the average tenure for employees aged 55-64 is 9.9 years,2 so if you don’t make your business the best place to work, then you’ll lose these valuable assets. Experienced staff members with an in-depth knowledge of your business and ethos are invaluable to your brand and customer retention. If your patients see that you have a high turnover of staff, they will wonder what you’re doing wrong and it’s important for other staff members to become friendly with patients – two new receptionists in a week doesn’t look good. Staff should feel heard and as though they can raise any concerns or requests they may have, and this is essential for staff satisfaction and retention. Bi-monthly one-to-ones are a great way of giving your staff an opportunity to voice anything they choose, and also gives you a chance to recognise anything you’ve been particularly impressed with. These meetings should always be as positive as possible, otherwise they will just feel like a personal attack, and your employee won’t get anything out of them. Performance reviews can be a really good way of comprehensively showing your employees where they’re excelling, and evaluating financial incentives like bonuses or raises, and also what opportunities you can provide them for further career development.

Whatever the stage of your business journey you’re in, the advice from our experts seems clear. Always think ahead, seek professional advice on the things you’re not an expert on, take your time when making big decisions like hiring staff, and don’t get complacent!

MEET THE EXPERTS

All our interviewees are sharing more of their secrets at the Aesthetics Conference & Exhibition on March 11&12! Scan the QR code to register for tickets.

“The average tenure for employees aged 25-34 is 2.8 years, while it’s 9.9 years for employees 55-64, so if you don’t make your business the best place to work, then you’ll lose these valuable assets”

Jean Johnston & Sue Thomson

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Eye of the Storm

Announcing the new Restylane® Eyelight™ for tear trough rejuvenation

When a patient sits in your chair looking at him or herself in the mirror, how often is it that the tired eyes looking back at them are their main cause for concern? Many just want to feel that their eyes reflect how they feel inside and don’t let them down. According to a recent survey, many people think their tired-looking eyes don’t match how they feel. Others

As part of the normal course of ageing, patients present with the deterioration of the skin in the delicate eye area which in turn can lead to hollowing, drooping, lines and wrinkles. The volume loss under the eyes can also create unflattering light refraction leading to dark circles. Whether it’s lifestyle choices, environmental factors, or simply the path of time, tear trough treatment can tackle many undereye complaints to produce a positive patient

Dr Munir Somji, founder of Dr MediSpa, says, “Improving tired looking eyes can often be the single most impactful tweak we can offer patients and I am treating more tear troughs in my clinics than ever before. The rise in anxiety levels and sleepless nights resulting from the pandemic, increased working hours, and the digital bathroom mirror we call Zoom, may all have a hand in this upward trend. But the best non-invasive treatment for hollowing under the eyes, however, remains the same. Expertly injected tear trough filler helps to correct hollowing, reducing shadowing under the eyes to give a brighter more well rested appearance. The new Restylane® Eyelight™ provides the ideal tool to deliver safe, reliable, lasting results. The consistency is perfect to sit in the intended treatment zone with little to no spread. More importantly it has low hygroscopic behaviour reducing the chances of periorbital oedema. It’s exciting to have this new filler as part of our library of offerings; I have confidence in the technology as it has over 25 years of history in the market, the safety profile is good and the studies are very promising.”

New from Galderma, Restylane® Eyelight™ is a hyaluronic acid filler formulated specifically to treat the eye area using the trusted NASHA® technology with the right gel properties for The NASHA cross-linking technology produces firmer gels that are ideal for the tear trough area to treat tired-looking eyes.2,3 This Restylane® technology has more Over 50 million treatments with Restylane® fillers have been performed to date worldwide, including tear trough treatments to combat

Restylane® Eyelight™ was recently investigated in a clinical study comprising women between

83% were satisfied or extremely satisfied with their tear trough treatment. Remember that in many cases, tired-looking eyes cannot be solved with a filler under the eye only. Despite that, the overall satisfaction in the study was very high. 82.9% still saw a noticeable improvement 6.5 months after treatment. As has been explained, your body will gradually break down the tear tough filler – how fast differs from person to person. The study clearly shows, however, that overall, the effect is long-lasting. 94.3% would recommend the treatment to a friend and repeat the treatment.

How long the effects of Eyelight™ last varies from person to person, but 83% of patients reported durable results at least six months after treatment.2

Discover the full range

To discover Restylane® Eyelight™ and the full Restylane® range, contact your Galderma representative for training via the GAIN (Galderma Aesthetic Injector Network) Program and marketing support: Sales.UK@galderma.com Restylane and the full Galderma portfolio is available is exclusively available with Medfx: www.medfx.co.uk

This advertorial was written and supplied by Galderma

UKI-RES-2200033 DOP January 2022

REFERENCES

1. Data on file (MA-46075) European market survey by Opticom and Galderma, Q4 2020.

2. A.Nikolis et al. A Randomized, Crossover-Controlled EvaluatorBlinded Trial Evaluating Cannula- Vs Needle-Assisted Hyaluronic Acid Injections for Infraorbital Deformities. ASJ 7-2021.

3. Data on file (MA-49047).

4. Data on file (MA-39680).

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Treating Migraines with Botulinum Toxin

Botulinum toxin (BoNT) is a powerful muscular paralytic agent through the inhibition of the release of acetylcholine vesicle at the pre-synaptic level.1 It is this very characteristic that allows this powerful toxin to be used in a vast array of medical conditions where an abnormal muscle activity of hyperactivity exists.2 This is the case for cervical dystonia, severe forms of lower limb spasticity and ophthalmic pathologies such as blepharospasm and strabismus.3

In aesthetic medicine, it is a cornerstone therapy for treating lines and wrinkles. In mixed pathologies such as temporal mandibular joint disorder (TMJD), bruxism and hyperhidrosis, botulinum toxin A (BoNT-A) has also demonstrated a significant efficacy.4

This article is aimed at highlighting the place of BoNT-A in the global armamentarium for migraine, as well as examining the new pathophysiological aspect, particularly with regards to the role of neuropeptide calcitonin gene-related peptide (CGRP). It will be examined whether BoNT-A has a viable role in migraine either as a stand-alone treatment or as an additional treatment.

Background

Fairly recently, the beneficial effects of BoNT-A on migraine have been observed more accidentally than by design, as was the case for depression. Indeed, in the early 1990s a significant proportion of patients having undergone BoNT-A treatment for wrinkles reported a significant subsidence in migraine symptoms.2 The fact that the pathophysiology of migraines lies principally in the sensory network, the mechanism of action of acetylcholine blockage becomes a largely insufficient way to explain its effect on the nociceptive network.5

Intense research was undertaken to determine the mechanism through which BoNT-A alleviates migraine. The most recent accepted theory relates to the critical role of neuropeptides, principally CGRP.6 In parallel, research into the pathophysiology of migraine has questioned the conventional mechanisms which have classically been put forward to explain migraine.1

The search and discovery for alternative therapies for migraine is crucial for several reasons. This neurological condition, which is defined by repetitive acute attacks of headaches, can affect a large proportion of the population. Indeed, its prevalence has been reported as being as high as 15% in a Norwegian study,7 and up to 25% of women and 10% of men in the UK.8

When it occurs more than 15 days a month and for a period, it is defined as chronic migraine.3 Almost 25% of American families have at least one member suffering from migraine.9 Because of its debilitating aspect, migraine is considered to be a huge socio-economic burden.10 The main purpose of migraine therapy is to alleviate the consequence of this condition on the patient’s daily life. Practically, it aims at reducing

both the rate of occurrence and the duration, hence reducing the consequent disability.

Although conventional therapies are known to carry some efficiency, they are associated with significant side effects which very often lead to noncompliance or dropout.3 These range from cognitive changes, drowsiness, and nausea to alopecia, sexual dysfunction and weight gain, among many others. Although the suitability of these medications can be adapted according to the patient’s medical history, the intensity of some of the side effects is such that dropouts remain an issue so it’s no surprise that many patient seek alternative solutions.10 In addition, 20% of migraine patients are non-responders to existing therapies.11,12 For all these reasons, BoNT-A as an alternative therapy has been welcomed and widely studied. This has led to its approval by the US Food and Drug Administration (FDA) in 2010 as a therapy for chronic migraine as it has demonstrated a significant efficiency both in terms of reducing the intensity of migraine as well as the frequency.3

How botulinum toxin impacts migraines

BoNT is a complex mega protein which essentially contains two subunits. When BoNT is injected, its mechanism of action involves its interaction with the complex process of neurotransmitter release.13 In normal conditions, neurotransmitters are incorporated in small vesicles at the presynaptic level, which is subsequently released in the neuromuscular junction.14 It then crosses the neuromuscular junction and acts on the receptors. This process includes different steps such as stockage and fusion within the membrane. These stages depend on the building and presence of a very large protein complex known as Soluble N-ethylmaleimide-sensitive factor

Nurse prescriber Clare Amrani explores the literature around the use of botulinum toxin as a treatment for migraines

Although conventional therapies are known to carry some efficiency, they are associated with significant side effects which very often lead to noncompliance or dropout

Figure 1: The diagram shows the specific injection points as described by PREEMPT protocol for using BoNT-A to treat migraines.34

activating protein receptor (SNARE). 14 This large protein is responsible for the mechanism of vesicle formation and release of acetylcholine. BoNT-A has the ability to destroy this large mega molecule making it impossible for the vesicle to adhere and eventually release the neurotransmitters, therefore provoking a paralysis of the muscle.2

This complex pathophysiological mechanism explains the beneficial effect of BoNT-A on every condition or pathology requiring a muscle paralysis.2 However, migraine is mainly a condition that involves sensory networks. Therefore, the conventional mechanism of BoNT-A through the inhibition of acetylcholine cannot be an explanatory mechanism behind the positive effect of BoNT-A on migraine. In order to fill the gap in our comprehension, it became obvious the neurological sensory network might be affected by BoNT-A as well.2,12 The early logical hypothesis put forward was the potential ability of BoNT-A to inhibit the nociceptive pathways.5 This was brilliantly demonstrated by an experimental study in which BoNT-A injected subcutaneously was able to eliminate delayed pain reflex without affecting the muscle contraction.15

Interestingly, as early as the mid-80s, clinical research in 93 patients suffering from cervical dystonia showed that injection of BoNT-A had more effect on pain than muscle contraction.16 This observation strongly suggested a lack of association between the nociceptive aspect and muscular paralysis in cervical dystonia. Furthermore, a subsequent study concentrating on the correlation between muscular contraction and pain were unable to find a significant association between them.17 All these observations strongly support the concept that the BoNT-A beneficial effects in muscular contracture and pain are two different entities.17

Perhaps the strongest evidence supporting the beneficial effect of BoNT-A purely on pain is provided by a small randomised control trial on 18 diabetic patients suffering from peripheral neuropathy.18 In those

patients, where pain is not linked to any muscular disorder, BoNT-A significantly reduced the pain. Although the observations were made on a small number of patients, the findings are extremely pertinent with regards to the effect of BoNT-A on the sensory network. All these observations put together form the strong explanatory platform behind the effect of BoNT-A in migraine.

Interestingly, as early as the mid-80s, clinical research in 93 patients suffering from cervical dystonia showed that injection of BoNT-A had more effect on pain than muscle contraction

Midpupillary line

Tragus Tragus line Limbus line Orbital rim Mid-helix

Orbital rim Medial canthus

Lateral canthus

Limbus

Frontalis Supraorbital notch Procerus

Corrugator

Hairline

Upper third of forehead

Crucial steps in our understanding of the mechanism of action of BoNT-A on migraine came about from pre-clinical research which demonstrated that BoNT-A was also able to inhibit the secretion of peptides like substance P and CGRP within peripheral sensory neurons.18

Recent research has highlighted that, at the presynaptic level, in addition to acetylcholine, many neurotransmitters and peptides are released using the same above-mentioned complex mechanisms involving the SNARE protein complex. This is particularly the case in cerebral areas known to be linked to migraine such as the trigeminal ganglion.18 The latter is also known to have the highest concentration of CGRP. These vesicles not only contain acetylcholine but other transmitters or neuro peptides such as substance P or more relevant CGRP.18 The ability of BoNT-A to inhibit the release of CGRP together with the crucial role of the latter in migraine explains the therapeutic action of BoNT-A and migraine.

The role of CGRP in the pathophysiology of migraine

The pathophysiology of migraine is not fully understood, although a large body of recent theories are slowly filling the gaps. The first theory that has been widely accepted and adopted up until recently is the vascular theory.19 The latter has been hypothesised by Dr Thomas Willis, an English medical doctor and pioneer in neurology, over four centuries ago and was based on the precept that migraine is due to the vasodilatation of some vessels included in the cerebral tissues and meninges.19 The vascular theory has been given a further impetus more than 100 years ago. One of the reasons behind the longevity of this theory is that drugs able to produce vasoconstriction such as Ergotamine have shown some degree of efficiency, particularly in acute migraine.20 However, with the advent of sophisticated blood flow measurement techniques,

the foundation of this theory has been somehow shattered. Indeed, MRI imaging of blood flow clearly demonstrated that there is a lack of correlation between the presence of migraine and the magnitude of blood flow.21 Furthermore, in patients known to be prone to migraine, induced vasodilatation of the brain cerebral arteries using powerful vasoactive intestinal peptides (VIP), no migraine developed, highlighting again the lack of correlation between the level of blood flow and migraine.22 Therefore, after the initial observation of Dr Willis more than 400 years ago, dynamic modification of the diameter of the arteries together with the variation of blood flow became an insufficient theory to explain the genesis of migraine.

One of the theories that replaced the vascular theory was the neurohormonal theory, which supports the notion that it is the protein extravasation with the subsequent oedema which produces migraine.23 However, in the 1990s, drugs such as Bosentan, which have the characteristic of being able to inhibit plasma extravasation, did not make any changes in terms of migraine triggering.24 The role of the neuropeptide, particularly CGRP as a pathophysiological mechanism behind migraine has now been put forward.1,2,25,26,27 The crucial role of CGRP in the genesis of migraine is supported by several experimental and clinical studies. Firstly, immunocytochemistry studies clearly showed the presence of large quantities of CGRP in some key vessels supplying the cerebral loci known to be involved in migraine.1 This is particularly the case for the trigeminal ganglion.24 Further similar studies have demonstrated that 50% of the cerebral tissue in this zone have a significant amount of CGRP. Beside the mere observation of presence of CGRP in the critical cerebral area linked to migraine, it has recently demonstrated that CGRP is found in high concentrations in blood of patients known to suffer from migraine.1,2 Further convincing evidence of the role of CGRP in the pathophysiology of migraine is provided by the fact that inhibition of this neuropeptide by antagonists have been able to provide a therapeutic efficiency comparable to the classical treatment for migraine.25,26,27

The role of BoNT-A in the prevention of chronic migraine through its inhibition of CGRP is supported by basic and clinical research. Indeed, an in vitro experimental study demonstrated a significant inhibition of CGRP release by BoNT-A from peripheral neuronal sensory networks 18 In culture medium, animal cells from trigeminal ganglion were subjected to BoNT-A. CGRP was measured and shown to be significantly reduced in the BoNT-A group when compared to the cells in the control group.28 In a clinical study involving 83 patients, BoNT-A was shown to diminish CGRP blood levels between migraine attacks in patients known to be positive responders to therapy but not in patients known to be non-responders.29 This suggests a clear relationship between the level of CGRP and pain.

With regards to the intrinsic mechanism behind the relationship between CGRP and migraine, there is no clear consensus or definitive theory. It is suggested that CGRP over expression in sensory nerves reflects a disturbance in the signalling mechanism within the trigeminal ganglion.19 Indeed, migraine can be seen as an abnormality in the filtering system of the sensory mechanism. In normal circumstances, several layers of the brain including the mid brain, the thalamus and the pons act as a control system that establish what information to filter and what information can be allowed to reach the thalamus and cortex. It is postulated that the usual migraine triggers could increase the level of CGRP and induce a high level of cerebral sensitivity.

Occipital protuberance

Helix

Nuchal ridge Mastoid process

Inion

Figure 2: The specific injection points as described by PREEMPT.34

This will lead to the anomaly in the filtering system. In turn, this allows information that is normally filtered to pass through and reach the cortex, which can trigger pain and other features of migraine such as photophobia.19,30

Is BoNT-A a viable option in the armamentarium against migraine?

Over the last 20 years, studies have repeatedly demonstrated the efficacy of BoNT-A in the treatment of migraine.1-3,5,6,12,29 However, when used as a standalone treatment its efficiency has been shown to be reduced or even discontinued in some patients.12,24,29 It has recently been suggested that monotherapy of any kind, including BoNT-A aimed at targeting chronic migraine is unlikely to work in the long-term due to a variety of reasons, including the fact that migraine is a polygenic pathology which involves many peptides and neurotransmitter pathways.24,29 All of this acts in a synergetic fashion and requires a synergetic approach.

In addition, whilst BoNT-A has been clearly shown to be an efficient therapy against chronic migraine, patients having treatment can still experience migraine attacks.24,25,29 For this reason, it has very recently been advocated that CGRP monoclonal antibodies should be associated with BoNT-A.24,25,29 The rationale behind this is that the monoclonal antibodies act directly on the CGRP whereas, BoNT reduce the concentration of CGRP indirectly. Although the number of studies are limited, there is clearly a beneficial effect, particularly in those patients who are on monotherapy. Current studies suggest that conventional therapy, BoNT-A and monoclonal antibody approach have the same efficiency. Although conventional therapy demonstrates an initial higher effect, it has the highest probability of dropout.29 Therefore, direct inhibition of CGRP could have a specific place in patients who do not respond to conventional therapy of those with low compliance.25

Injection sites for migraines

The specific injection site and the timing of BoNT-A has been previously described in detail, particularly the Phase III Research Evaluating Migraine Prophylaxis Therapy (PREEMPT) trials involving 1,384 patients.31 This subsequently led to a set of protocols. In essence, it consists of an injection into 31-39 locations involving seven muscles located in the head and neck area.33 The rationale behind this relates to the fact that the sensory nerve endings that connect to bodies found in the trigeminal and cervical ganglia are found in these areas.2 Over time, modifications have been made to the PREEMPT protocol in clinical practice making its application in practice less standardised and more patient specific.33

Summary

Given the shortcomings of conventional therapies against migraine, several alternatives were considered, among which BoNT-A. The pathophysiology of migraine has remained unclear and has been based on successive theories that have been ruled out by new research. The latter has led to the development of the peptide theory, within which CGRP plays the major role. In parallel, our understanding of the mechanism of action of BoNT-A has expanded to include a specific action on the sensory/nociceptive network. This has helped elucidate the logic behind the effect of BoNT-A on migraine. Recent data suggests that combination of BoNT-A and other therapies such as monoclonal antibodies can improve the outcome.

Clare Amrani is an independent nurse prescriber and was previously a surgical care practitioner in cardiac surgery and lead tissue viability. For the last six years she has led her own medical aesthetic clinic Luvenis Aesthetics. She is a board member for the BACN and also a technical expert marker for VTCT for Level 7 in Aesthetic medicine. Amrani is currently completing her second year of a MSc in Cosmetic Medicine. Qual: RGN, INP, ANP/SCP (MSc), PG Cert, PG diploma (CosMed)

TO

Test your knowledge!

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

Question Answer

1. Regarding the mechanism of action of BoNT-A, which statement is correct?

a. BoNT-A exclusively inhibits acetylcholine release b. BoNT-A only acts on axons c. BoNT-A also has an action on sensory networks d. BoNT-A exclusively acts on sympathetic networks

2. BoNT-A effect is exerted via: a. Action potential b. Modification of the membrane potential c. SNARE protein complex d. Combining directly to acetylcholine molecule

3. Migraine pathophysiology can be exclusively explained by: a. The neurohormonal theory b. The vascular theory c. Muscular contracture d. None of the above

4. The neuropeptide theory behind the physiology of migraine involves: a. Vasoactive intestinal peptides (VIP) exclusively b. Secretion of CGRP c. Noradrenaline d. Catecholamine

5. Role of BoNT-A and migraine: a. BoNT-A always works for all forms of migraine b. As a standalone BoNT-A can work continuously and without fail c. In some instances, it is better to combine BoNT-A with other therapies d. The site of injection is not relevant

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

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Sculptra

FINALIST 2022

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1. Goldberg D, et al. Dermatol Surg. 2013;39(6):915–922.

2 . Hexsel D, et al. Dermatol Surg. 2020;46(8):1122–1124. UKI-SCU-2200008 DOP February 2022

stimulates natural collagen production to gradually restore firm skin 1,2

Adverse events should be reported.

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

For Ireland, Suspected adverse events can be reported via HPRA Pharmacovigilance, Website: www.hpra.ie; Adverse events should also be reported to Galderma (UK) Ltd, Email: Medinfo.uk@galderma.com Tel: +44 (0) 300 3035674

Revision 2019-09-09. 8. Juvéderm® ULTRA 4 DFU. 73663JR10. Revision 2019-09-09. 9. Juvéderm® ULTRA SMILE DFU. 73664JR10. Revision 2019-09-09. 10. Juvéderm® ULTRA XC DFU. 73659RX10. Revision 2019-09-09. 11. Juvéderm® ULTRA PLUS XC DFU. 73660RX10. Revision 2019-09-09.

Injecting the Male Mid-face

The number of men who are interested in and who are seeking aesthetic treatments has been on the rise over recent years.1 As life expectancy increases, our expectation and demands in our mature years have dramatically changed. We now expect to continue to be competitive in our work as well as active in our social and family lives for longer than our parents and grandparents. Improvements in the quality of non-surgical treatments with better products with greater longevity, improved techniques, and minimal downtime make non-surgical treatments more appealing. One may argue that we now enjoy a greater cultural acceptance of aesthetic treatments, which has undoubtedly contributed to higher numbers of men seeking treatment.2

Commonly, male patients seek aesthetic treatments to not only look younger or less tired, but also to improve their competitiveness in their work environment, as youth is seen as a desirable quality and vitality often equated to productivity.3,4

It is essential for the aesthetic practitioner to understand how to enhance or rejuvenate male patients with dermal fillers and how their treatment approach needs to differ to that of females. For example, practitioners can often misunderstand the proportions of the male cheek, and it is commonly said that the male cheek has more anteromedial projection and women have more lateral projection.5,6

This article will explore the assessment of the male mid-face, pertinent dermal filler treatments, how the male mid-face ages and some key differences you should consider compared to treating female patients.

Male vs female ageing in the mid-face

Just as the influence of oestrogen will produce the characteristic physiognomy in females, similarly testosterone produces features that we regard as typically masculine. These include heavier brows, thinner cheeks, bigger squared off jaws and chins.7

From a skeletal perspective the male zygoma is flatter anteriorly compared to the female zygoma which is fuller, higher, and more projected in all dimensions. Male cheeks are less projected and have less fullness in the anteromedial area.8,9

Male ageing is more linear; for instance, it occurs at a steadier pace when compared to female ageing,10 whereas female volume loss and atrophy will accelerate in the

perimenopausal period.4

The ageing process in men results in a redistribution of volume from lateral to medial, creating more fullness in the anterior mid-face noticeable in the area nasolabial fat.5

Periocular ageing is a common concern in male patients. This is attributed in part to a prominent supraorbital ridge and deeper set eyes in men and the projection of the subciliary muscle which occur naturally and typically in the male face. Therefore, the tear trough may appear deeper in men and does not always need to be corrected.4,5

The maxilla and masseter are prominent in men. The zygomatic arch and masseter are dominant with a zygoma:soft tissue ratio of 1.1:1.5 The male profile will help establish the contours and vectors of the mid-face. Projection in all directions of a round and high cheekbone is seen in women and is considered a feminine feature with a zygoma:soft tissue ratio of 2:1.5

The periocular region sees the most changes men experience with ageing. The lower eyelid is mostly affected, infraorbital thinning with increased periocular fat leads to an increased appearance of infraorbital hollowing. The orbital aperture increases with age in both area and width.4

Assessment and treatment options

Dermal fillers can be used successfully in the male cheek. The treatment strategy should involve the use of a high G-prime, highly cohesive volumising dermal filler. The treating clinician may use a needle, cannula or a combination. In our clinical experience, a multi-layered approach, for instance, deep supraperiosteal and subcutaneous injections may be employed to maximise

The goal of any male mid-face treatment is accentuation and not exaggeration

Dr Raul Cetto, Dr Jeremy Isaac and Dr Lee Walker provide their techniques for treating the male mid-face with dermal fillers

A broad range of indications for face and body treatments

juvenus is easy to inject and specifically designed to treat a variety of skin concerns of the face and body, with instantly visible results. The moisturising and antioxidative activity help create the optimal environment for the growth of fibroblasts, which leads to an improved tissue elasticity.

the soft tissue loss. The injection sites in male patients along the zygomatic arch should be lower and less volume should be injected than in the female face – with a view to correction only and an avoidance of over projection and the appearance of ‘fullness’ which can have a feminising effect.6,9 The zygoma should also extend laterally to the hairline, further accentuating the desired angular appearance. When treating the ageing process in the male patient with dermal fillers, volumisers should be used to create lateral support and increasing anterior cheek volume should be avoided in most cases. Lateral volume restoration should be along the inferior border of the zygoma in small amounts to avoid over projection and to respect the natural proportions of the male cheek.5,6 Injection of dermal filler directly into the nasolabial fold in men is preferred in most cases to soften its appearance.6

The male mid-face has more emphasis on the zygoma and zygomatic prominence, creating a more clear-cut irregular surface with little to no anterior projection.6,9 Men’s cheeks are flatter in all directions and should not be altered in this regard if feminisation is not the aim of treatment. The goal is accentuation and not exaggeration. Male cheek landmarks (Figure 1) include a horizontal line from the lateral canthus, another line from the lower tragus to the lateral oral commissure and another from the lateral canthus to the lateral oral commissure.5 The oval within these lines depicts the area of natural male cheek volume. We see from medial to lateral a 1.1 to 1 cheek volume ratio. Flatter antero-medial projection and a more medial, lower positioned cheek apex. Practitioners should avoid overcorrecting in the region of the cross in Figure 1

In men, an even distribution between the medial and lateral cheek is more appropriate (ratio of 1:1). The cheek apex sits more medially compared to the female face, with a wider-based malar

prominence.5 Overcorrection may lead to a more feminine appearance.

Other methods of mapping the mid-face have also been described in literature. For example, the malar eminence can be located using the Hinderer method or Wilkinson method.3

The Hinderer line (Figure 2) defines the anteromedial border of the cheek mound and is composed of one line drawn from the lateral commissure toward the ipsilateral lateral canthus and another line from the alar to the ipsilateral infra-tragal notch. The intersection of these two lines denotes the apex of the malar eminence.3

The Wilkinson method (Figure 3) consists of a vertical line drawn from the lateral canthus to the edge of the mandible; the malar eminence is located about one-third down this line. In addition to the location of the malar eminence, it is important to appreciate the anterior projection of the cheek. In men, the ogee curve, an s-shaped curve from the cheekbone to the mid-cheek hollow tends to be flatter in its lower concavity.5

Accentuation not exaggeration

Men have an even distribution between the medial and lateral cheek. The male mid-face is flatter in all directions and should not be altered in this regard if feminisation is not the aim of treatment. The antero-medial projection is flat, more medial and with a lower positioned cheek apex, compared to the female cheek.

The goal of any male mid-face treatment is accentuation and not exaggeration. The ageing process of the male mid-face sees a redistribution of volume from lateral to medial. This should be taken into consideration when carrying out a rejuvenation treatment with dermal fillers, by injecting along the lower zygomatic arch using low volumes. Ageing is more linear and occurs at a

steadier pace in males compared to female ageing. The periocular region sees the most changes men experience with ageing and is one of the most common areas of concern.

Dr Raul Cetto practises at Clinic 1.6 London, specialising in aesthetic medicine and has been awarded a Diploma in Otolaryngology and Head and Neck Surgery from the Royal College of Surgeons of England as well as completing the College’s membership examinations. His surgical training led to the completion of a PhD on nasal airflow at Imperial College London. He has also holds a post-graduate certificate in Aesthetic Medicine and a postgraduate diploma in Medical Education.

Qual: MBBS, PhD, MRCS, DOHNS, PGDip (MedEd), PGCert (AesthMed)

Dr Jeremy Isaac practises at Wish Skin Clinic in Port Talbot. He is a Country Expert for Teoxane and is a national trainer for Teoxane and 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)

Dr Lee Walker is an aesthetic dental surgeon, director and clinical lead at BCity clinics, Liverpool and has more than 20 years’ experience in the field of medical aesthetics. He is a visiting Professor of Aesthetic Medicine at the Andres Bello University Santiago, Chile and is chairman of CMAC.

Qual: BDS, MFDS, RCPSG, FDS RCS ENG., PGA CERT. CLIN. ED

Dr Raul Cetto and Dr Lee Walker will be speaking at ACE on 11 & 12 March. Scan the QR code to register.

Figure 3: Wilkinson’s method for marking the male cheek5

Figure 2: Hinderer’s method for marking the male cheek3

Figure 1: Male cheek landmarks. Image courtesy of Aesthetic Medicine Pathways

Mr Mark Devlin

Dr Jo Ward

Sharon Bennett

Dr Kuldeep Minocha

Dr Munir Somji Dr Simon Ravichandran Learning

Mr Dalvi Humzah, Dr Simon Ravichandran, Dr Emma Ravichandran & Dr Paula Mann

Dr Paula Mann

Dr Emma Ravichandran

Ultrasound is utilised in most fields of clinical medicine. Ultrasound allows us to visualise the anatomical layers of the face, helps improve practitioners’ anatomical knowledge and can help in identifying the correct layers for augmentation.1 Ultrasound has been shown to make placement of filler safer and improve results.2,3 Ultrasound use also improves the identification of filler complications, allowing practitioners to accurately and swiftly treat the diagnosed concern.2,3 Personally, I feel ultrasound use has increased my anatomical knowledge and improved my injection technique. My knowledge of complications and comfort with addressing these has also increased.

Ultrasound The Next Best Thing in Aesthetics?

How do I use the machine in clinic now?

I haven’t used the device for management of an occlusion as yet, I have however treated other filler complications. I have found encapsulated filler nodules in patients who have had treatment elsewhere and I have used the device to look for old filler in all my new patients.

How did I train myself in ultrasound use?

Ultrasound had been something I had been thinking about for a while. I had used a lot of ultrasound when I was working in the emergency department and I had also made use of ultrasound with my Ultherapy® device. Ultherapy®, is an ultrasound guided lifting and tightening machine, used to stimulate collagen and elastin production, through heat stimulation.

Ultherapy® uses ultrasound to both visualise target collagen and deliver treatment to exact tissue depths.4 So, I had been visualising superficial tissue depth for a period of time before actually purchasing a device. It was after treating a filler complication, that I bought a handheld ultrasound device to use in clinic. I was convinced it would have made the resolution of the complication quicker and made the experience less traumatic for my patient. Although filler complications are not that common, some calculations place the incidence at 1:6800, so most practitioners, especially if they work in busy clinics, will see filler complications at one point or another. Ultrasound use can help identify these complications and aid with speedier resolution.5

As part of my initial consultation, I now look for the large blood vessels and vascularly map these patients. I basically look for big deviations in recognised vascular patterns in the face, I look at the quality of the blood flow before and after treatment and I look for any previous filler or other treatments such as threads to see if they are causing any concerns that need addressing. Identifying the vascular pattern of a facial vessel has shown to help injectors take measures to avoid vessels and in so avoiding serious complications such as tissue necrosis or permanent vision loss.6 The ultrasound can be used to visualise vessels in the temporal fossa, lips, piriform space, mid-face, nose and locate the facial artery course.1 Ultrasound is therefore useful to plan where to place filler. If I can locate the deep temporal artery or follow the labial arteries this knowledge then guides me in how I will place the filler to get the best result for the patient while respecting the vascular anatomy and not putting undue pressure on the vessel. Ultrasound has also improved my filler placement in that I am able to identify the anatomy of the treatment area before injecting, select a safe area for treatment and then review if I have placed the filler in the correct area, such as a fat pad or periosteal region. In the past we have relied on tactile feedback to decide if we are placing filler periosteally or intrafascially, and on occasion we are not in the correct place, ultrasound use reinforces the feel of correct placement and allows early correction, before complications arise, if the filler is incorrectly placed.7

I was lucky in that I had used ultrasound for eFast scans, placing central and peripheral lines and looking for cardiac functionality in an arrest situation, so the fundamentals and ‘knobology’ of ultrasound was familiar to me. But facial anatomy was not. I spent most of lockdown scanning my own and my husband’s face trying to identify and follow vessels, looking for muscles and trying to marry that with the 2D images I had seen in anatomy text books. I spent a lot of time looking up what different muscles and vessels looked like on ultrasound. As with everything repetition is key. Initially it took me ages to find the vessels, now with a lot of practice it is quicker and I can scan and find vessels in a short time and my treatment times are not that much longer using the ultrasound.7 Once lockdown finally lifted I was able to attend training with Dr Leonie Schelke and Dr Peter Velthius, who are considered the pioneers of aesthetic ultrasound and complications management. Merz Aesthetics UK, also arranged for further training for the Merz Innovation Partners (MIPs) with these two thought leaders. The MIPs spent two days training in facial muscle and structure recognition and also ultrasound guided injection. Each MIP now uses a handheld ultrasound in their clinic to help with training and treating of patients.8 Lastly I was privileged to attend Dr Schelke and Velthuis’ complications clinic at the Erasmus University in the Netherlands courtesy of Merz Aesthetics UK. This clinic has been running since 2011 and received referrals from all over the Netherlands.5 I was able to observe the clinic over two days and saw how patients with hyaluronic acid filler were treated with ultrasound. I also saw some patients with permanent fillers. These were identified with ultrasound and then treated, as much is possible with a permanent filler. Attending this clinic, further reinforced the need for accurate injections technique and for improving filler safety with ultrasound use.

Why did I initially introduce ultrasound into my clinical practice?

Is

We have all seen the recent wave of aesthetic clinics implementing ultrasound into their daily clinical practice. But, Dr Kim Booysen questions is it something you should be considering?

Advertorial Merz Aesthetics

and Dermis Orbicularis

identify the anatomy of the treatment before injecting, select a safe area treatment and then review if I have placed the filler in the correct area, as a fat pad or periosteal region. the past we have relied on tactile feedback to decide if we are placing periosteally or intrafascially, and occasion we are not in the correct place, ultrasound use reinforces the feel correct placement and allows early correction, before complications arise, filler is incorrectly placed.7

did I educate train myself ultrasound use?

training in facial muscle and structure recognition and also ultrasound guided injection. Each MIP now uses a handheld ultrasound in their clinic to help with training and treating of patients.8 Lastly I was privledged to attend Dr Schelke and Velthuis’ complications clinic at the Erasmus University in the Netherlands courtesy of Merz Aesthetics UK. This clinic has been running since 2011 and received referrals from all over the Netherlands.5 I was able to observe the clinic over 2 days and saw how patients with hyaluronic acid filler were treated with ultrasound. I also saw some patients with permanent fillers. These were identified with ultrasound and then treated, as much is possible

Oris Muscle Mucosa

How did I choose an ultrasound to get started?

I luckily have been able to use two different types of ultrasound devices. Deciding on the one you want to purchase can be difficult as there are advantages and disadvantages to each device. Most handheld devices are lightweight, can be charged in a handy desktop charger or charging pad and the images can be viewed on a mobile or iPad. Images are saved to a cloud and can be retrieved on a laptop at a later date. In my clinic I have a separate stand for my iPad and this is set up next to the treatment couch so it is ready to go with each

training in facial muscle and structure recognition and also ultrasound guided injection. Each MIP now uses a handheld ultrasound in their clinic to help with training and treating of patients.8 Lastly I was privledged to attend Dr Schelke and Velthuis’ complications clinic at the Erasmus University in the Netherlands courtesy of Merz Aesthetics UK. This clinic has been running since 2011 and received referrals from all over the Netherlands.5 I was able to observe the clinic over 2 days and saw how patients with hyaluronic acid filler were treated with ultrasound. I also saw some patients with permanent fillers. These were identified with ultrasound and then treated, as much is possible

with a permanent filler. Attending this clinic, further reinforced the need for accurate injections technique and for improving filler safety with ultrasound use. I would advise reading some studies on ultrasound, perhaps look at some textbooks on facial ultrasound and then attend training, such as that provided by Merz Aesthetics UK, to see how ultrasound can be used in aesthetics, before you commit to purchasing an ultrasound device.

ultrasound image of the lower lip showing flow in the inferior labial artery.

structure ultrasound guided uses a handheld help with patients.8 Lastly Dr Schelke clinic at the Netherlands UK. This since 2011 all over the observe saw how filler were also saw permanent fillers. ultrasound

training in facial muscle and structure recognition and also ultrasound guided injection. Each MIP now uses a handheld ultrasound in their clinic to help with training and treating of patients.8 Lastly I was privledged to attend Dr Schelke and Velthuis’ complications clinic at the Erasmus University in the Netherlands courtesy of Merz Aesthetics UK. This clinic has been running since 2011 and received referrals from all over the Netherlands.5 I was able to observe the clinic over 2 days and saw how patients with hyaluronic acid filler were treated with ultrasound. I also saw some patients with permanent fillers. These were identified with ultrasound and then treated, as much is possible

lucky in that I had used ultrasound eFast scans, placing central and peripheral lines and looking for cardiac functionality in an arrest situation, so fundamentals and “knobology” ultrasound was familiar to me. But facial anatomy was not. I spent most of lockdown scanning my own and my husband’s face trying to identify and follow vessels, looking for muscles and trying to marry that with the 2D images I seen in anatomy text books. I spent of time looking up what different muscles and vessels looked like on ultrasound. As with everything repetition key. Initially it took me ages to find vessels, now with a lot of practice quicker and I can scan and find vessels in a short time and my treatment times are not that much longer using ultrasound.7 Once lockdown finally I was able to attend training with Leonie Schelke and Dr Peter Velthius, are considered the pioneers of aesthetic ultrasound and complications management. Merz Aesthetics UK, also arranged for further training for the Merz Innovation Partners (MIPs) with these two thought leaders. The MIPs spent 2 days

Teeth

How did I choose an ultrasound to get started?

with a permanent filler. Attending this clinic, further reinforced the need for accurate injections technique and for improving filler safety with ultrasound use. I would advise reading some studies on ultrasound, perhaps look at some textbooks on facial ultrasound and then attend training, such as that provided by Merz Aesthetics UK, to see how ultrasound can be used in aesthetics, before you commit to purchasing an ultrasound device.

I luckily have been able to use two different types of ultrasound devices. Deciding on the one you want to

How did I choose an ultrasound to get started?

treatment.7 You don’t need to purchase the most expensive machine when you get started. At a minimum you need 4-5cm visualisation depth and a scanning frequency of around 20MHz. This will allow you to visualise all the necessary facial structures. Higher frequencies and shallower depths of penetration are ideal for facial ultrasound as facial structures are rarely deep and therefore a higher frequency will get clearer images of these shallower facial structures.7 Over the years, you may decide to upgrade to a more advanced device, but as an initial device, I have found my handheld scanner perfectly adequate for my needs.7

with a permanent filler. Attending this clinic, further reinforced the need for accurate injections technique and for improving filler safety with ultrasound use. I would advise reading some studies on ultrasound, perhaps look at some textbooks on facial ultrasound and then attend training, such as that provided by Merz Aesthetics UK, to see how ultrasound can be used in aesthetics, before you commit to purchasing an ultrasound device.

I luckily have been able to use two different types of ultrasound devices. Deciding on the one you want to

How did I choose an ultrasound to get started?

I luckily have been able to use two different types of ultrasound devices. Deciding on the one you want to

1.

H-J.

TO REGISTER SCAN THE QR CODE OR VISIT merz-aesthetics.co.uk/ecademy

of

Procedures, An

Dr Kim Booysen is an independent aesthetic clinic owner in South East London. She holds degrees in Medicine, Law, International Health Management and Business Management. Her special interests are medico-legal aesthetics and aesthetic education. Her spare time is spent travelling with her husband and working on local environmental causes. Dr Booysen is a Merz Innovation Partner and received compensation for this advertorial.

ACCESS TO EXPERT-LED CLINICAL EDUCATION AT YOUR FINGERTIPS

and a scanning frequency of around 20MHz. This will allow you to visualise all the necessary facial structures. Higher frequencies and shallower depths of penetration are ideal for facial ultrasound as facial structures are rarely deep and therefore a higher frequency will get clearer images of these shallower facial structures.7 Other the years, you may decide to upgrade to a more advanced device, but as an initial device, I have found my handheld scanner perfectly adequate for my needs.7

for my iPad and this is set up next to the treatment couch so it is ready to go with each treatment.7 You don’t need to purchase the most expensive machine when you get started. At a minimum you need 4-5cm visualisation depth and a scanning frequency of around 20MHz. This will allow you to visualise all the necessary facial structures. Higher frequencies and shallower depths of penetration are ideal for facial ultrasound as facial structures are rarely deep and therefore a higher frequency will get clearer images of these shallower facial structures.7 Other the years, you may decide to upgrade to a more advanced device, but as an initial device, I have found my handheld scanner perfectly adequate for my needs.7

purchase can be difficult as there are advantages and disadvantages to each device. Most handheld devices are light weight, can be charged in a handy desktop charger or charging pad and the images can be viewed on a mobile or iPad. Images are saved to a cloud and can be retrieved on a laptop at a later date. In my clinic I have a separate stand for my iPad and this is set up next to the treatment couch so it is ready to go with each treatment.7 You don’t need to purchase the most expensive machine when you get started. At a minimum you need 4-5cm visualisation depth and a scanning frequency of around 20MHz. This will allow you to visualise all the necessary facial structures. Higher frequencies and shallower depths of penetration are ideal for facial ultrasound as facial structures are rarely deep and therefore a higher frequency will get clearer images of these shallower facial structures.7 Other the years, you may decide to upgrade to a more advanced device, but as an initial device, I have found my handheld scanner perfectly adequate for my needs.7

Guideline for Ultrasonographic-Guided Procedures. Singapore, Springer Nature. 2021.

2018 Dec;17(6):1019-1024. doi: 10.1111/jocd.12726.

Plast Surg. 2019;35(2):193-203.

L, Decates T, Kadouch J, Velthuis P. Incidence of Vascular Obstruction After Filler Injections. Aesthet Surg J. 2020 Jul 13;40(8):NP457-NP460. doi: 10.1093/ asj/sjaa086. PMID: 32538425; PMCID: PMC7357869. 6. Velthuis PJ, Jansen O, Schelke LW, Moon HJ, Kadouch J, Ascher B, Cotofana S. A Guide to Doppler Ultrasound Analysis of the Face in Cosmetic Medicine. Part 2: Vascular Mapping. Aesthet Surg J. 2021 Oct 15;41(11):NP1633-NP1644. doi: 10.1093/asj/sjaa411. PMID: 33954749. 7. Booysen, K. Introducing ultrasound to your clinic. Aesthetics 2021 Aug 8;9. 8. Merz UK. Advertorial: Ultrasound Imaging. Aesthetics 2021 Dec. Available from: https://aestheticsjournal.com/news/advertorial-ultrasound-imaging

Adverse events should be reported. Reporting forms and information for United Kingdom can be found at www.mhra.gov.uk/yellowcard. Reporting forms and information for Republic of Ireland can be found at https://www.hpra.ie/homepage/about-us/report-an-issue/mdiur. Adverse events

2018 Dec;17(6):1019-1024. doi: 10.1111/jocd.12726.

Velthuis PJ, Jansen O, Schelke LW, Moon HJ, Kadouch J, Ascher B, Cotofana S. A Guide to Doppler Ultrasound Analysis of the Face in Cosmetic Medicine. Part 2: Vascular Mapping. Aesthet Surg J. 2021 Oct 15;41(11):NP1633-NP1644. doi: 10.1093/asj/sjaa411. PMID: 33954749. 7. Booysen, K. Introducing ultrasound to your clinic. Aesthetics 2021 Aug 8;9. 8. Merz UK. Advertorial: Ultrasound Imaging. Aesthetics 2021 Dec. Available from: https://aestheticsjournal.com/news/advertorial-ultrasound-imaging

PMC7357869.

with a permanent filler. Attending this clinic, further reinforced the need for accurate injections technique and for improving filler safety with ultrasound use. I would advise reading some studies on ultrasound, perhaps look at some textbooks on facial ultrasound and then attend training, such as that provided by Merz Aesthetics UK, to see how ultrasound can be used in aesthetics, before you commit to purchasing an ultrasound device. How did I choose an ultrasound to get started? I luckily have been able to use two different types of ultrasound devices.

purchase can be difficult as there are advantages and disadvantages to each device. Most handheld devices are light weight, can be charged in a handy desktop charger or charging pad and the images can be viewed on a mobile or iPad. Images are saved to a cloud and can be retrieved on a laptop at a later date. In my clinic I have a separate stand for my iPad and this is set up next to the treatment couch so it is ready to go with each treatment.7 You don’t need to purchase the most expensive machine when you get started. At a minimum you need 4-5cm visualisation depth and a scanning frequency of around 20MHz. This will allow you to visualise all the necessary facial structures. Higher frequencies and shallower depths of penetration are ideal for facial ultrasound as facial structures are rarely deep and therefore a higher frequency will get clearer images of these shallower facial structures.7 Other the years, you may decide to upgrade to a more advanced device, but as an initial device, I have found my handheld scanner perfectly

Kim, H-J. , et al., Ultrasonographic Anatomy of the Face and Neck

should also be reported to Merz Pharma UK Ltd by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143.

Doppler ultrasound image of the lower lip showing blood flow in the inferior labial artery.

Epidermis and Dermis

Orbicularis Oris Muscle

Mucosa Teeth

Dr Kim Booysen is an independent aesthetic clinic owner in South East London. She holds degrees in Medicine, Law, International Health Management and Business Management. Her special interests are medico-legal aesthetics and aesthetic education. Her spare time is spent travelling with her husband and working on local environmental causes. Dr Booysen is a Merz Innovation Partner and received compensation for this advertorial.

24/7 ACCESS TO EXPERT-LED CLINICAL EDUCATION AT YOUR FINGERTIPS

References:

Kim,

, et al., Ultrasonographic Anatomy

the Face and Neck for Minimally Invasive

Anatomic

Doppler ultrasound image of the lower lip showing blood flow in the inferior labial artery.

Epidermis and Dermis

Orbicularis Oris Muscle

Mucosa Teeth

Dr Kim Booysen is an independent aesthetic clinic owner in South East London. She holds degrees in Medicine, Law, International Health Management and Business Management. Her special interests are medico-legal aesthetics and aesthetic education. Her spare time is spent travelling with her husband and working on local environmental causes. Dr Booysen is a Merz Innovation Partner and received compensation for this advertorial.

Epidermis

This advertorial is sponsored by Merz Aesthetics UK & Ireland

Exploring SOC and Laser Hair Removal

and knowledge of treating skin of colour (SOC) was the primary reason they chose a particular clinician.7

These statistics highlight how imperative it is that aesthetic practitioners are fully educated and informed about all skin types, and to avoid a ‘one size fits all’ approach. There are various physiological differences between dark and fair skin types that should be acknowledged, including the stratum corneum cell layers,8 ceramide levels,9,10 skin pH,11 transepidermal water loss (TEWL),12 and pigmentation.13 Specific knowledge and understanding should be applied, with particular focus on understanding melanin distribution in skin types, and how melanin reacts to laser wavelengths. It is also important to acknowledge the potential psychological impact of former treatment exclusion and how treatment disadvantage can be stressful and upsetting to explain.

The consultation itself should be structured as such so that concerns about safety and efficacy on darker skin types are answered before questions are even asked. This is in addition to standard consultation discussion points such as treatment goals and expectation, current method of hair removal, how laser treatments work, different types of laser technology and why certain treatments are more effective than others, the treatment process and any factors that may affect outcome, medical history, pre- and post-treatment treatment care, cost and frequency and anticipated outcome.

In addition, in my clinic, I will always perform a patch test to observe epidermal responses, establish the best treatment parameters for the specific skin type, and ascertain any adverse reactions 48-72 hours pre-treatment.

The global laser hair removal industry is growing and is expected to be worth $3.4 billion by 2026, according to market experts Acumen Research and Consulting.1

Despite this buoyant growth prediction, laser hair removal has historically been a subject of avoidance for patients who have darker skin tones, specifically those identified as skin types IV, V and VI on the Fitzpatrick skin type scale.2,3 Predominantly, this can be attributed to many professional laser hair removal devices being unsuitable for use on these skin types due to the possibility of certain adverse effects. These include (but are not limited to) hyperpigmentation,4 hypopigmentation,5 blistering and scarring.6

The previous inability within the aesthetics industry to treat patients with skin types IV, V and VI has been problematic to patient and practitioners alike. This treatment exclusion meant that patients were not able to experience the same level of technology as their fair-skinned counterparts and were left having to resort to more traditional, and less sophisticated and effective methods of depilation including shaving, waxing, depilatory creams and electrolysis. The situation is thankfully, if somewhat slowly, changing. Ongoing technological advancements coupled with improved awareness and education within the specialty in recent years means that laser hair removal devices can now reliably treat patients with darker skin tones, providing excellent outcomes.

The initial consultation

One UK survey by the Black Skin Directory revealed that 92% of black women said it was a challenge to find a skincare professional who could meet their needs.7 In addition, 90% of respondents said the experience

Skin type scales

Part of the consultation process should include an analysis of skin type. The current industry standard is to use the Fitzpatrick scale that classifies skin into six broad categories (I being the fairest skin types and VI being the darkest) and is used to establish how much melanin is in the skin.14 As the population continues to diversify, there is conversation within the industry as to whether the Fitzpatrick scale is still relevant. As a result, some practitioners use a combination of different scales. One such example is the Roberts Skin Type Classification System, which observes both the Fitzpatrick and Glogau scales, and considers propensity to pigmentation, scarring and inflammation which can be useful when planning a patient’s treatment regimen.15,16

What current skin type scales do not explain and is useful to acknowledge are the physiological differences in skin types. This is important to ensure that different skin types are treated appropriately and safely, and to form an understanding of why difficulties in treating darker skin types can arise.

A key difference pertaining to laser hair removal lies in skin pigmentation. Up to 8% of the cells in the stratum basal level of the epidermis is a melanocyte.17 Melanocytes make the pigment called melanin. When laser and light energy passes through the epidermis to target its chromophore, the energy has to go through the melanocytes in the epidermis. Melanocytes in the hair bulb, epidermal melanocytes and the melanin within them can act as competing chromophores and absorb this energy, resulting in an increased risk of complications and a higher frequency of adverse events such as erythema. Longer

Dr Baldeep Farmah provides an introduction to how laser hair removal can be made more accessible for patients with skin of colour

wavelengths are considered to be more effective on darker skin types as they are absorbed less by melanin.17

In addition, longer pulse durations are also recommended to prevent overheating. Excessive overheating of melanocytes in darker skin types can result in post-inflammatory hypopigmentation which is a widely recognised adverse event of laser hair removal.17

Available technology

Given the wealth of technological capabilities within the sector, it’s almost unbelievable to conceive that only a decade ago, laser hair removal on darker skin tones was unheard of. Part of the historic problems lie in the basic fundamentals of how lasers work. Many devices were simply not sophisticated enough to distinguish sufficiently between the increased amount of epidermal melanin in skin types IV-VI and melanin present in the hair follicles and shaft. It is this technological ‘confusion’ that led to a higher frequency of adverse effects. Technology is fundamental to aesthetic clinics becoming more inclusive and it’s essential for practitioners to carefully consider what a laser hair removal device can offer their clinic and patients before making an investment commitment. Different types of laser hair technology include Ruby, Alexandrite, Diode and Nd:YAG.

Ruby (694.3 nm)

A Ruby laser produces pulses of red visible light at a wavelength of 694.3 nm. It is very well absorbed by the melanin pigment in the hair, making this system very effective for people of skin tones I to III on the Fitzpatrick Scale. However, due to the shorter wavelength of the Ruby laser system being absorbed more by melanocytes, is not recommended for individuals with darker skin tones due to the possibility of pigmentation issues and scarring in skin tones IV to VI.18

Alexandrite (755 nm)

The Alexandrite is a red-light laser that uses an Alexandrite crystal as a medium and operates at a shorter wavelength of 755 nm. This makes it ideal for targeting the melanin in the hair follicles of individuals with light to olive skin tones. Extreme caution is recommended in patients with skin types IV to VI as the laser can destroy melanin, resulting in hypopigmentation.19,20

Diode (808 nm)

A precursor to the arrival of Nd:YAG technology, Diode lasers use semiconductor technology combined with a single narrow spectrum light beam to target specific chromophores in the skin. The 808 nm diode laser wavelength has a high abruption rate in melanin and uses the principle of selective photothermolysis (SPTL) to target melanin. The

laser selectively heats the melanin and destroys the root and blood flow to the hair follicle, which results in the disruption of hair growth and regeneration. Suitable for use on all Fitzpatrick skin types, a diode laser can be complemented by cooling technology, or other pain reducing methods which improve treatment efficacy and patient comfort.21

Nd:YAG (1064 nm)

In my view, practitioners looking to improve their inclusivity and widen their patient demographic should ensure that the device they choose includes Nd:YAG technology. It’s generally accepted that the use of Nd:YAG wavelength at 1064 nm is the most suitable for treating skin types IV-VI as the absorption by epidermal melanin is much lower than with other wavelengths such as Alexandrite, that are better suited to treating skin types I-III. Nd:YAG is also highly absorbed in oxyhemoglobin, which affects the blood supply to the hair follicle.22,23

Choosing a device

I personally choose to use a device that combines both Nd:YAG and Alexandrite in my clinic. My device of choice is the Lumenis SPLENDOR X system, although there are many other devices available which are suitable for treating SOC. When choosing a device, I would always encourage practitioners to assess the clinical studies relating specifically to SOC for the specific device and look for a device that is customisable so you can tailor the treatment to fit the patient’s specific skin type, hair colour and thickness for the most effective treatment. You also want to consider speed for hair removal, so be sure to enquire about the spot size. This is because larger spot sizes allow the laser to penetrate deeper into the epidermis and allows the practitioner to cover larger areas more quickly.24

Consider advancing technology

Technological advancements in the aesthetics industry and specifically laser hair removal have opened a wealth of opportunities to patients and practitioners alike. Practitioners should ensure that they research available system technology thoroughly and choose an option that not only allows them to treat a diverse patient base, but that also offers them the ability to expand their expertise, knowledge and training – all fundamental elements for procuring trust between patient and practitioner. All decisions should involve an element of inclusion so that all patients feel respected and treated as an individual and their physiological and psychological needs are considered and fulfilled simultaneously.

Dr Baldeep Farmah is the medical director of Dr Aesthetica clinic. His aesthetics skills are uniquely combined with years of experience as a psychiatric consultant to encourage a more holistic approach to aesthetic treatments. He specialises in offering patients natural-looking results that leaves a positive impact on their mental and emotional wellbeing.

Qual: MBBS, RCPSYCH

Given the wealth of technological capabilities within the sector, it’s almost unbelievable to conceive that only a decade ago, laser hair removal on darker skin was unheard of

BOCOUTURE®

was the first neurotoxin treatment approved for upper facial lines1

FEEL GOOD LOOK GOOD

Bocouture® (botulinum toxin type A (150 kD), free from complexing proteins) 50/100 unit vials*. Prescribing information: M-BOC-UK-0432. Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: 50/100 units of Clostridium Botulinum Neurotoxin type A, free from complexing proteins as a powder for solution for injection. Indications: Temporary improvement in the appearance of moderate to severe upper facial lines (glabellar frown lines, crow’s feet lines, horizontal forehead lines) in adults ≥18 and <65 years when the severity of these lines has an important psychological impact for the patient. Dosage and administration: For intramuscular use only. Unit doses recommended for Bocouture are not interchangeable with those for other preparations of botulinum toxin. BOCOUTURE should only be administered by an appropriately qualified healthcare practitioner with expertise in the treatment of the relevant indication and the use of the required equipment, in accordance with national guidelines . The intervals between treatments should not be shorter than 3 months. Reconstitute with 0.9% sodium chloride. Glabellar Frown Lines: Total recommended standard dose is 20 units. 4 units into 5 injection sites (2 injections in each corrugator muscle and 1 injection in the procerus muscle). May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Total recommended standard dosing is 12 units per side (overall total dose: 24 units); 4 units injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Horizontal Forehead Lines: The recommended total dose range is 10 to 20 units; a total injection volume of 10 units to 20 units is injected into the frontalis muscle in five horizontally aligned injection sites at least 2 cm above the orbital rim. An injection volume of 2 units, 3 units or 4 units is applied per injection point, respectively. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Infection or inflammation at the proposed injection site. Special warnings and precautions: It should be taken into consideration that horizontal forehead lines may not only be dynamic, but may also result from the loss of dermal elasticity (e.g. associated with ageing or photo damage). In this case, patients may not respond to botulinum toxin products. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Caution in patients with botulinum toxin hypersensitivity, amyotrophic lateral sclerosis, peripheral neuromuscular dysfunction, or in targeted muscles displaying pronounced weakness or atrophy. Bocouture should be used with caution in patients receiving therapy that could have an anticoagulant effect, or if bleeding disorders of any type occur. Too frequent or too high dosing of botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Should not be used

during breastfeeding. Interactions: Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects: Usually, undesirable effects are observed within the first week after treatment and are temporary in nature. Undesirable effects independent of indication include; application related undesirable effects (localised pain, inflammation, swelling), class related undesirable effects (localised muscle weakness, blepharoptosis), and toxin spread (very rare - exaggerated muscle weakness, dysphagia, aspiration pneumonia). Hypersensitivity reactions have been reported with botulinum toxin products. Glabellar Frown Lines: Common: headache, muscle disorders (elevation of eyebrow). Crow’s Feet Lines: Common: eyelid oedema, dry eye, injection site haematoma. Upper Facial Lines: Very common: headache. Common: hypoaesthesia, injection site haematoma, application site pain, application site erythema, discomfort (heavy feeling of frontal area), eyelid ptosis, dry eye, facial asymmetry, nausea. For a full list of adverse reactions, please consult the SmPC. Overdose: May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Legal Category: POM. List Price: 50 U/vial £72.00, 50 U twin pack £144.00, 100 U/vial £229.90, 100 U twin pack £459.80. Product Licence Number: PL 29978/0002, PL 29978/0005 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100,60318 Frankfurt/Main, Germany. Date of Preparation:August 2021. Further information available from:. Ground Floor Suite B, Breakspear Park, Breakspear Way, Hemel Hempstead, Hertfordshire, HP2 4TZ Tel: +44 (0) 333 200 4143

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard for the UK. Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143.

*Botulinumtoxin type A, purified from cultures of Clostridium Botulinum (Hall strain)2

References: 1. Merz Pharma GmBH & Co. Merz Announces European Approval of Bocouture for the Treatment of Upper Facial Lines. Available at: https://www.merz.com/blog/news/merz-announces-european-approvalof-bocouture-for-the-treatment-of-upper-facial-lines/. Accessed November 2021. 2. BOCOUTURE® (incobotulinumtoxinA) Summary of Product Characteristics. Merz Pharmaceuticals GmbH. M-BOC-UK-0445 Date of Preparation: December 2021

Free from complexing proteins

Advertorial Allergan

Treating the Perioral Area

The lips are a popular area to treat, but the perioral area is one of the most complex regions to master and difficult to get right. I regularly treat ageing lips of middle-aged patients, and it’s one of the first areas, together with the mid-face, that patients ask about. Here are many factors to consider such as the down turning of the mouth, loss of volume in the lips, and fine lines in the perioral area can create negative signals, which patients feel makes them look sad. With so many fears surrounding dermal filler treatments, particularly in the lip area due to a lot of unnatural, over-volumised lips, I find that a holistic consultation and treatment is a good approach for optimum results and happy patients.

bone including dentition. Although a patient might present with perioral concerns, it’s important not to view this area in isolation and conduct a full-face assessment as all the facial landscapes relate to one another. In filler consultations, I begin with the mid-face by assessing the volume, lateral support and how this is impacting the lower face. Look at how they express themselves and how you might need to treat individual layers.

The more you can show that you understand your patient, the more trust they feel and know they are in safe hands. Remember, the consultation and assessment is your chance to show yourself as a true leader in aesthetics, so do this thoroughly.

Product selection

I’ve always used the Juvéderm portfolio because it’s a brand I trust with an excellent support network. When the Juvéderm Vycross range first launched it demonstrated a coordinated full-face approach. It’s important to match your products to the key facial areas they are indicated for.

My top treatment tips

Tip 1: If your patient has perioral lines, I suggest you enter the lateral aspect of the lip with a cannula and go back and forth to break collagen fibres (subcise) before placing the filler. I have found that this releases the tissues, activates neocollagenesis and the filler can play a role in dermal cell biochemical response.

Tip 2: Remember to have a full-face approach as it’s possible to cause facial disharmony and make patients look worse otherwise! I believe you shouldn’t just treat one area in isolation and explain to the patient why this approach is necessary.

Tip 3: Always consider safety – I use a mixture of needle and cannulas and will choose cannulas in higher risk areas like the nasolabial folds and marionette lines. When using a needle, I will always aspirate. Also know the anatomy and how vessel location may slightly differ.

Learn more tips & tricks live at ACE 2022!

A thorough consultation and assessment is vital, as is informing and educating your patient to get them on board with your treatment plan. To learn more about my holistic approach, come to my talk on treating the perioral area at ACE 2022 in March (HCPs only). Scan the QR code to register! This talk is produced and sponsored by Allergan Aesthetics.

The holistic consultation and assessment

Connecting with your patient with empathy and understanding is key. To do this, learn about their lifestyle, general health, diet and psychosocial wellbeing. As the consultation must involve careful assessment, which often can often feel negative, I always ensure that I balance this out by pointing out their unique beauty and complimenting them on this. Explaining the ageing process is so important and enables the patient to understand your treatment approach – this is never a waste of time and lays foundation for return visits. I explain every level of the ageing process from the skin surface to the

Volite: I use this product to hydrate the skin, soften lines and inject into the lip for those who prefer hydration rather than volume. Volbella: for more mature lips adding subtle volume, can form a crisp vermillion boarder and improve perioral lines. It’s also useful for tear troughs! I advise a slow injection to reduce swelling.

Volift: I use this for more youthful lips as it’s soft. I also find it helpful for improving lateral support of the mid-face and for nasolabial lines, which helps enhance the look of the perioral area.

Voluma: I use this to support the underlying structures. It is a mouldable product and my go-to for temples, mid-face and occasionally the labiomental crease. Volux: for treating the jawline to improve definition, structure and support to the perioral area! You can really profile balance with this in your toolkit.*

Rosey Drewitt-Staples has been working in aesthetics for 17 years. She has practised at The Hospital Group, Transform Medical and now has her own clinic, ProAesthetics (Nottingham) and training company, ProAesthetic Courses. Rosey is one of four UK nurses on the esteemed Allergan Faculty.

Qual: RGN, HV, INP

This advertorial was produced and funded by Allergan Aesthetics

UK-JUV-220039 DOP: February 2022

*Please see the respective product ‘directions for use’ before administration. The Juvéderm range is only licensed for patients over the age of 18. Please ensure the filler risks, complications and potential side effects as listed in the directions for use have been fully communicated to the patient prior to use.

Aesthetic nurse prescriber Rosey Drewitt-Staples provides her holistic approach to rejuvenating the lips and perioral area

60-year-old patient before and immediately after using the full-race approach with 5ml of Juvéderm Voluma to the mid-face, 3ml of Juvéderm Volux to the chin and jawline and 1ml of Juvéderm Ultra to the lips.

Exploring LED Phototherapy

Nurse precriber Anna Baker discusses the considerations around LED treatment

The rise in popularity of non-invasive treatments which improve the quality and condition of the skin continues.1 In particular, there has been a rise in the use of non-invasive devices, with a total of 280,815 procedures last year in the UK.2 Particular technology that I’ve found gaining momentum in my clinic is Light Emitting Diode (LED) phototherapy, which refers to the use of low-level light energy at defined wavelengths to elicit a range of cellular and regenerative benefits.3 The mechanisms of action are based on the same principles as photosynthesis, known as photobiomodulation, which means that light is absorbed by target cells to activate specific biological functions.4 In addition, there are multiple reported pathways by which clinical benefit is achieved.5 LED phototherapy positively impacts cellular metabolism by triggering intracellular photobiochemical reactions, which include increased adenosine triphosphate (ATP), modulation of reactive oxygen species, stimulation of angiogenesis and increased blood flow among others.6

LED phototherapy provides an affordable and effective option for practitioners, in part due to the diverse number of skin conditions it can treat, such as rosacea, acne, psoriasis, eczema, dermatitis, wound healing, dry/irritated skin (for both the face and body), musculoskeletal conditions, repair/regeneration at a cellular level.6 It is also suitable for all Fitzpatrick skin types.6 In contrast to traumatic ablative (e.g. laser resurfacing), and non-ablative (e.g. intense pulsed light) modalities, which induce secondary tissue repair by causing controlled damage, LED phototherapy is atraumatic and bypasses the initial destructive step by triggering regenerative processes within the skin.7 Successful LED treatment rests on many key factors aligning, and I find that practitioners often misunderstand the significance of correct wavelength, dose, energy and treatment time. Here I will discuss some key considerations for successful treatment using LED in terms of wavelength, but dose and treatment are beyond the scope of this article.

Wavelength specification

There are many LED devices on the market and it’s key to understand the basics in determining the importance of clinicallyproven wavelengths and how this impacts on the efficacy of the treatment.

This is a critical factor, as light is a powerful energy, and when it’s applied as phototherapy at a cellular level, it allows photoreceptors to absorb specific wavelengths.5 The correct wavelengths will ensure absorption of photons (light is made of photons-microscopic particles of electromagnetic energy), on the target chromophore.8 The waveband in which the wavelength of the photon is located determines not only which part of the cell is the target, but also the primary photoaction.7 There are other reported variables within the literature that can affect the outcome of treatment, such as the energy density, power density, total energy, tissue absorption characteristics, as well as the total number of treatments.9

The wavelengths with the strongest clinical evidence are blue light 415 nm, red light, 633 nm and near-infrared (NIR) 830 nm. In addition, another variable is time which is relative to the total treatment energy/ energy density.10

Using different lights

Blue light

Blue light 415 nm wavelength delivers calming benefits to congested and acneic skin through its bactericidal action without irritation.11 Blue light at 415 nm stimulates porphyrins through a photochemical reaction, and as a result, singlet oxygen is released, which selectively and atraumatically irradicates bacteria. Its calming benefits make it ideally suited for problematic skin types,12 as well as reported improvements in mood and fatigue.13 It has the ability to penetrate 2-3mm in the epidermis.6

Red light

Red light 633 nm is proven to stimulate collagen and elastin synthesis, as well as skin tone, texture, and reduce the appearance of fine lines.14 Red light specifically at 633 nm can penetrate at 8-10mm in the mid dermis, and recharges ATP which enhances and restores optimal cell function, whilst accelerating cell renewal.9 In addition, it helps to reduce hyperpigmentation, increase skin hydration and stimulate blood circulation.4

Near-infrared light

Near-infrared (NIR) light 830 nm provides advanced skin rejuvenation benefits by specifically modulating inflammation and accelerating healing, and is suited to even the most sensitive skin types.7 NIR 830 nm is outside of the visible light spectrum and is invisible to the naked eye, but can penetrate to the subcutaneous layer at between 20-100mm.4

Different types of power

As well as the wavelength, two additional parameters are also important to understand; the irradiance, or power density, which is measured in mW/cm2, as well as the dose or energy density, which is measured in J/cm2. The power density, sometimes referred to as intensity, can be thought of as the spatial concentration of power.9 Reduced power density, as well as the energy density may impede treatment outcomes as it means treatment will be unsuccessful at a cellular level within the skin. Essentially, effective LED treatment, at whichever wavelength is used, refers to using low-level light energy through specific wavelengths to stimulate, regulate, or inhibit specific cellular processes to deliver therapeutic benefits. LED phototherapy delivers energy to improve cellular performance and facilitate repair mechanisms.15

Combining wavelengths

This will partly depend on the condition(s) being treated. Not all colours/wavelengths are supported by strong evidence to demonstrate effective skin rejuvenation and/or medical benefits,7 particularly when used in combination. Where devices have more than one colour/ wavelength, it’s key to ensure that the manufacturer specifications are supported by evidence and appropriate for use. Blue 415 nm, red 633 nm and NIR 830 nm are robustly supported clinically,2-10 and each

wavelength is capable of delivering multiple benefits. By comparison, green 520 nm and yellow 590 nm wavelengths are blocked by blood and have limited clinical data and mixed outcomes with regard to demonstrating consistent therapeutic benefit.16 Yellow LED application has limited evidence to support clinical benefit to individuals with photodamaged skin. Both wavelengths have limited clinical evidence to support clinical use.17

Add-on treatments

The versatility and diversity of clinically-proven LED wavelengths means that it can be used as a highly effective standalone course, as well as a combination treatment alongside almost all other treatments, most commonly injectables, chemical peels, threads, fractional procedures, radiofrequency, and microneedling. The scope of indications ranges from cosmetic, including photodamage/dyschromia, rejuvenation, moderate and severe acne, redness, as well as inflammation.10 Medical conditions that benefit can include improving musculoskeletal pain, wound healing, as well as psoriasis.9

Treatment is contraindicated in individuals who suffer with epilepsy or seizures which are triggered by light, porphyria, autoimmune conditions, polymorphic light eruption, photosensitive eczema and active cancers.9 Caution should also be exercised by the treating practitioner in patients who are pregnant, those with eye disease and related conditions, light induced migraines, photosensitising medications/skincare products and St John’s Wart.18

Utilising LED

LED using clinically-proven wavelengths can be considered an integral part of many treatments. The cumulative and longterm benefits are widely described and supported in the literature in both men and

women, across all Fitzpatrick skin types. There is considerable data to demonstrate that LED can effectively enhance and accelerate the results of any skin treatment, and arguably provides a more effective skin maintenance regimen than a topical skincare approach alone. Many inflammatory skin conditions on the face and body require long-term management and can benefit from LED (excluding photosensitive diagnoses), both as an initial and intensive course, and as maintenance.

Anna Baker is an aesthetic nurse prescriber, trainer and qualified educator. She is a key opinion leader, BACN Board member and jointly leads on the BACN Education and Training Committee. Qual: BN RGN INP PGCert (App. Clin. Anat.), PGDip (Clin. Ed)

VIEW THE REFERENCES ONLINE! AESTHETICSJOURNAL.COM

11 & 12 MARCH 2022 / LONDON

Anna Baker is speaking at ACE on March 11. Scan the QR code to register for free

The long-term benefits are widely described and supported in the literature in both men and women, across all Fitzpatrick skin types

Understanding Toxin Resistance

Botulinum toxin type A (BoNT-A) has been used since the 1970s,1 and these anti-wrinkle injections are one of the most popular cosmetic treatments in the world.2 With estimates of nearly seven million injections per year globally,3 it’s no wonder that the discussion surrounding BoNT-A resistance and concerns of its effectiveness, have become more prevalent. The issue of antibody-induced treatment failure is well-known in the therapeutic setting, but with more use cosmetically we are seeing more reports of resistance.4,5 At the time of writing, I have just had my first experience with a patient who seemed to be resistant to all FDA approved toxin brands, which were tried with no effect.

Understanding toxin

Firstly, to understand how/why resistance happens we must understand how botulinum toxin works. BoNT is composed of a core neurotoxic protein and nontoxic accessory proteins (NAPS) that have a light chain and a heavy chain. A normal vial of the neurotoxin will consist of 150kD that contains 100kD heavy chain (which helps bind the neurons) and a 50kD light chain that helps entry into the cell. These heavy and light chains are linked together by a disulfide bond.6 The NAPS contain hemagglutinin (50Kd) and non-hemagglutinin proteins (130kD) to help prevent the toxin from breaking down.7,8 NAPS vary in different brands, but most include albumin, sucrose, lactose, sodium chloride and disodium succinate.6 BoNT prevents the release of acetylcholine at the axon endings at the neuromuscular junction. It does this by affecting the SNARE (SNAP receptor) proteins that transport the acetylcholine and their docking with the presynaptic membrane, before it is released into synaptic cleft. BoNT-A and BoNT-B work differently, as BoNT-A works on the SNAP-25 protein and BoNT-B works on synaptobrevin, and impairing this process prevents acetylcholine from being released, therefore making it hard for the muscles to contract.6,8

Causes and categorisations of resistance

Resistance is defined as the process wherein the body forms an antibody response to a drug medication, or something that the body regards as foreign. An antibody response can happen because botulinum toxin is regarded as foreign by the host and therefore has the potential to induce an immune response, this then results in the production of antibodies.8 These antibodies block the pharmacological effects of the botulinum neurotoxin.9,10 There are two types of resistance to BoNT-A type A: primary and secondary.

Primary is where a patient has had a first-time treatment and has no response instantly, however this seems to be very rare, and there are a limited number of cases that have been reported.11 Whilst there is no evidence suggesting the main causes of primary failure, it is thought it may be caused by a cross-reaction of other antibodies such as tetanus toxin A, pre-existing antibodies to botulinum toxin, chronic exposure to botulinum in childhood, and abnormalities of BoNT-A acceptors.1 The main cause of this BoNT-A resistance currently identified in the literature is that the presence of a foreign protein in the body causes antigens to induce a biological immune response.9,12-14 Antibodies can block the pharmacologic effects of the botulinum toxin, which are known as neutralising antibodies, and some patients can lose their response to botulinum injections over a period of time.12,14 The antibodies that can cause resistance to botulinum toxin have not yet been defined, and immune responses can differ between patients.11,14

Secondary resistance is described as initial results/benefits from treatments followed by a decrease in effect or no effectiveness at a later treatment date. This is defined as being after two subsequent treatments of botulinum toxin treatment.11 The literature suggests that secondary resistance is likely to develop within the first year of treatment, and if it’s not seen after the first four years it is highly unlikely that it will develop.15 Currently, it is thought from the evidence that secondary resistance occurs due to NAPS, however the research is limited.16 It is thought that NAPS can act like an adjuvant in a vaccine which stimulate your immune system causing an antibody response, which makes resistance more likely. There is very little evidence at present for us to understand why some patients get resistance and some don’t, and much more research is needed to valid the current research which suggests that NAPS can cause antibodies to be produced.17 The existing evidence shows that the factors that may contribute to antibody formation include longer large doses, a shorter time period between injections and decreased purity of botulinum toxin preparation.18,19,20

Studies in current literature

Preliminary research in animals injected with IncobotulinumtoxinA suggests that BoNT-A, which has the absence of complexing proteins (proteins that have no therapeutic function and don’t influence the diffusion of neurotoxin),21,22 is indeed associated with

reduced immunogenicity. A study involving cynomolgus monkeys that received repeated four-weekly injections with 4, 8, or 16 U/kg of IncobotulinumtoxinA or control group were not associated with the development of neutralising antibodies in any animal, despite clear evidence of biologic activity of the neurotoxin, which was more prominent in the highest dose group.23 However, this study lacked a positive control group, therefore more research and data is required to show that complexing proteins do indeed result in antibodies forming. A recent cross-sectional study in humans contained 59 patients that had exclusively been treated with IncobotulinumtoxinA (mono group) and 32 patients having been treated with other BoNT-A preparations less than nine times, who were then switched to at least 14 sessions of IncobotulinumtoxinA treatment (switch group). The study checked for the prevalence of neutralising antibodies, and was tested by means of the mouse hemi-diaphragm assay (MHDA). The study found that none of the patients in the mono and only two in the switch group had a positive MHDA-test, suggesting that there’s an association between neurotoxin (complex) protein load and neutralising antibody formation.24

The study concluded that to reduce the risk of antibodies forming, a toxin with the lowest amount of complex proteins should be used.25 Research shows that in addition to selecting a low-risk antigen to reduce the risk of antibodies developing, we should wait at least three months in-between treatments and use the lowest most effective dose.8,26 There have been multiple studies that have shown higher rates of resistance linked to treatments where patients have had higher therapeutic doses, such as in 22 patients with cervical dystonia or oromandibular dystonia who developed resistance and were found to have NAPS. This showed that the mean dose per visit and the dose of BoNT-A were significantly larger than those without NAPS, showing a link between developing NAPS and high doses of BoNT.19 Another study involving 616 patients receiving BoNT-A for cervical dystonia of which nine patients had NAPS, showed a link between those receiving higher doses at shorter treatment intervals. It also showed that patients who were reinjected within six weeks were more likely to develop NAPS.20 In cosmetic use this could validate why the evidence shows that resistance to botulinum toxin is less common in patients who receive BoNT-A at lower doses.

A recent systematic review was carried out using 43 studies, including 8,833 patients being treated with all available toxins on the UK market. The research showed that the number of patients with NAPS was 1.8% and there was a slight increase related to the duration the patient had been receiving BoNT-A. Those being treated for medical conditions using high doses was shown with the highest incidence of NAPS. Patients being treated with Abobotulinumtoxin-A were shown to have the most incidence of NAPs (7.4%) whilst Incobotulinumtoxin-A and Onabotulinumtoxin-A were shown to have a rate of 0.3%. The study concluded that whilst NAPS following BoNT-A is relatively low, there is limited evidence on what can cause a secondary response.27

Solutions to toxin resistance

With the risk of BoNT-A resistance, albeit small, it’s important to know what alternative treatments we can offer to our patients should the problem arise. Currently there is limited evidence for determining if antibodies disappear over time and whether as medical practitioners we should reinject or not. According to the literature, it is however important that the quality of the botulinum toxin used is neurotoxin free of complexing proteins with low antigenicity, to prevent a resistance happening again.28

Although there are no current guidelines, it is recommended in the

literature that patients who develop immunoresistance to BoNT-A can be treated with higher doses or by trying different brands, although there is debate around whether complex proteins are a help or a hindrance for the BoNT-A molecule.9 If there are no changes after trying an alternative brand, another alternative could be to try botulinum toxin type B (BoNT-B). The only commercially available BoNT-B drug available in the UK is RimabotulinumtoxinB (Neurobloc), but is indicated only for the treatment of cervical dystonia (torticollis) in adults.11 In terms of secondary resistance, a recent study containing 36 patients who had cervical dystonia (involuntary muscle contractions in the neck) and a secondary non-response to BoNT-A showed that 36% of the trial patients had a good clinical response to Neurobloc. The other 23 patients either had no response, a poor response, or side effects and stopped treatment. Another study containing 20 patients that were resistant to BoNT-A showed that seven of these patients showed some response to type B.29 These findings show that BoNT-B may have a place as an alternative treatment for patients who have have become resistant to type A, but overall the research shows that BoNT-B has no guarantee for an effective treatment.29

There is some guidance from the British Neurotoxin Network30 in 2016, which recommends distinguishing no response to the toxin and then considering a dose revision. Where resistance is identified it recommends a switch to BoNT-B or a treatment break. This guidance is not specific to cosmetic treatments or primary causes.30 Another paper discusses the association between secondary botulinum toxin treatment failure in cosmetic indication and anti-complexing protein antibody production, and proposes a protocol for the treatment of patients who are suspected to have resistance to BoNT-A.31 The protocol recommends that instead of switching brands, all practitioners should stop injecting BoNT-A for at least six months to prevent further antibody production or immune responses.31 Practitioners may also use other aesthetic treatments such as cosmeceuticals to help prevent wrinkles and skin tightening treatments using energy-based devices.

Conclusion

From the current literature it is easy to see that there is limited evidence to support how common resistance to BoNT-A is and why it happens. However, based on the research available there is a small amount of evidence that shows resistance may be linked to complex proteins. Until there is more clinical evidence it is wise to follow best treatment guidelines by using the lowest most effective dose and to have intervals of at least 12 weeks. In future, we need more long-term clinical studies to follow up patients and to understand the causes of botulinum toxin resistance and how we can treat them.

Lucy Williams is an independent nurse prescriber and the owner of Aurielle Aesthetics. Williams is registered with ACE Group and recently completed the Lee Walker Aesthetics Academy and continues to educate and evolve her skills and profession within the industry.

Qual: RN, INP

Growing Your Practice

Integrating skincare into your patient’s treatment journey

At SkinCeuticals, our mission is to improve skin health. We provide advanced skincare backed by science, research and innovation. Centered around three main pillars: Prevent, Correct and Protect, our products work in synergy to provide effective results.

We believe that long-lasting comprehensive results are achieved though the combination of state-of-the-art clinical protocols, professional treatments and advanced homecare – and we believe the best results are integrated. Our Integrated Skincare programme is built around clinical procedures, offering homecare for pre-conditioning, post-treatment and daily use. The benefits are long-lasting results and healthier, youthful looking skin.

81% 35%

Dr Ana Mansouri, aesthetic practitioner at Kat & Co, Birmingham: “I am a firm advocate for the value of early integration of medical-grade skincare, particularly with my injectable cases. This is due to experiencing first-hand how this has transformed my practice, both from a business point of view and also by enhancing clinical outcomes. My approach to SkinCeuticals integrated skincare at Kat & Co is based around a simple ‘ABC + targeted treatment’ routine where I utilise vitamin A, sun Block and vitamin C to prepare my patients’ skin for any rejuvenating treatments. This is carried out for four to eight weeks pre-procedure, as well as for ongoing maintenance of results by optimising neocollagenesis in the longer term. I also recommend adding targeted HA serums and ceramidebased moisturisers to support the maintenance process postinjectables in dry and mature skin types. For this purpose, my recommended product combination is the HA intensifier, as this has been shown to improve HA levels by up to 30% in just four weeks, paired with the Triple Lipid Restore to support the barrier function of the skin.”

SkinCeuticals Brand Background

Benefits

• Combining clinical procedures with professional treatments and advanced home care delivers comprehensive results

• Professional pre-conditioning and recovery post-treatment helps to reduce downtime and feelings of discomfort

• Advanced home care aids in protecting results due to the additional benefits of antioxidants

C E Ferulic & Laser Treatments

C E Ferulic is a patented triple antioxidant serum that fights environmental aggressors caused by UV, IR-A and pollution. When used in combination with laser treatments, it is clinically proven to complement results and reduce downtime post non-ablative laser.

Triple Lipid Restore 2:4:2 & Retinoids

Triple Lipid Restore is an advanced corrective moisturiser that improves skin firmness, laxity, pore appearance and refined texture for a more radiant complexion. When used in combination with retinoids, it is clinically proven to significantly improve dryness and shorten retinoid adjustment period to one week.*2

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

Contact SkinCeuticals

Speak to your SkinCeuticals representative for more information about the range. If you do not have a dedicated contact please email Contact@SkinCeuticals.co.uk

H.A. Intensifier & Injectables

Phyto Corrective Mask & Light Therapies

The Phyto Corrective Masque is an intensive treatment for soothing temporary skin reactivity caused by external triggers, replenishing moisture and reducing the sensation of heat. When used in combination with light therapies, it is clinically proven to reduce skin temperature immediately after procedure.*3

The H.A. Intensifier is an advanced, corrective serum that is clinically proven to amplify the skin’s hyaluronic acid levels by up to 30%.4 When used in combination with injectables, it improves visible firmness and facial plumpness, complementing the in-clinic injectable treatment.

A summary of the latest clinical studies

Title: Efficacy Assessment for Low-Level Laser Therapy in the Treatment of Androgenetic Alopecia

Authors: Qiu J, et al.

Published: Lasers in Medical Science, February 2022

Keywords: Androgenetic Alopecia, Low-Level Laser Therapy

Abstract: Low-level laser therapy has been a treatment modality by many androgenetic alopecia (AGA) patients in recent years. It remained unclear as to how long the treatment regime should be maintained, and which characteristics of patients should this be recommended. A study was carried out with an FDAcleared low-level laser helmet for 1,383 patients. Ordinal logistic regression analysis with propensity score matching (PSM) was used to investigate the factors related to efficacy assessment. More than 80% of users were between 18 and 40 years old. The median use times were 133 for mild AGA patients and 142 for moderate-to-severe AGA patients, which equated to 38 weeks and 40 weeks. The overall clinical effectiveness was nearly 80%. PSM analysis revealed that gender, use period, scalp conditions with dandruff, rash, and itchy symptoms were associated with the grading of efficacy assessment. Male users use for more than 180 times or use period for one year and those with scalp dandruff, rash, and itchy symptoms had better efficacy assessments. The recommended treatment regime with low-level laser helmet was more than one year or 180 use times. Male patients with dandruff, rash, and itchy symptoms in scalps tended to have a better efficacy assessment.

Title: Size and Perception of Facial Features with Selfie Photographs and Their Implication in Rhinoplasty and Facial Plastic Surgery

Authors: Pressler M, et al.

Published: Plastic and Reconstructive Surgery, February 2022

Keywords: Photography, Rhinoplasty

Abstract: Patients use photographs taken with a front-facing smartphone camera – ‘selfies’ – to discuss their goals with a plastic surgeon. The purpose of this study was to quantify changes in size and perception of facial features when taking a selfie compared to the gold standard of clinical photography. 30 volunteers took three series of photographs. A 12-inch and 18-inch series were taken with a front-facing smartphone camera, and the 5-foot clinical photography series was taken with a digital single-lens reflex camera. Subjects filled out the FACE-Q inventory when viewing their 12-inch selfies and when viewing their clinical photographs. Measurements were taken of the nose, lip, chin, and facial width. Nasal length was, on average, 6.4% longer in 12-inch selfies compared to clinical photography, and 4.3% longer in 18-inch selfies compared to clinical photography. The alar base width did not change significantly in either set of selfies compared to clinical photography. The alar base to facial width ratio represents the size of the nose in relation to the face. This ratio decreased 10.8% when comparing 12-inch selfies to clinical photography and decreased 7.8% when comparing 18-inch selfies to clinical photography. This study quantifies the change in facial feature size/perception seen in previous camera-to-subject distance studies. This data allows for a more precise conversation between the surgeon and the patient.

Title: Descriptive Study on Vascular Anatomy of the Upper Lip

Authors: Mohanty S, et al.

Published: Aesthetic Plastic Surgery, February 2022

Keywords: Embranchment, Facial Artery, Superior Labial Artery

Abstract: The superior labial artery (SLA) is a facial artery (FA) that drains into the perioral region. Owing to the recent rise in the demand for reconstructive procedures and filler injections in this region, it is important to understand its arterial topography. This paper aims to study the embranchment pattern of the labial arteries in the eastern Indian population. An observational study using conventional dissection and dry dye injection methods was conducted to visualise the facial and superior labial arteries in 56 hemifaces. The origin, morphometry (length and diameter), branching pattern, and termination of the arteries were recorded and compared with the existing data. Two hemifaces were excluded from analysis (vessels damaged in dissection); in the remaining 54, a single SLA was present in all samples originating at a mean distance of 1.29 ± 0.32 cm from oral commissure. Lee type II (independent SLA giving off alar branch) was the predominant pattern, followed by type I (independent SLA and alar branches, 33%) and type III (FA terminating as SLA, 10.8%). The average length of SLA was 4.75 ± 1.28 cm and 4.56 ± 0.78 cm on the right and left sides. The SLA is highly variable in occurrence, course, and depth, sometimes occurring unilaterally; any intervention in this region should be done with caution. Since the SLA was not found subcutaneously at the vermillion border, the intradermal and the subcutaneous injections used here are relatively safer.

Title: Histopathological Changes Induced by Malassezin: A Novel Natural Microbiome Indole for Treatment of Facial Hyperpigmentation

Authors: Grimes P, et al.

Published: Journal of Drugs in Dermatology, February 2022

Keywords: Hyperpigmentation, Malassezin

Abstract: Malassezin is a natural indole compound produced by the fungus Malassezia furfur and investigations have demonstrated an ability to suppress melanogenesis. In this study, seven subjects with facial hyperpigmentation caused by melasma or photodamage applied topical malassezin twice daily for 14 weeks, followed by eight weeks of observation. At baseline, 2mm punch biopsies were taken from hyperpigmented areas and adjacent uninvolved skin. Skin biopsies from hyperpigmented areas were repeated at 8, 14, and 22 weeks. Paraffin-embedded sections were cut and stained with H&ampE, Fontana Masson, and MART 1 and assessed for histopathological changes. Increased epidermal melanin and dermal melanophages were observed in all biopsies at baseline in the hyperpigmented compared to uninvolved skin of all subjects. Eight and 14 week biopsies of involved skin revealed decreased epidermal melanin in all subjects treated with malassezin. Melanocytes appeared less dendritic compared to baseline, and numbers were slightly reduced at eight weeks. Biopsies at 22 weeks showed no difference in epidermal melanin levels compared to baseline hyperpigmented skin, and melanocytes were comparable in number and dendricity to baseline. There was no evidence of melanocyte atypia in any of the biopsies. These features were similar in melasma and photo-damaged skin.

these could be red flags. Sometimes I have experienced candidates who think aesthetics is easy, but they soon realise it’s a very specialised area of expertise and can’t handle the workload.

Taking your time

It is important to take the time and thoroughly assess each potential candidate and how they would fit into your business in the long-term as opposed to hiring an individual quickly for the short term. All new staff in my clinic are on a six-month probation period which allows us time to assess all areas of their suitability within the team.

Managing Staff Recruitment and Retention

We, as clinic owners, should be putting a lot of time and effort into the recruitment process and for good reason. Hiring the wrong person for an important role can be a major inconvenience, not to mention a potentially huge waste of time, and money. It’s important to get a clear sense of both how you foresee the ideal candidate growing in the role that you’re hiring for, as well as an understanding of the career goals of your potential candidates.

First impressions can always be used as a guide, and assessing interpersonal skills with other members of staff can be an indication of how they will treat your patients. In many cases you might be eager to fill a specific role within your business, but don’t rush it. Trying to hire someone as quickly as possible increases the likelihood that you’ll wind up with someone who ultimately isn’t a great fit.

My advice is be very clear on all aspects of the role from the beginning to avoid any misinterpretations and having to have difficult conversations down the line. Most importantly, trust your gut at all times.

What does the right candidate ‘look

like’

Sounds obvious, but candidates’ knowledge, level of expertise, and skills are all important factors to take into consideration when hiring for the first time. Advanced laser or skin treatments for example, require overall knowledge of anatomy, dedication and willingness to learn and therefore these are an important thing to ascertain when beginning the hiring process. Make sure you create a detailed job description, with everything you want and expect in there so you attract only the right people. This will avoid wasting your own time and the time of the wrong candidate.

Hiring a medical doctor, dentist or nurse who is used to working alone and now will be part of a team needs to be assessed on how they will integrate into the multi-disciplinary team. When hiring for a non-medical position, such as front of house staff, enthusiasm in the field of medical aesthetics is vital and an important factor to consider as an individual needs to be committed to the process and progression from the offset. So, before you start the induction training, be sure they have a genuine interest in working with people, either by highlighting any previous experience in these areas, or asking them what it is they like about aesthetics. If all they say is ‘free treatments’ or have done no previous research in to aesthetics, then

A typical journey for us when hiring a potential candidate starts with an in-depth job advertisement, incorporating the requirements of the role. This advertisement is posted across all of our platforms, both corporate and social. Once we start to receive applications, we review as a management team, assess all relevant skills and experience and proceed in organising interviews. These interviews would occur in-clinic, or in some cases via online communication platforms, and successful candidates will then proceed to the secondary round of interviews which can require hands-on demonstrations or presentations. If successful, the candidate will be offered the role, and they will receive a copy of their employment contract to review prior to commencing the role.

The current team

Teams can vary in size, approach and of course personality. It is important when beginning the hiring process that the current team remains at the forefront of your mind. The new team member needs to come in with an open attitude, willing to learn from the more experienced existing team members, and to fit in to the team as a whole. We monitor new starters closely in the first few months, and encourage input from existing staff to monitor how well they are blending into the team, as well as performing their role to a high standard.

Mentoring

Once a new team member is employed, they will work closely with our clinic co-ordinator to plan in-house training and shadowing other members of the team. Mentoring and continuous education is a key developmental part in our business. Each team member will be coached and developed and be guided in their personal development in the framework of the business, as well as their

Aesthetic nurse Anna Gunning examines recruiting and maintaining relationships with staff and how to manage human relations situations

own personal goals. We are always working as a team to improve all areas of the working environment, both in dealing with each other and our patients.

Staff satisfaction

Communication is extremely important within any company, no matter the size of the corporation. In a small team it is a great way to discuss potential issues before they arise and potentially grow into a larger and more difficult situation. Good communication can also equip each individual team member with the necessary skills to develop and progress within the workplace by effectively getting across where they may need more support, or where they would like to take on more responsibility.

At my clinic, we provide monthly meetings with each individual staff member to allow time to discuss sales, personal and business growth, and to share any ideas and make plans going forward in any areas that may need attention, and I find this invaluable for both sides. We hold daily morning briefings which are great to share with all team members and keep everyone up-to-date with goings on, as well as motivating the team.

Positive relationships among team members are a key attribution to running a successful business. I have found that when there is a positive environment, many other things fall into place, productivity improves alongside overall job satisfaction, in turn staff turnover rate decreases. It is important to take the time out of a typical working day to come up with a plan on how to get to know each individual within the workplace, what makes them successful in the role, and what can be done to aid them in this succession. It is well documented that a happier employee returns a more successful outcome; therefore, employee satisfaction is an important factor to consider.1

Seeking external help

Human resources and the legal side of managing staff can be a challenging field to master. Recording and documenting dates and times of any incidents in a log book and acting quickly when any issues occur is important in case anything progresses. You can either have a HR company employed just for advice when needed so you know you are within all the legal requirements if anything were to progress, or it can be a good strategy to outsource various administration HR duties like employee contracts and employee records. The reasoning behind an HR department is to act almost as an interface between the employee and the business itself, therefore confidentiality is a key element to ensure the employee feels secure enough to share any difficult queries or concerns they may have. This approach ensures fairness and accurate responses.

If you are a smaller company, you can outsource online resources in HR to manage your team and also save on extra expense. As your team grows it may be advisable to either pay a small fee for advice when required or use HR services for all of your needs.

Reasons you might need HR support

• Employee questions – It is inevitable that staff members will at some point or another have questions about the business and their role. Maybe they want a pay rise, more flexible hours, to know about sick pay or annual leave. An HR representative can present all this information, with all the details in an impartial way and they can answer any questions with in-depth answers and a knowledge of policy and legality, taking the heat off you and enabling you to run your business.

• Staff satisfaction – Retaining key staff is essential to running a successful business. Understandably sometimes, employees will leave for reasons out of your control, but it is important to identify every reason a member of staff might want to leave to see if it is preventable in the future. This is a conversation that can be more easily had by an HR representative who is a step removed from your business and is therefore less personally involved.

• Disciplinary action – As uncomfortable as this topic is, it is inevitable that at some point as a manager or a member of a HR team you will be involved in some degree of disciplinary action. An HR expert can make sure this process runs as smoothly as possible, and keep everything legal and above board, which not only protects the employee, but protects you from any repercussions from bad practice.

Finding your way through recruitment

In my experience, staff management is one of the most challenging areas of running a business. When you invest heavily in to training and mentoring a new member of staff, it can be frustrating finding out you have hired an unsuitable person. This is why it’s important to solidify your recruitment process as if someone is not the right fit, or has no interest or passion in aesthetics or your business, then it can not only be a negative experience for the candidate but also damage your business in the short term. Deal with all disputes quickly, appropriately and within the law, keep moving forward and find the right candidate who will help you grow your business.

Anna Gunning is an aesthetic nurse with 17 years’ experience. She is the founder of the award-winning The Laser and Skin Clinics in Ireland and has won a number of awards within the specialty. Gunning has a particular interest in promoting safety in aesthetics and is also one of the founding members of the Dermatology and Aesthetic Nurses Association of Ireland.

Qual: RGN, H Dip Opth, H Dip Teaching

REFERENCES

1. Pravamayee, S., ‘Strategy to Develop an Effective Workplace Environment’, International Journal of Language & Linguistics 1:1 (57), 2014

Trying to hire someone as quickly as possible increases the likelihood that you’ll wind up with someone who ultimately isn’t a great fit

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Utilising Outsourcing

Business consultant Stuart Rose shares advice on the importance of outsourcing non-core skills to specialists

Picture the scene. It’s Monday morning and you arrive for your dental appointment. The dental nurse gets you settled into the chair and explains that your normal dentist is off sick today so you’ll be seen by their colleague. The new dentist walks in and introduces herself. You cover some pleasantries and ask, since you don’t recognise her, if she’s new to the practice. “Oh no, I’ve been here for years” she replies chirpily.

“Sorry I assumed you were new” you say. “I haven’t seen your picture on the staff board.” “I’m more of what you’d call a back-office bod really. I’m the accountant. We’ve got a dentist off today and I thought, well, how hard can this be? Can’t keep the patients waiting. Now…” as she reclines your chair and the drill whirs into life, “Open up and let’s have a crack at this dentistry lark!”

Of course, this would never happen – or would it? The reality is that all of us have a go at things that we’re not trained to do. I’d happily re-wire a socket or service my ancient oil-fired AGA, but I wouldn’t replace my car’s clutch or the circuit breakers on my mains electricity. But why not? – after all I’d save some money in doing it. The reason is simple – there’s a far greater chance of things going wrong if I do and the consequences could be dire.

What is outsourcing?

All of us recognise the value of getting somebody else in to do the things that we don’t have the skills, or the time, to do ourselves. As qualified aesthetic practitioners you have years of training in arguably the most important career and life skill there is – maintaining human health. You can perform CPR, map out facial vasculature, know where to place the right amount of toxin or filler for the correct aesthetic outcome and make the lives of many people better in doing so. But your specialist training didn’t include employment law, recruitment, IT, accountancy, digital marketing, how to put together a business plan or negotiate a contract, how to read a profit and loss account, the importance of free cash flow or the impact that culture has on business performance and staff retention. Nobody could master all of these skills to the extent that they were able to perform all of them optimally – that’s why 70% of all UK companies contract out some of their business tasks to third parties.1 Typically, outsourcing is used as a strategy to save costs or improve efficiency. IT is the number one outsourced function by British companies because it requires

specialist skills, but the need for these can ebb and flow and so to have those services on tap, paid for on an as-you-use-it basis makes perfect sense.1

Business guru Peter Drucker said, ‘Do what you do best and outsource the rest.’ Doesn’t it make sense for the medical aesthetics sector to do the same? Therefore, it makes sense to focus on what you can do best, the medicine bit, and ask others who are specialists on their areas, to help you. There are many around – just take a look at some of the names in the pages of this journal or go to any of the major trade events such as the Aesthetics Conference and Exhibition in March (see Table 1 for the list of possible companies to see at ACE this year) and CCR in October, and you will find people who are perfectly suited to helping you and who understand this industry. The purpose of this article is not to highlight any individual area but simply to give you some insight into the perspectives of those who offer the services.

Everyone loves choice

Choice is good. Sometimes it can be agonising and take time, (and you have precious little of that), but consumer choice improves competition which drives quality up and keeps prices affordable.

To help you to choose your best business partners, (and it will almost certainly be several rather than just one or two), the checklist below can help:

• Experience: can they do the job you want them to do and how long have they been doing it?

• Reputation: do they have recommendations or ratings from people you respect?

• Sector knowledge: do they have experience in the aesthetics industry? Does this matter? Not so much in IT or payroll, but it’s important in digital marketing or business planning

• Compliance: do they have the relevant professional qualifications, registrations and insurance?

• Availability: can they do the work you need in your timescale?

• Conflict of interest: are they working for a competitor of yours and would this affect your decision, (maybe your competitor has made it conditional not to work with anyone in their area for a certain time period)?

• Price: are they good value for money?

Service or servility?

Just like you, the outsourced professionals are proud of what they do and work hard on their reputation. If you approach them as a partner or peer you will always get more bang for your buck. Nobody likes to feel just like the hired help! One of the key things to do is to take the time to brief them on your business, your brand and your values. Because you’re hiring an expert it’s often easy to assume they know everything – but they don’t! The more time you invest in the early stages of a working relationship, the better and more fruitful it will be for you. It’s no different than onboarding a new member of staff. What’s more, by making this investment you will engender more loyalty from your service partner. An old boss of mine taught me that the goal was to achieve such a strong relationship that if you needed them at 5pm on a Friday and called them, they would pick-up!

Cost vs price vs value

These terms often get confused, but they have important and subtle differences that will help you understand the perspectives of outsource partners.

Cost

It sounds obvious but this is what something costs the person who is providing it to you. In the instance of a product that is simple to appreciate. If you are buying a product that costs £5 to make and ship to the retailer, when you buy it for £10 the retailer makes 50% profit. We understand that tangible products have an acquisition cost to the retailer, and we are typically accepting of the price. When it comes to services however, (and that is what you are predominantly

buying when you outsource), the actual cost of the service is less tangible or transparent, and this can make us more inclined to try to negotiate the price down. But the cost of a service is every bit as real as that of a product. Consider your own clinic where you offer both service and product. You charge for the product element (toxin or filler etc) that includes a profit margin, and you add that to the charge for your time. You may think that there is no actual cost for that time but if you operate from a clinic your business will have overheads (utilities, insurance, staff costs, business rates etc) that must be covered to simply stand still. To grow you will also need to recover a profit. You are also covering the time that you have invested historically in training and education to get your skill level to a place where you can offer great aesthetic outcomes. When you are learning you are not earning and so your service charge covers historical costs, possibly from years ago. This is exactly the same for an outsourced specialist.

Price

This is typically a monetary measure that covers costs and profit. Price and cost are both quantitative measures and the former typically includes the latter. So, when a client asks, ‘how much does it cost?’ what they are really asking is ‘how much will it cost me?’

The difference is subtle and we have blurred the lines by how we use the word cost – we should really be using price.

Value

This is the most conceptual and intangible measure of worth. It is also constantly in flux and subject to many influences. If a product or service fulfils an unmet need it has a high value. Supply and demand also have a significant effect. At the beginning of the

pandemic the shortage of PPE made it enormously valuable and increased demand saw prices soar. As product became more widely available the price dropped to reflect the reduction in value. The same is true of services. If somebody offers a unique service that truly fulfils a need then people will pay a higher price because the perceived value is higher.

This comes to the heart of the matter in how much you pay for specialist services – and also how much you may want to negotiate. When you are outsourcing to external partners just remember – like you they want to provide a great service and they work hard on their reputation. That reputation comes at a cost to them but the medical aesthetics sector can benefit hugely from their specialist advice. When you look for an outsourced partner perhaps do so through a lens which considers value rather than just price.

Don’t do it alone

Remember Peter Drucker’s wise words and focus on the things that only you can do well. Get people who are as good as you in their specialist fields to do the rest. That way ALL elements of your business offering will be the very best. And if, at any moment, you consider doing some of your non-core services yourself, take some time to think. Would I want an accountant to do my root canal?

Stuart Rose is an independent consultant with 35 years’ experience in pharmaceuticals in a variety of commercial and leadership roles.

He set up Merz Aesthetics in the UK & Ireland and has created MiViVa Ltd to help private aesthetic practitioners through offering business consultancy.

REFERENCES

1. YouGov, Seven in ten British businesses outsource to third parties, 2019, https://yougov.co.uk/topics/finance/articlesreports/2019/10/24/seven-ten-british-businesses-outsourcethird-parti

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Becoming a Sustainable Clinic

As the daily news stories concerning COVID-19 ease, the airtime given to sustainability issues will arguably increase, as the Government tries to implement and enforce the targets that they have committed to in relation to the 17 United Nations Global Sustainability 2030 Goals.1 Certain sectors are already grappling with huge consequences to their business models, with the proposed gas boiler ban in three years’ time followed by combustion engines in 2030.2

When I was growing up, environmental activism was almost exclusively known as ‘green issues’ and was limited to a few deeply committed organisations such as Greenpeace, who were often not represented in the best light in national media. In the last few years however, campaigners like Greta Thunberg have mobilised a new generation of ‘young activists’ to participate in school strikes and rallies throughout cities in the UK and around the world. Some of these demonstrations have been aimed specifically at aspects of the beauty and aesthetic sector, with a ‘Plastic Free Beauty Day’ march on June 17 planned for this year in London.3

The consumer can no longer ignore the importance of sustainability and how their

daily lives and habits can affect the planet, and this feeling is driving their behaviour. Business owners working in the aesthetic specialty must therefore think about this if they want to compete in this sustainability focused age.

Modern attitudes and adaptations

This is a significant shift from what consumers wanted five or 10 years ago when the gold standard for brands was to deliver a great product or service. Now companies (large and small) are expected to go much further to stand for something beyond their products. Beauty and aesthetic brands and companies will increasingly have to prove that there is a reason for their existence beyond profits, one that contributes in some way positively to the environment, to society, or to supporting individual expression. This requires CEO leadership, deep thought and a commitment

and focus on inward investment in both time and money to address sustainability issues relevant to that business. Ex Unilever CEO, Paul Polman, is a case study worth reading on what can be achieved over a decade whilst also keeping shareholders happy.4

A recent study by the British Beauty Council found that of 23,000 beauty shoppers, almost half (48%) are looking for more information, clarity and transparency about beauty brands’ values and commitments to the environment.3

In fact, the British Beauty Council has launched a Sustainable Beauty Coalition with a wide range of industry leaders (including Boots) represented to address sustainability issues, which has resulted in the publication of a 48-page sustainability report called ‘The Courage to Change’. The report highlights compelling reasons for taking action noting that ‘current industry efforts are too patchy and uncoordinated’, and that the sector ‘must move together, from the smallest independent, to the largest corporate brand’.5 In addition, they released a ‘Planet Positive Guide’ aimed at the consumer, with a headline stating that ‘our planet is in a code red situation’.6 Within the guide they highlight claims made by skincare brands and educate consumers about how to avoid ‘greenwashing’ – where ‘green’ marketing is used deceptively to persuade the public that an organisation’s products, aims and policies are environmentally friendly.

Even as far back as the 80s beauty business like the Body Shop were championing environmental and suitability causes. More recently skincare powerhouses such as L’Oreal (the largest skincare company in the world) have joined the cause – with ‘We Fight Climate Change’ emblazoned across their website and commitments to sustainable development goal targets including: ‘by 2030, 95% of our ingredients will be bio-based, derived from abundant minerals or from circular processes’ and ‘by 2025, 100% of our plastic packaging will be refillable, reusable, recyclable or compostable’.7

The pressure to incorporate sustainability goals into future plans for companies quoted on stock exchanges around the world is also being driven by investment houses. In 2022,

Business development consultant Ron Myers explores the emerging importance and advantages of sustainability in aesthetic medicine and tips for starting out

50% of consumers are looking for more clarity and transparency about values and commitments to the environment

LEARNING IN LAYERS

Larry Fink, the CEO of Blackrock, the largest investment management company in the world managing over $7 trillion of funds, wrote an open letter to CEOs warning them about a fundamental reshaping of finance in relation to climate change.8 Companies can no longer ignore this subject as it is becoming a greater determining factor in deciding where huge sums of pension fund moneys are invested with a resultant impact on share price.

Smaller ‘disrupter’ companies are entering the sector with claims that aim to resonate with consumers such as ‘palm oil free’, ‘vegan’, ‘recyclable or refillable packaging’ and ‘sustainable ingredients’.

Embracing sustainability

In talking to practitioners, clinic owners and suppliers in recent months, I think a lot of inaction comes down to a lack of understanding of what they can practically do to make a difference, alongside a belief that this subject is not yet an important factor that their customers take into account. Here are some ideas as to how you can make your start towards a more sustainable business in aesthetics.

Become more educated

The first step is to understand more about sustainability issues and practices through reading articles, books and watching videos on YouTube (just type in sustainable business ideas). There are also courses available which can really broaden your horizons on this topic. I personally explored the dynamics around business and sustainability with a course that I undertook with Cambridge University. By looking at many business case studies, this course highlighted how incorporating more sustainable business practices into an aesthetic clinic can be a powerful differentiating factor from a marketing perspective, so this isn’t just helping the environment, but helping your business.

Research your suppliers

Find out more about the companies behind your products and treatments and find out what their sustainability stance is. I recently spoke to a clinic owner who had become increasingly frustrated with a well-known aesthetic skincare brand that she had used for many years, in regard to sustainability issues. The supplier failed to address her concerns even resulting in an email that said, ‘maybe we aren’t the right company for you!’ This spurred her on to find a skincare company that addressed her concerns

surrounding sustainability – and, with careful messaging, within two months, she changed over the majority of her skincare patients to this new brand. Of course, I appreciate that it is still early days and that not all companies will have solid procedures and policies in place, however it is up to you to ensure they know that this is a priority for their customers. These are some of the questions you can consider asking your suppliers:

• What are your long-term commitments to sustainability?

• Is your packaging fully recyclable or reusable?

• Are there any sustainability issues in relation to chemicals you use that could be harmful to the environment?

• Do you have future plans to be carbon neutral?

• Do you recycle any of your key inputs, such as water or chemicals?

Connect with like-minded people

For those that really understand where all of this is going, they will become ambassadors for sustainability. You should start to forge connections with like-minded businesses from other industry sectors in your locality. Talking to owners of local environmental focussed cafes/zero waste shops, or doing some volunteer work at a local community recycling/upcycling centre can also give you ideas and contacts. The resultant increased visibility and differentiation versus other local aesthetic providers can be a valuable marketing tool for patient attraction and retention.

You should also forge relationships within your own industry and join suppliers, clinic owners and practitioners who are interested in learning more about sustainability issues related to aesthetics. There is a Facebook group called ‘Sustainability in Aesthetics’, which I formed in the hopes to kick start these connections.

Have a focus on sustainability

I believe we are all personally on a sustainability journey, where the noise around different issues will get louder and louder, and where the Government will increasingly legislate to ensure that they hit our countries commitments to global sustainability targets. Businesses that strive to develop a close ongoing relationship with their customers, and start to embrace this journey, incorporating meaningful changes and discussing this in their marketing will seem more relevant than those that ignore it. None of this is going to be easy, and there

are many things that will be difficult to change, due to innovation issues, or capital requirements – but starting small and gradually making progress will change your focus to ensure that this is a subject that you take positive action on, rather than watch others lead the way.

Ron Myers is a business coach and mentor specialising in helping aesthetic clinics and suppliers to maximise their profits. He is the co-founder of The Consulting Room, launched in 2002, which aims to help practitioners successfully develop and sustain their businesses.

REFERENCES

1. Corporate Report- Implementing The Sustainable Development Goals. <https://www.gov.uk/government/publications/ implementing-the-sustainable-development-goals/ implementing-the-sustainable-development-goals--2>

2. UK Gas Boiler Ban – Everything you need to know; <https:// www.edfenergy.com/heating/advice/uk-boiler-ban>

3. Awareness Days – Plastic Free Beauty Day 2022 <https://www. awarenessdays.com/awareness-days-calendar/plastic-freebeauty-day-2022/?fbclid=IwAR2AD8AWOYDLbxULHVMayk190 6Ey4-SkU8SMj0HPmiW1bUN2se0Xktglaz8>

4. Putting sustainability at the center of business strategy: An interview with Paul Polman; Mongabay; <https://news.mongabay. com/2020/10/putting-sustainability-at-the-center-of-businessstrategy-an-interview-with-paul-polman/>

5. The Courage to Change Report; <https://britishbeautycouncil. com/wp-content/uploads/2021/03/the-courage-to-change.pdf>

6. The British Beauty Council’s Sustainable Beauty Coalition launches the Planet Positive Beauty Guide to help consumers avoid ‘greenwashed’ products, 2021, CISION PR Newswire, <https://www.prnewswire.co.uk/news-releases/the-british-beautycouncil-s-sustainable-beauty-coalition-launches-the-planetpositive-beauty-guide-to-help-consumers-avoid-greenwashedproducts-873068605.html>

7. Planet Positive Beauty Guide; <tps://britishbeautycouncil.com/ wp-content/uploads/2021/10/BBC-Green-Guide-FINAL-CS.pdf>

8. L’Oreal Groupe; Fighting Climate Change; <https://www.loreal. com/en/commitments-and-responsibilities/for-the-planet/ fighting-climate-change/>

9. Larry Fink’s 2020 letter to CEOS;A fundamental reshaping of finance; <https://www.blackrock.com/us/individual/larry-finkceo-letter>

10. Aesthetics definition, Lexico, <https://www.lexico.com/definition/ aesthetics>

11. 2030 Petrol and Diesel Car ban – 12 things you need to know; The Sunday Times Driving; <https://www.driving.co.uk/car-clinic/ advice/2030-petrol-diesel-car-ban-12-things-need-know/>

11 & 12 MARCH 2022 / LONDON

Ron Myers will be speaking on sustainability in aesthetics at ACE on March 12 at the Business Design Centre, London.

Recognising Guilt and Shame

When I first began working in aesthetics, I was conscious that my patients were coming to me with this real dichotomy in their heads. On the one hand, they were saying, ‘I look really tired and exhausted’, ‘I feel old’ or ‘I feel bad about myself’. However in the same breath they were also saying, ‘I feel guilty’, ‘My partner doesn’t know I’m here’, or ‘I am selfish to be spending this much money’. With a lack of data and peer-reviewed studies about the role which guilt and shame play in patients’ decisions surrounding cosmetic treatments, any discussion around it primarily revolves around anecdotal in-clinic experience. From conversations with colleagues, I know I am not alone in hearing this narrative from patients. These kinds of conversations are sadly commonplace within our clinics, but why? You wouldn’t go and have your hair cut and say, ‘I feel terrible about spending this money on myself. I don’t want anyone to know’, so why does it happen with aesthetics? This article will explore why our patients might be feeling guilty and ashamed to seek cosmetic interventions, and explore what we can do to put them at ease.

What are guilt and shame?

While guilt and shame are often referred to interchangeably as synonymous moral emotions, they are two different things. Personally, I believe guilt is a subset of shame and tends to pertain to someone feeling they have done something wrong. Shame is more visceral – it is a feeling that you, as a whole, are wrong. While a ‘guilty pleasure’ is seen as something naughty that we overindulge in, the word shame is loaded, and it is this which is dangerous among patients. In their book Shame and Guilt (Emotions

and Social Behaviour), authors June Price Tangney and Ronda Dearing describe guilt and shame as ‘key self-conscious emotions’.1 They present compelling evidence to demonstrate that these ‘universally experienced affective phenomena’ have significant – and disparate – implications for many aspects of human functioning.

In fact, there is a growing number of studies showing that shame and guilt are important features of various psychological problems, including anxiety disorders.2

One study showed that shame was more strongly associated with anxiety symptoms than guilt and that external shame (perceived negative evaluations of others) seemed to be more strongly associated with social anxiety symptoms than internal shame (negative self-evaluations).2 Another study showed that guilt and shame lead to contrasting human behaviours or behavioural tendencies.3 Shame drives people to hide or deny something, whilst guilt drives people to amend their mistakes.

Why do patients feel guilty about having aesthetic treatments?

More than 80% of our patients don’t tell their families, friends or even partners, that they’ve come to seek aesthetic treatments.5,6

The question I ask myself is, ‘why do they feel bad?’ and I think the answer is complex. Some studies have looked at depression scores in patients who’ve had botulinum toxin treatments, and there has been a significant improvement in their Hospital Anxiety and Depression Scale (HADS) score.7-11

Psychologically, when we look in the mirror and we’re looking good, and not tired, angry or ill, we feel better. So why is that not to be celebrated? Why is it we feel ashamed about owning the desire to look good?

Women especially are often told we should look a certain way and care for ourselves, yet we’re not encouraged to talk about it or

More than 80% of our patients don't tell their families, friends or even partners, that they've come to seek aesthetic treatments

Dr Mayoni Gooneratne discusses feelings of guilt and shame among patients in aesthetic clinics and what practitioners can do to shift perceptions around cosmetic procedures

seek treatments. Sadly, we hear a lot about ‘shaming’, particularly on social media today – fat shaming, body shaming and now even dermal filler shaming.

I am often surprised by how it can take a major life event to get people out of this mindset. Patients say, ‘I’ve lived through breast cancer. I don’t care what XYZ thinks. I’m going to do this for me’. It’s brilliant that they’re doing it, but I also feel sad that it’s taken a significant life event to make them live their lives.

Another factor of guilt is about spending money on yourself. Women are hormonally created due to our ability to have children. We nurture, love and care, but it’s difficult if you’re coming from a place of resentment, tiredness, and feeling bad about yourself. It’s that guilt that particularly mothers have about putting themselves higher up the ladder.

Addressing guilt and shame among your patients

Recruitment

In my clinic, our messaging is about ‘self-care, guilt-free’. I think it begins with training your team and recruiting members who have similar values to you. The message of looking after yourself is important. Those core values must come through by your team.

When we recruit, we actively ask candidates about self-care as an interview question. We ask, ‘are you someone who engages in self-care?’ or ‘what’s your idea of self-care?’ If there’s someone who says, ‘oh, I don’t really think about self-care,’ then perhaps they are not the right person.

The messaging also comes through in our social media, newsletters and marketing. We give patients tips on how to implement it as we want them to look at themselves, rather than just their skin or comparing frown lines. We even created self-care boxes in lockdown so that patients could still access a ritual for themselves and do their own facials.

Consultation

For the patient, it begins with bringing the conversation into your consultation. You will never get anyone to engage with your services if they are feeling guilty. I lay it out on the table, so they can talk and express it openly. It is powerful to engage people in a conversation about their preconceptions of aesthetics and tell them they are not alone in

the feelings they are experiencing. To explore this with your patients you should ask open questions. You should always ask them what brought them in? Why now? What will the results mean to them? Other good questions include, ‘what is it going to give you? Not just how you look, but how are you going to feel?’, ‘have you told anyone?’, ‘does anyone else know you’ve come along?’ It is important to ascertain how much stress is there and helps gauge my understanding of them.

For American research professor Brene Brown, vulnerability is part of the key to addressing shame. She says that when we are in shame, it is because we feel unworthy of love.4 If we can hold a space for our patients to be vulnerable and talk about these feelings, we can start to challenge them. We must never pressure patients into treatments, but I think we can pick patients up on their language in the consultation and gently challenge these stories. For example, if a patient is repeating a message or brings up a shame-fuelled concern such as, ‘what sort of role model am I for my daughter?’, I might say, ‘can I just challenge that? I disagree with you. I think it’s important that your daughter is growing up to see her mum putting herself first and looking after herself. You are saying to her, ‘I value my appearance’, and there is no shame in that.

Red flag patients

There are many types of red flag patients, but one key red flag for me, which would cause me to refuse a patient treatment, is if someone is putting themselves in danger. This could be financial danger because they are maxing out a credit card or getting in debt. If they are in a situation where they’ve been frog-marched in, or feeling fearful of being there, for fear of their partner finding out. These are extreme examples, but I would argue that most people will voice an opinion about feeling shameful and guilty to some extent.

There is a theory that sometimes people are too scared to be brilliant. However, American author Marianne Williamson wrote in A Return to Love: Reflections on the Principles of A Course in Miracles, ‘Our deepest fear is not that we are inadequate. Our deepest fear is that we are powerful beyond measure. It is our light, not our darkness that most frightens us. We ask ourselves, ‘who am I to be brilliant, gorgeous, talented, fabulous? Actually, who are you not to be?’12 Some of my patients say, ‘I’m not going to look too done, am I?

Is anyone going to notice?’ My response is ‘most likely, no one’s going to know that you’ve had injectables done, but they’re going to know that you’re looking well. Are you ready for those comments? How are you going to deal with the positive feedback about how you’re looking?’ People aren’t used to living their best life. We shouldn’t underestimate the importance of self-esteem.

Open up the conversation!

I would like to see patients moving away from shame-driven denial or hiding away when having procedures. Brown says that shame needs three things to grow: secrecy, silence and judgement, and empathy is the antidote.4 By opening the conversations around shame in our consultations, we can break the silence, challenge the judgment, and remove the stigma around the need for secrecy.

Miss Mayoni Gooneratne is a London-based general surgeon with more than 18 years of medical and surgical experience. Her professional career began in surgery, as a graduate of St George’s Hospital Medical School in London and she has been a member of the Royal College of Surgeons since 2002. In 2017, Miss Gooneratne received a high commendation for the Aesthetics Award for Best New Clinic UK And Ireland and was also shortlisted for Best London Clinic in 2018. Qual: MBBS, BSc, MRCS

11 & 12 MARCH 2022 / LONDON

Dr Mayoni Gooneratne will be speaking at ACE on March 11. Scan the QR code to register!

VIEW THE REFERENCES ONLINE! AESTHETICSJOURNAL.COM

After spending time in the NHS and exploring other avenues outside aesthetics, Mr Benji Dhillon had an unconventional route into specialty. Completing his medical training at Guy’s and St Thomas’s Hospital in London during 2006, Mr Dhillon was transferred to various hospitals in Kent and Sussex to complete his two final medical training years. He reflects, “I did most of my senior house officer plastic surgery and early registrar training at St Thomas’s and The Queen Victoria Hospital. They were amazing years! I worked under a lot of exceptional names such as Mr Paul Banwell and Mr Marc Pacifico. It was a great place to learn, however, it was during this time that I felt the need to explore other industries outside of medicine to further develop my knowledge. This included the world of business and finance which has always been an interest of mine.”

After his training, Mr Dhillon was close to joining a private equity company as a medical advisor, but instead he joined Allergan as a clinical director for Europe, Africa and the Middle East. He reminisces, “It was during this time that I was exposed to the medical aesthetics world. I was responsible for a lot of the training, education, science and data. I began watching other plastic surgeons who practised aesthetics, such as Dr Mauricio de Maio and Dr Arthur Swift and was inspired! I realised it was something that I wanted to try and discover if I was good at it. Soon after undergoing some courses, I started practising injectables in my own time after hours and on weekends, taking my time to develop my skills. It grew from there and within a couple of years, I had the opportunity to join PHI Clinic in London with Dr Tapan Patel. At this point, I knew it was something I wanted to do for the rest of my career.”

As Mr Dhillon’s journey into aesthetics began, his enjoyment and passion for the industry also grew. He notes, “I really enjoyed

Cosmetic surgeon Mr Benji Dhillon reflects on his aesthetics career and presents his tips for success

performing injectable treatments. It’s a blend of anatomy, good technique and artistry. I think you can achieve quick results with fillers which are noticeable. I also loved the impact aesthetics had on patient’s lives! As a result of spending time at PHI Clinic, I was able to advance my skills with Dr Patel.”

In 2019, Mr Dhillon decided to open his own clinic, Define Clinic, in Beaconsfield. He comments, “I lived outside of London and wanted to be a bit closer to home and my family. I felt that Beaconsfield had a perfect market opportunity to create something unique and set up an aesthetics brand. I wanted to bring the world of cosmetic dentistry and medical aesthetics together under one roof with two independent teams. It had been something I had been thinking for a while and it came around at the right time!”

Throughout his years in aesthetics, Mr Dhillon has become a key opinion leader (KOL) and brand ambassador for many companies, as well as speaking and teaching at numerous conferences such as the Aesthetics Conference & Exhibition (ACE). “My career has led me down many different paths which I really enjoy. Currently, I’m very fortunate and humbled to be a part of the International Teoxane Faculty. It’s something I really enjoy, and I think one of the main reasons is that you get exposed to many people, countries and ethnicities, so you learn something new wherever you go! One of the best aspects of teaching is you have to be at the top of your game, so you need to invest into your own personal development by reading and studying to ensure you are at the forefront of your knowledge,” he explains. Mr Dhillon is also an ambassador for CoolSculpting, AlumierMD and Obagi skincare, as well as a KOL for SkinPen, Cynosure, Sciton and miraDry. He adds, “As well as aesthetic companies, I am an advisor for a few financial companies. It is really interesting as you begin

to learn about the investment of aesthetics from a commercial perspective.”

Looking back on his career thus far, Mr Dhillon has three pieces of advice for anyone looking to start working in aesthetics. He notes, “Firstly, identify what you want to stand for. Are you going to focus on a certain age group or a certain demographic for example? Know what you aim to achieve for those people. Secondly, remember that you are always going to have to develop yourself! Don’t become complacent. Finally, don’t underestimate the power of mentoring! Learning from someone else can help development

progression.”

Favourite treatment to perform…

Definitely fillers! Jawline contouring with fillers creates a powerful outcome for a lot of people and the results are quick to achieve.

Biggest achievement… Finding a work-life balance! I finish work earlier now than I ever have as I want to get home to my four kids.

Best piece of career advice… You’ll never lie on your death bed thinking about all the things you did; you’ll think about the things you didn’t do, so remember to seize every opportunity!

Mr Benji Dhillon will be speaking at ACE on March 12. Scan the QR code to register for free!

and

“I knew aesthetics was something I wanted to do for the rest of my career”

The Last Word

The presence of mirrors in treatment rooms is an extremely common occurrence for many aesthetic clinics. This is because they can be beneficial to both practitioner and patient, which has been detailed in relation to critical care nursing.1

However, there are some clinics that choose not to have mirrors in their treatment rooms, largely due to the impact mirrors may have on self-image and confidence. This article will go through what I believe to be the pros and cons of having mirrors in your treatment rooms so you can consider what the best approach might be for your clinic.

Why mirrors are integral to aesthetic practice

Personally, I find that the use of both handheld mirrors and a larger full-length mirror helps me to determine my treatment plan and to educate my patients. One of the early stages of the consultation process is to position my patient in front of the full-length mirror and undergo a static analysis of both the paralysed and animated face.2 Following this I would talk them through various aspects of their face, including factors such as asymmetry, the golden ratios for facial beauty3 and signs of ageing such as wrinkles and sagging skin. Although I could, of course, analyse without it, I believe that it’s necessary for the patient to see and understand what I am talking about in a large mirror.

Similarly, after the treatment has been performed, the mirror is an invaluable tool with which to present the work to the patient and allow them to see the difference it has made, whether this is medical or aesthetic. Of course this can also be achieved with before and after images (which should also be utilised) the mirror can be good for patient satisfaction as well as for managing their expectations. For example with lip filler, the patient can see their lips immediately after treatment and you can explain that the swelling is the worst it’s going to be and it will go down, rather than the patient seeing them for the first time at home and panicking. So, in my experience the mirror is both a necessary and useful tool for both the initial consultation and discussion about treatment, the treatment plan itself, and then the presentation of the treatment and follow-up.

The considerations of mirrors in practice

There are a number of reasons why people might find the presence of mirrors in a clinic room challenging, from general self-confidence issues, to not wanting to see the procedure because they may be needle-phobic or squeamish. Mirrors affecting mental health is also an issue which is extremely significant in society today, particularly in the case of body dysmorphic disorder (BDD), which although rare, can be severe and debilitating.4 In this case, the presence of mirrors may encourage the patient to spend an unnecessary amount of time

staring at themselves and fixating on something that they think needs to be addressed.4

Practitioners should always be mindful of how the presence of too many mirrors could impact a patient who may be experiencing these self-confidence issues. It could therefore be a good idea to have a moveable, full-length mirror as opposed to large fixed wall mirrors, as it allows it to be decided on a patient-by-patient basis. Whereby, in the rare case that there are concerns about the patient’s self-confidence or desire to see themselves in the mirror, then steps can be taken to conduct the consultation and treatment without it. These concerns may be raised by the patient themselves or be things that were noticed by the practitioner during the initial consultation.

It’s in the eye of the practitioner

In light of the duty of care that aesthetic practitioners have to their patients, both physically and psychologically, I believe mirrors are a necessary part of a practitioner’s work. They are not only useful to explain the anatomy of the face before referencing the work that will be done on relevant areas to establish an effective treatment plan, but they are also useful for the patient to see the results afterwards. I think there should not, however, be a one rule fits all strategy. If concerns are raised during the initial consultation, taking into account issues such as BDD and self-confidence, it’s my view that practitioners should be able to remove the mirror, which is why I personally don’t have fixed or decorative mirrors in my treatment rooms.

Nina Prisk is a registered nurse and independent prescriber and a highly trained specialist in non-surgical advanced aesthetic procedures and rejuvenation treatments. Prisk is director of Update Aesthetics with two practices in both Harley Street, London, and Cornwall. She is a member of the British Association of Cosmetic Nurses and the ACE Group World.

Qual: INP

Nurse prescriber Nina Prisk presents her thoughts on whether or not aesthetic practitioners should have mirrors in treatment rooms

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