MAY: THE POSITIVITY ISSUE

K N A H U !

T YO S H N

VOLUME 7/ISSUE 6 - MAY 2020

UNITING FOR THE

READ OUR SPECIAL REPORT ON P.36!

Efficacy of Mesotherapy CPD Miss Mayoni Gooneratne explores the considerations for mesotherapy treatments

Special Feature: Contouring a Male Jawline Practitioners advise on using hyaluronic acid to treat the lower face

Treating Men with Toxin

Dr Ahmed El Houssieny details the use of botulinum toxin in male patients

Understanding COVID-19 Support

Accountant Samantha Senior outlines grants and schemes available

Contents • May 2020 06 News The latest product and industry news 16 News Special: Expecting the Unexpected

Aesthetics explores the importance of business contingency planning

CLINICAL PRACTICE 19 Special Feature: Contouring a Male Jawline

Practitioners advise on using hyaluronic acid to treat the lower face in men

25 CPD: Understanding the Efficacy of Mesotherapy

Miss Mayoni Gooneratne explores uses, techniques and considerations for mesotherapy treatments

Cover Feature: Positivity in a Pandemic Page 36

29 Treating Men with Toxin

Dr Ahmed El Houssieny details the use of botulinum toxin in men

32 Using PDL for Non-vascular Indications

Consultant dermatologist Dr Firas Al-Niaimi outlines the lesser-known uses of pulsed-dye lasers

34 Advertorial: Advanced Esthetics Solutions

Introducing Lipofirm: the gold standard non-invasive platform for inch loss

36 Positivity in a Pandemic

Aesthetics celebrates the positive actions of those in the industry during the COVID-19 crisis

40 Case Study: Treating a Drag Queen

Special Feature: Contouring the Male Jawline Page 19

Aesthetic nurse Kerry Hanaphy enhances the beauty of a male patient

43 Managing Snoring

Dr Natasha Verma considers the use of botulinum toxin to reduce snoring

49 Abstracts

A roundup and summary of useful clinical papers

IN PRACTICE 50 Understanding COVID-19 Support

Accountant Samantha Senior outlines the grants and schemes available to clinic owners throughout the coronavirus pandemic

55 Attracting Male Patients

Digital specialist Alex Bugg and branding professional Russell Turner explore how to increase the number of men visiting your clinic

58 Conducting a Successful Video Consultation

Aesthetics shares advice on holding patient consultations online

61 Becoming a Prescriber

Nurse prescriber Donna Barleycorn highlights key considerations before embarking on a prescribing course

64 Boosting Your Profile

Learn how you can become better known and respected in aesthetics

66 Reflecting on Your Business Nurse Tracey Jones details the importance of business evaluation 69 In Profile: Dr Vincent Wong

Aesthetic practitioner Dr Vincent Wong discusses how he started the first LGBT campaign in the specialty

70 The Last Word: Breaking the Stigma

Dr Preema Vig explores the concerns men have around having facial aesthetic treatments and how practitioners can change this

NEXT MONTH IN FOCUS: COMPLICATIONS • Oxygen Therapy • Mesotherapy Complications • Self-harm Scars • Complications and Mental Health

In Practice Becoming a Prescriber Page 61

Clinical Contributors Miss Mayoni Gooneratne is a graduate of St George’s Hospital and has been a member of the Royal College of Surgeons since 2002. She founded The Clinic by Dr Mayoni in 2016 and is an associate member of BCAM. Dr Ahmed El Houssieny is a trained anaesthetist and lecturer at the University of Chester, as well as an education provider for cosmetic procedures.

He is an associate member of the British College of Aesthetic Medicine.

Dr Firas Al-Niaimi is a consultant dermatologist, Mohs and laser surgeon. He is a group medical director at sk:n clinics and a senior research fellow in the dermatology and laser department at Aalborg University, Denmark.

Kerry Hanaphy is an aesthetic nurse based in Dublin. She spent more than 20 years working as a respiratory and chemotherapy nurse, before moving into aesthetics and opening the Kerry Hanaphy clinic.

Hanaphy is a trainer for Galderma.

Dr Natasha Verma graduated from the University of Newcastle upon Tyne with a Bachelor of Dental Surgery qualification. She has a background in oral and maxillo-facial surgery and teaches undergraduate dental students at King’s College, London.

Editor’s letter Hello everyone, welcome to your May journal! As you will have seen from our front cover, this month’s issue has a slightly different focus than usual. Originally, it was meant be our male issue – sharing the very best advice on how to increase your male Chloé Gronow database and tailor aesthetic treatment to men.

Editor & Content Given the current COVID-19 crisis, however, Manager we thought it necessary to do things a little @chloe_aestheticseditor differently. So while you will find some excellent pieces with men in mind, we have dedicated this issue to celebrating the incredible NHS and doing our part to help you reopen your clinics as soon as this is all over.

It is wonderful to see so many people within the aesthetics community uniting to support the NHS – from returning to the hospitals to manufacturing ventilators – everyone has jumped into action to help get the country through this pandemic. We want to commend you all, so as well as our beautiful rainbow front cover with the faces of Aesthetics readers working in the NHS, on p.36 we have put together

a special four-page article detailing some of the amazing actions we’ve seen over the past month – we hope it brings a smile to your face! That said, we know times are challenging at the moment, so we’ve added more business-focused articles than usual to help you through the next few months. To start, accountant Samantha Senior has put together a comprehensive overview of all the grants and schemes available to you on p.50, while we cover how to deliver the most effective video consultation on p.58.

Next, if you’re using this time to focus on your future development, check out p.66 for advice on evaluating your business by nurse Tracey Jones, p.64 for insight on how to boost your profile amongst your aesthetic peers, and p.62 for considerations on becoming a prescriber by nurse and clinical educator, Donna Barleycorn.

Finally, research from Hamilton Fraser Cosmetic Insurance indicates that 72% of aesthetic practitioners did not have a contingency plan in place should they not be able to continue to practice. Unfortunately, this may be having an impact now, so why not use this time to plan going forward? For some valuable advice on things to consider, turn to p.16.

Clinical Advisory Board

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

WE WANT TO HEAR FROM YOU!

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

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

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

Dr Christopher Rowland Payne is a consultant dermatologist and internationally recognised expert in cosmetic dermatology.

As well as being a co-founder of the European Society for Cosmetic and Aesthetic Dermatology (ESCAD), he was also the founding editor of the Journal of Cosmetic Dermatology and has authored numerous scientific papers and studies.

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

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

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

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

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

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

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

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

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

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Skincare

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

#Education @sarahwhitehead.official Getting ready for @biorepeelcl3.official webinar! #Medfx #freewebinar #Connecting @drbenjidhillon Lockdown virtual catchup with some of the @defineclinic team.

I am so fortunate to love and appreciate going into ‘work’ each day. However what makes it even better is getting to work with this amazing team! #Charity @anjalimahto Delighted to represent @bsfcharity early this morning on @gmb discussing hand care and measures to look after our skin to prevent dryness and irritant contact hand eczema #Technology @kendrickpr_uk Things look a little different right now, but it’s business as usual at Kendrick – although of course we’re all separated. We’re grateful for the small mercies of great technology keeping us all in touch with each other! #Learning @doctoramiee Thank you again to every single person who joined our packed webinars today!

#Community @ekaesthetics Our obsession with aesthetics means every Monday eve we Zoom!

Missing interaction with my Cosmetic Courses team.

Lockdown has changed so much about the way we live our lives but not everything has been negative and this is something that we trainers have really enjoyed doing

HydraFacial launches four new boosters Skincare brand HydraFacial has released its latest treatment protocols, launching two collaborations and four boosters. The company explains that the boosters are designed to help clinics build a menu of prescriptive HydraFacial treatments.

Two of the boosters have been developed in partnership with Zo Skin Health. The HydraFacial Rozatrol Booster aims to minimise inflammation and redness, and the HydraFacial Brightalive Booster Serum is designed to block the production of pigmentation.

HydraFacial has also partnered with Nassif MD Dermaceuticals to create the NassifMD Hydraglucan Intense Hydration Booster, which is designed to hydrate the skin while restoring plumpness, according to the company. Developed in-house, the fourth booster, called the ReGen GF, is a bioidentical growth hormone which aims to support collagen synthesis and restore skin elasticity. Director of HydraFacial, Martyn Roe, commented, “Our booster vials, and the collaborations behind them, offer unrivalled personalisation opportunities for clinics, harnessing name-recognition skincare pioneers with scientifically-validated ingredients, all delivered through the trusted HydraFacial technology.”

Regulation

Practitioners warned against IVNT and coronavirus advertising Aesthetic clinics are being cautioned against marketing their intravenous nutritional therapy (IVNT) services as a method of prevention and protection against coronavirus. In newly released rulings by the Advertising Standards Authority (ASA) it has advised three clinics to take down their adverts.

The ASA sought the view of the Medicines and Healthcare products Regulatory Agency (MHRA) regarding the marketing language used, to which the MHRA said that any mention of coronavirus/COVID-19 in the promotion of an IVNT would bring the product under medicines regulations, as would any claim that implied treatment of, or protection from, the virus. The complaints to the ASA highlighted that these products were not licensed as a medicine by the MHRA, therefore breaching CAP Code rules 12.1 and 12.11 (medicines, medical devices, health-related products and beauty products). The ASA formally stated that the adverts must not appear again in their current form, and told the clinics to remove medicinal claims for unlicensed products from their advertising and not to use them in future.

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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Celebration

Date confirmed for Aesthetics Awards The prestigious Aesthetics Awards will take place on March 13 following the second day of the Aesthetics Conference and Exhibition (ACE) 2021. The ceremony will celebrate the achievements of clinics, products, companies and individuals working across the specialty in 2019-2020.

In a first for the Aesthetics Awards, the ceremony will be held after ACE rather than in December to better support the medical aesthetic specialty through the COVID-19 pandemic.

Alison Willis, director of Aesthetics Media as part of Easyfairs, said, “We understand the challenges that companies and clinics will face this year as a result of the pandemic. As such, we have decided to combine ACE and the Aesthetics Awards, holding them at a later date in March, to allow everyone time to get back on their feet, as well as save on travel and accommodation costs.” She continued, “Along with CCR in October, ACE and the Awards are both extremely valuable events for practitioners’ continued professional development, networking opportunities and, of course, recognition of achievements. It is important we do our very best to bring them to the industry in the safest and most suitable way possible.

After a challenging year, it will be brilliant to come together to celebrate everyone’s positive actions throughout this difficult period!”

Vital Statistics Male cosmetic surgery accounted for 8% of 2019 total procedures in the UK (BAAPS, 2020)

In a study of 2,000 people, 30% said they would consider a cosmetic procedure to copy how they look with a filter (Really, 2020)

One in five people wouldn’t delete Instagram even if it was harming their mental health (Ocean Finance, 2020)

Entry to the Aesthetics Awards will open on June 1, with 27 categories designed to celebrate everyone involved in the specialty. Five new categories have been introduced for this year, which include those designed to recognise the surgical side of aesthetics, with trophies handed out for Surgical Product of the Year and Consultant Aesthetic Surgeon of the Year. In addition, practitioners are encouraged to submit their most impressive case studies for the Best Surgical Result and Best Non-surgical Result categories, while Rising Star of the Year will reward practitioners with less than five years’ experience who’ve made a notable difference to the specialty. Chloé Gronow, editor and content manager at Aesthetics Media, said, “With the importance of working collaboratively in mind, we want to recognise aesthetic surgeons and the valuable products they use with these exciting new categories. We have also found that more and more practitioners new to aesthetics are achieving excellent results and working hard to uphold high standards. While they may not have the experience to enter our traditional Best Practitioner categories just yet, we want to give them the opportunity to be recognised, which they so deserve. Now, doctors, dentists and nurses with less than five years’ experience can enter Rising Star of the Year, as well as submitting case studies to our results categories, which are open to all.”

Follow our social media channels for regular updates on the Aesthetics Awards, ACE and CCR.

72% of practitioners spend their time working in aesthetics alone (Hamilton Fraser survey, 2020)

On average, male social media influencers earn 7% more than women (Hypeauditor.com, 2020)

There has been a 3.1% increase in women enrolling in scientific studies from 2017/18 to 2018/19 (STEM, 2020)

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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Events Diary

1 & 2 October, EXCEL www.ccrlondon.com

3 1 JM UA LYR&C1HA U1G2U S&T 1 20 32 0| /2L0O2N1D O N AESTHETICSCONFERENCE.COM

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Online education

Dr Lee Walker and Dr Raul Cetto launch talk show Aesthetic practitioners Dr Lee Walker and Dr Raul Cetto have launched a new online talk show, Talking Faces, on YouTube.

Dr Cetto commented, “The show is aimed at practitioners and the idea is for us to share knowledge, experiences, as well as to interview people with areas of expertise reaching beyond what we can offer. We felt that launching the series at this time would be the best way to support and interact with our friends and colleagues who are mostly at home currently.”

Dr Walker added, “We wanted to create a platform for medical practitioners to access that would give an unbiased, unbranded view of aesthetics. We are both very evidence-based practitioners and wanted to share the most pertinent and up-to-date references we could.

Along with the strong educational messages we broadcast, we decided to bring along our personalities and friendship to the show to give it an element of fun.”

Lasers

Guidelines

Practitioners breach lockdown Government-approved register of accredited practitioners, Save Face, has recieved 80 complaints of private procedures being promoted on social media, despite current government guidelines to social distance.

Ashton Collins, director of Save Face, commented, “Social isolation applies to all, it is not for practitioners to take it upon themselves to measure the risks and tell patients that it is safe to have treatments. We are extremely disappointed that some practitioners are putting their businesses before the safety of their patients. These are not essential treatments and can resume when the danger to us all has passed. Practitioners who continue to offer a service in this way are not safe, not responsible, not ethical and are to be avoided.” She encourages anyone who sees clinics breaching guidelines to report them to Save Face, which the organisation will then report to relevant authorities. Save Face has published further guidance on the issue on its website, reinforcing that practitioners should remain home depsite having no symptoms, even if a patient contacts you.

Cutera sponsors virtual qualifications Aesthetic technology manufacturer Cutera will be sponsoring virtual versions of Wynyard Aesthetics Academy’s laser qualifications. The virtual courses include the Core of Knowledge qualification and the Level 4 Hair and Skin Rejuvenation qualification.

By sponsoring the courses, Cutera’s aim is to make them more affordable for those who have suffered the effects of the COVID-19 crisis. Tim Taylor, Cutera UK country manager, commented, “COVID-19 is having a huge impact on our industry, but I truly believe now is the time for many aesthetic professionals to enhance their knowledge and get qualified in laser and IPL technologies. That is why I have decided to sponsor the upcoming virtual qualifications run by the Wynyard Aesthetic Academy, which would usually require a much higher fee for training and certification.”

Industry

New home-treatment distribution company launches Medical device and services distribution company, Medical-Up, has launched in the UK and Ireland. The company explains that it exclusively distributes products and treatments to aesthetic clinics for their patients to use at home such as Re-collagen, a collagen drink for skin protection, and Dimagra weight loss supplements. Mickey Carlin, managing director of Medical-Up, said, “Despite the challenging circumstances in which we find ourselves, several of the brands within our portfolio are perfect for at-home use. We’re well placed to assist those clinicians looking to offer innovative solutions to their patients who are currently unable to visit the clinic.”

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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Rejuvenation

Industry

Image skincare releases two new products Clinical skincare company Image Skincare has introduced two new products to its portfolio, the Max Wrinkle Smoother and the Max Contour Gel Crème.

The company explains that the Max Wrinkle Smoother contains acetyl hexapeptide-1, a peptide that aims to improve the appearance of lines and wrinkles; sweet iris, an aromatic sacred plant that aims to help firm and boost the appearance of lax skin; caesalpinia spinosa fruit extract and kappaphycus alvarezii (red algae) extract; a naturally-derived polymer that creates an invisible, mesh-like network that aims to visibly reinforce and lift the skin. According to Image Skincare, the Max Contour Gel Crème is designed to restore firmness and volume to the lower face. The formula consists of sodium acetylated hyaluronate, a bioavailable form of hyaluronic acid that aims to smooth the appearance of wrinkles; acetyl tetrapeptide-2, a peptide that the company states supports collagen and elastin fibres in the skin; sweet iris and orchid stem cells for elasticity, and babassu oil for moisture.

FillMed hires two new account managers Aesthetic company FillMed has appointed two new regional account managers, Jennifer Kinney and Jennifer Kinney Amie Williams Amie Williams.

Their new roles will include providing product support and advice about ‘at-home’ treatments and to help clients prepare for clinics reopening after lockdown.

Williams commented, “For me the role is about knowledge – whether that relates to treatments, products or supporting you to grow your business – I’m here for clinics to offer advice and guidance and to help you make the best plans.”

FillMed is also offering to replace any ART FILLER products that expire during lockdown with new replacement stock free of charge.

Rebecca Denham, UK director of FillMed, said, “I think the most important thing in these unprecedented times is to show a strong level of support and solidarity to our customers and potential customers! It is extremely important to us that all aesthetics businesses survive and we want to help them do that!”

Peel treatment

Cosmo Pro creates Cosmed collections

Aesthetic distributor and manufacturer Cosmo Pro has launched new collections featuring its Cosmed products, which the company states were created to make it easier for practitioners to target their patients’ specific skin concerns.

The six different collections consist of the S.O.S Skin Revival, which is a homepeel system, the Daily Essential collection for rejuvenation and antiageing, the Calming Collection that aims to improve rosacea, the Brightening collection for dull and uneven skin, the Purifying collection to address acne or oily skin, and the Momma collection, which was created for women to use during pregnancy or when breastfeeding. According to the company, patients will receive enough product for a three-month supply. Barbara Pointon, independent nurse prescriber, said, “Both my patients and I are loving the Cosmed Collections – the products are amazing. The S.O.S Revival is proving hugely popular due to the home-peel treatment option, allowing patients to take care of their own skin during lockdown.”

Technology

Blowmedia introduces new automated sales tool Digital design agency Blowmedia has launched SkopBot, a new e-commerce tool to support aesthetic businesses during the COVID-19 crisis. The company explains that SkopBot is an automated sales bot designed specifically for aesthetic clinics with no existing e-commerce functions.

According to Blowmedia, a bespoke SkopBot can be created and set up for a clinic in 48 hours. Unlike chat bots which need to be ‘manned’ by a person, SkopBot is entirely automated with pre-defined questions to channel customer website visits into a skincare purchasing funnel.

The customer can select from the skincare brands available at the clinic and pay for them via the secure bot. The practitioner can then send out the product order directly from their stock.

Tracey Prior, operations manager at Blowmedia, said, “The team at Blowmedia were keen to support clinics during this crisis. Our first step was to move to a non-profit business model across the board at Blowmedia, and our second step was creating this game-changing product, not to drive profit, but to help the whole industry survive and thrive through this difficult time. Both these initiatives will hopefully help our clients to enjoy stability, and in some cases growth, throughout this uncertainty.”

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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

CALL TO OPPOSE NON-MEDICS’ LICENCE IN SCOTLAND The BACN Board has submitted a response to the Consultation on the Regulation of Non-Surgical Cosmetic Procedures in Scotland and urges all members to do the same.

The Scottish Government has proposed new legislation for the aesthetics industry which could see non-medical practitioners requiring a licence in order to perform injectable treatments.

BACN members, along with other medical professionals in the specialty, do not agree that non-medics should be given a licence to practice so is urging medics to submit their opposition to the proposal to the Scottish Government by June 30.

BACN member Jackie Partridge, who has clinics in Edinburgh and Aberdeen, said, “We do NOT agree that non-medics (not qualified healthcare professionals) should be receiving ANY recognition or approval allowing them to put patients at risk, by injecting when they have no medical qualification. Therefore, we do NOT agree that these unqualified persons should be licensed, they should simply be stopped. Any form of license is, in itself, giving ‘approval’ that what they (non-medics) are doing is acceptable. We urge our fellow practitioners to complete this consultation and to stand up to this proposed idea.”

SUPPORTING MEMBERS While the BACN is running with reduced staff at the moment, the team are doing everything they can to continue to support members. The Board is still working on the BACN competencies, as well as putting together a social media campaign to share positive messages with the specialty over the next few months. Look out for them on the BACN Instagram page: @bacnurses

BACN CONFERENCE The BACN conference will be moved from November this year to February 2021. More details will be released on this soon.

This column is written and supported by the BACN

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Skincare education

AlumierMD introduces online learning for practitioners Skincare brand AlumierMD is now offering online education to its new and existing stockists.

The AlumierMD Online Education Academy is comprised of two digital platforms; one for professionals beginning their training with AlumierMD and another for those already certified by the company.

The company explains that the medical and skincare professionals beginning their AlumierMD education journey will be offered foundation training. This patient-centric course offers clinical education as well as practical tools that support delegates in educating patients towards medical-grade skincare.

Modules within the foundation training include patient assessment, skin condition diagnostics and recommending hyper-customised skincare regimes.

According to the company, the course is delivered via an interactive, virtual classroom and includes a digital AlumierMD manual, learning checks and a final exam. A 75% pass rate is needed to become a certified AlumierMD professional.

For certified AlumierMD professionals, the AlumierMD professional portal now includes more than 30 on-demand educational webinars and tutorials, with more to be released. The modules, curated by the global AlumierMD medical board, include a lecture by Dr Karl Lintner on the discovery of cosmetic peptides. It also includes a five-part online consultation workshop and business webinars.

Victoria Hiscock, medical communications manager, said, “Education that fits the modern-day schedules of our medical partners has never been more important and the AlumierMD Online Education Academy offers education 24/7. It’s a demonstration of our commitment to the success of our medical partners.”

Recruitment

VIVACY UK appoints new product specialist Aesthetic product manufacturer VIVACY UK has appointed Chloee Alesbury as its new product specialist for the South West.

Alesbury commented, “I’ve been in aesthetics since 2016 and started my career with injectables. The technology in the industry is always developing and new treatments are regularly found. This is one of the main reasons I was so drawn to VIVACY UK as the technology is so advanced and they have treatment areas that other companies don’t have. I am extremely excited to be on this journey with the VIVACY UK team.” Terina Denny, national sales manager at VIVACY UK, added, “We are truly delighted to announce Chloee’s appointment.

She brings many years of experience in aesthetics and VIVACY is thrilled to welcome a new addition to the growing commercial team.”

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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Weight loss

Allurion produces 20,000 weight loss balloons Medical technology manufacturer Allurion now has 20,000 global clients using Elipse, a non-surgical, non-permanent gastric balloon. Released in 2017, the balloon was designed to suppress patient appetite and teach portion control. On the business growth, Shantanu Gaur, co-founder of the Elipse, said, “I am very proud of our team for building one of the fastest growing weight loss brands in the world.

What I am more proud of, however, is how we have built our brand. Amidst our rapid growth, we have never lost sight of our ultimate goal of creating frictionless weight loss experiences that delight our customers. That desire has been in our DNA since day one and will remain there whether we have 20,000 or 20 million clients.” The company has also set up the One Million Weight Loss Challenge, aiming to help its customers’ patients around the world shed a million pounds by the end of the year.

Regulation

3D-Lipo gains new certification Aesthetic device manufacturer 3D-Lipo Ltd has achieved the EN ISO 13485:2016 certification in line with the Medical Device Regulations, which was to be fully implemented on May 26 but will likely be extended due to COVID-19. Following the implementation of the Medical Device Regulations, equipment suppliers will be required to demonstrate their adherence to the regulations by developing a comprehensive quality management system, which is independently audited by an external body.

The certification specifies requirements for a standard level of quality of devices and services, which is then reinforced though inspections by the Medical and Healthcare Regulation Agency (MHRA). Roy Cowley, managing director of 3D-Lipo Ltd said, “This accreditation is fantastic for 3D-Lipo Ltd because by integrating our quality management system within the business, this has significantly improved our operations. Our customers can now have the confidence that we are not just saying that we are great, but that we have been independently certified to demonstrate this.”

Skincare sales

Harpar Grace introduces e-commerce solutions UK aesthetic product distributor Harpar Grace International has launched a fully integrated e-commerce solution, the new Affiliate Programme, designed to help practitioners manage an online e-shop. The company explains that a ready-made iframe shop becomes integrated within an existing practice/clinic website, which enables a patient to order for their favourite or recommended products. The clinic receives commission based on the net revenue their site generates on a quarterly basis.

The e-shop solution enables clinics and practitioners to access all four of the brands within the Harpar Grace portfolio, iS Clinical, Codage, Déesse and Totally Derma.

Alana Marie Chalmers, director of Harpar Grace International, commented, “We wanted to develop a solution for our existing and new clinics that retail the Harpar Grace brands to support them in this challenging period of the Covid-19 pandemic. Our Affiliate Programme takes care of the full ordering process including fulfilment, dispatch and payment, and reassures our clients that they are rewarded with commission based on the new revenue generated and the margin tier that they are on.”

News in Brief American College of Surgeons releases COVID-19 guidelines The American College of Surgeons (ACS) has released a new surgical resource document titled ‘Local Resumption of Elective Surgery Guidance’, as a guide for facilities that are preparing to resume elective surgery once COVID-19 has peaked in their respective areas.

The guidelines provide information about how to understand both the local facility capabilities such as beds, testing and operating rooms, as well as potential constraints such as the lack of workforce. It also includes ‘five phases of care’, which addresses ensuring safe, high quality and high value care of the surgical patient.

Acquisition Aesthetics announces 100% pass rate Training provider Acquisition Aesthetics has confirmed a 100% pass rate for its Level 7 certificate for aesthetic medicine. Acquisition Aesthetics directors Dr Lara Watson and Dr Priyanka Chadha commented, “We feel the diligence of our academic team, combined with the talent of our practical trainers and online support staff, has created a water-tight training experience to carry our Level 7 candidates from novice to graduate in a way that is safe, effective and of course enjoyable!”

New supplement website launches Supplement brand Rejuvenated has launched its new Rejuvenated Pro professional website for aesthetic practitioners, to help them sell the supplements online. Brand assets can be downloaded directly from the site and include training manuals, ingredient information, treatment protocols, promotional material, social media content and video content. Kathryn Danzey, founder of Rejuvenated, said, “We’re thrilled to see Rejuvenated Pro come to life; the launch has been months in the making, but it couldn’t have come at a better time with many of our stockists taking a step back to re-set and focus on their business during these uncertain times. We hope that our new website provides each and every one of them with the resources and guidance they need.”

Abstract submissions open for BAPRAS meeting The British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) is now accepting abstract submissions for its ‘masters of disaster’ section at the 2020 December meeting in Manchester. The association explains that abstracts should be about a practitioner’s most complex wound problem that led to an innovative solution. Submission closes midday on July 24, and those chosen will be voted upon by the conference audience to determine the best case. Abstracts can be submitted via the BAPRAS website.

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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Education

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e-learning

Qualification in aesthetic teaching established Former BCAM president and aesthetic practitioner Dr Paul Charlson and clinical lecturer Mr Vikram Sinai Talaulikar have created an Ofqual-approved teaching qualification for aesthetics, available through the British Society of Aesthetic Examiners and Assessors (BSAEA). The Level 3 Award in Education and Training (L3AET) can be achieved by completing online coursework and assessments, and practitioners can register online. Dr Charlson said, “There are a lot of good technical people out there who are also teaching aesthetics but they don’t have any baseline teaching skills – there’s no formal understanding of getting feedback, asking questions or running groups and that kind of thing is key to people learning. There’s a need to ensure that people have the necessary soft teaching skills and not just aesthetic ability and understanding. It’s also beneficial to have a formal qualification and not just an experiential one – with a lot of people now coming into the aesthetics field, they need to learn from people who know how to teach. This way, we can better help to safeguard patients in the UK, as well as gain their confidence.”

In order to register as a member of the BSAEA and take the course, you must have finished basic facial aesthetic training, be practising in the field of aesthetic or cosmetic medicine, have a current role as a clinical trainer or examiner/assessor for an aesthetic non-surgical organisation, or aspirations to become an aesthetic trainer or examiner, and hold valid profession healthcare registration and insurance.

Recruitment

Cynosure University launches Laser manufacturer Cynosure has launched its new online aesthetics educational platform, Cynosure University. The company explains that the series has been designed to provide practitioners with a variety of educational resources that can be accessed any time. The topics will cover popular patient treatments such as hair removal, pigmentation, wrinkles, scars and stretch marks, which will be supported by a series of webinars for practitioners to join.

Fiona Comport, marketing and communications manager for Cynosure, commented, “We are so thrilled to be able to support our clinics with a comprehensive, educational platform.

Created to educate with best practices and clinical information, marketing tips and product demonstrations, the Cynosure University was developed to really help our valued partners learn, grow and thrive.”

Regulations

RCS announces new senior appointment The Royal College of Surgeons of Edinburgh (RCSEd) has appointed a new honorary secretary, consultant surgeon Miss Clare McNaught, who currently works for the Harrogate Foundation Trust.

She will take on the role in November 2020, when current Honorary Secretary Dr Judy Evans comes to the end of her term.

Miss McNaught said, “It’s a huge honour to be appointed Honorary Secretary for the Royal College of Surgeons of Edinburgh. I’ve thoroughly enjoyed my involvement with the College over the years and have found it to be hugely useful for my professional development, so it means a lot to be taking on this role. I’m looking forward to a new and exciting challenge.” President of the Royal College of Surgeons of Edinburgh, Professor Michael Griffin OBE, said, “Clare has proven her dedication to the College over the years, becoming an elected Council member, being involved in the Trainee Committee, founding and chairing the Younger Fellows Group. I’m sure Clare will bring that dedication and passion for surgery to the role, and I’m delighted to have her on board.”

Delay proposed for new Medical Device Regulations The European Parliament has adopted a proposal to postpone the full implementation of the Medical Device Regulation (MDR) 2017/745 for one year to allow relevant parties to prioritise the fight against the coronavirus pandemic.

The EU MDR 2017/745 was meant to come into force on May 26 to ensure better protection of public health and patient safety for certain products without an intended medical purpose. Listed under Annex XVI, the new MDR will regulate certain groups of products which a manufacturer claims only has an aesthetic or another non-medical purpose, but which are similar to medical devices in terms of functioning and risk profile.

These include dermal fillers, body sculpting equipment and intense pulsed light (IPL) machines for body hair removal. The proposal needs to be approved by the member states and published in the Official Journal of the European Union before it will enter into force, which is expected to be by 26 May 2020.

Rejuvenation

Radara now available for home delivery Skincare brand Radara is now available to be delivered to patients on behalf of a clinics. The brand’s manufacturer commented that this was designed as a way to help clinics stay connected to their patients during lockdown. Ken Jones, chief executive officer of the UK Innoture Medical Technologies, manufacturer for Radara, commented, “For us, it was thinking about how we can keep personal engagement involved. We want to help our clients keep some contact with their patients and help them make some income while their clinics are shut. With nobody able to get injections during lockdown, it’s also a way to help people take care of themselves at home”. Radara products are available to order through Innoture Medical Technology and Church Pharmacy.

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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Charity

Aesthetics and COVID-19: A Perspective from China

Allergan donates $20,000 to help NHS

With China being impacted by COVID-19 much earlier than the UK, Aesthetics was keen to find out how it has impacted the market and what practitioners can learn moving forward.

Dr Vincent Wong kindly interviewed his peer and plastic surgeon Dr Hu Jin Tian and translated it for Aesthetics readers. Dr Tian explained that he made the decision to close his clinic from January 23, which was Chinese New Year. After 54 days, Dr Tian’s clinic reopened on March 17 and is readjusting following the crisis.

On the current state of aesthetics industry in China, Dr Tian commented, “The pandemic had a major impact on China’s overall market. At present, even in the recovery phase, my colleagues and I are only seeing 50% of our usual patient volume and the number of treatments has also reduced by at least 50%. It is common practice to work up to four days a week and stay home at other times. We try to only book patients and treatments on selected days. This way, we can centralise treatments and ensure that the diary is full for those working days to meet demands. As working days have been reduced, business outgoings are also reduced. Unfortunately, this includes staff wages.” On how to keep positive, Dr Tian advised, “Have confidence in the future. Everyone has a unique set of skills and treatment techniques, so patient loyalty will remain high. My main advice would be to find your unique selling point. Be a leader and develop exclusive techniques or protocols that cannot be copied, and keep improving them. For example, I developed my own unique technique for botulinum toxin injections, but it took me 15 attempts to perfect it. It’s also important to participate in educational activities, for example webinars or online lectures, and promote your business on social media. Finally, practitioners should maintain a positive image/reputation overall, and use this time to be seen as an expert in your field.”

The Allergan International Foundation (AIF), run by global pharmaceutical company Allergan, has awarded $20,000 to UK charity Lenderhand, Essex, which is currently supporting its local community in response to the COVID-19 pandemic by supplying meals and supplies for NHS staff.

The foundation explains that the donation is estimated to provide around 400 meals a day for the NHS over the next month.

Brent Saunders, chairman of The Allergan Foundation, said, “The goal of these grants is to put much needed financial help in the hands of organisations who support vulnerable people in need of food, housing, healthcare and mental health services as quickly as possible as communities continue to manage the impact of COVID-19. We are humbled by the care these front-line organisations provide to people in local communities and are proud to add them to the many organisations we support who are making a difference in the health and wellbeing of our communities during this time.”

Lois Heller, co-founder of Lenderhand, commented, “Thank you to Allergan for their great generosity, we at Lenderhand greatly appreciate your donation. We are delighted with this donation as it will allow the charity to continue to fund the NHS with food and supplies that they desperately need.”

The donation to Lenderhand is part of a wider scheme, in which the AIF have donated $2 million globally to more than 70 organisations that are helping communities around the world that have been impacted by COVID-19.

Thought Piece: COVID-19 and its ramifications on cosmetic dermatology Consultant dermatologists Dr Firas Al-Niaimi and Dr Faisal R. Ali shared their views with Aesthetics on how coronavirus will impact cosmetic dermatology. Dr Al-Niami commented, “Whilst the world is battling a pandemic with COVID-19, the entire medical profession and its allied services are reshaping and adjusting its non-acute services which will inevitably shape our future approach. These changes are not limited to a speciality and will inevitably affect cosmetic dermatology.”

To explain the current changes in the practice of cosmetic dermatology, Dr Al-Niami and Dr Ali created an acronym of COVID-19, which they state practices should take note of in order to safeguard their future services. ⊲ Consultations are likely to be prioritised and optimised with the use of telemedicine. This is a branch that is finding a rapid growth within dermatology.

⊲ Operations amongst other procedures are being prioritised with acute and urgent cases being dealt with and many others being postponed. Further information is needed regarding the risk to the operator (or injector) of contracting COVID-19 from potentially infected patients. ⊲ Virtual conferences and meetings are being established and this is likely to grow and expand beyond the COVID-19 era. ⊲ Isotretinoin prescribing is limited and re-evaluated given concerns of its effects on the mucosal surfaces leading to an increased potential viral load. ⊲ Devices and equipment are being assessed and some might be in short supply, such as masks and protective anti-septic material. Vapour from ablative lasers might interact with the mucosal respiratory system and its implications on viral inhalation and load.

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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Charity Facing the World

Occurrence of facial differences It is estimated that 6%, or 7.9 million, annual global births result in serious defects and are of genetic or partially genetic cause.

In Vietnam, however, the occurrence of severe facial defects is estimated to be between four and 10 times higher than in other neighbouring countries. This is believed by many to be as a result of exposure to Agent Orange, a chemical which was used in the Vietnam War. Thousands of children suffer from serious health conditions arising from their facial differences, which is why Facing the World has focused its efforts in the country.

In addition, statistics suggest that 90-94% of all infants with serious birth defects are born in low-middle income countries (LMICs). The Lancet Commission on Global Surgery has called for global investment in surgical and anaesthetic care in LMICs, without which, it is estimated that between 2015-2030, the countries will have losses in economic productivity of US $12.3 trillion.

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

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

Community support This year, we’re asking the aesthetics community to join us in supporting Facing the World. This worthy charity raises desperately needed funds to treat children in Vietnam born with facial defects. Not only are these children suffering from psychological trauma associated with their facial deformity, but serious physical concerns too. Throughout the year, we’ll be bringing you key stats and facts on children affected, as well as explaining how you can help support them.

The Facing the World charity was suggested to us by nurse prescriber and BACN member Sharon Gilshenan. She has a special affiliation with the Sharon Gilshenan charity after being born with a cleft lip, so understands the noteworthy work it is doing to help children who aren’t as lucky to receive the support she has had in the UK. She said, “Facing the World is such a pertinent charity for the industry we represent. As aesthetic practitioners, we are in the unique position to see and understand the value and importance our faces have on us in society.”

Gilshenan continued, “I also have a special affiliation to this charity because if I had been born in Vietnam, I could have been

one of the children in pain and unable to speak properly, eat or drink, or possibly shunned by my community, as I was born with a bilateral cleft lip and palate and have had 25 operations. Yet I consider myself lucky as I was born in a society that had the ability to change my outcome and have consequently enjoyed a fulfilled life. I wish that for the children of Vietnam.”

NEXT MONTH: We look at how facial differences impact children living in Vietnam FURTHER READING Katrin Kandel, Vietnam Training Program, Facing the World <https://facingtheworld.net>

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

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and cause them to be unable to carry out aesthetic procedures. Although no one could have predicted the COVID-19 pandemic, in other circumstances these eventualities could include a fire or flood in the clinic, the unexpected absence of a key person or perhaps the theft of vital machines. Planning can help manage these circumstances if, or when, they occur.” Aesthetic nurse prescriber, Lorna McDonnell Bowes, has extensive experience owning and running aesthetic clinics and is now the CEO of product distributor AestheticSource. In 2018 she suffered a health issue forcing her to step away from managing her business for for a period. Speaking from experience, she highlights the importance of business contingency planning, explaining, “I think it is a business essential to have a disaster management plan and to have thought through how you will keep your business going should something unforeseeable With new stats highlighting a low rate of business happen.”

However, Myers adds, “A lot of business contingency planning for practitioners in the owners struggle to put together what I industry, Aesthetics explores the importance of call a straightforward strategic plan and expecting the unexpected won’t include issues related to business interruption and its associated financial These are unprecedented times. No aesthetic business owner implications. This would include looking at best and worst-case could expect or foresee that by March 2020, clinics all over scenarios from a cash flow perspective because every aspect of the country would be closed and, for many, this eventuality is business interruption will relate to cash flow – how much is going out extremely difficult. But for a second, pretend that you haven’t even and coming in, and what reserves you have.” heard of COVID-19 and consider; as a business owner, have you ever thought about what would happen if you were suddenly unable What should your contingency plan involve? to work tomorrow?

Your plan doesn’t need to be a large formal document, Myers says, A new survey by Hamilton Fraser Cosmetic Insurance focusing but it should be written down and easily accessible. “A few pages of on the impact of the COVID-19 pandemic has highlighted that steps you would take is all that you need to really make a difference to chances are, you haven’t.1,2 the way the situation is managed,” he advises.

Of 1,360 aesthetic practitioners surveyed between March 22 to When McDonnell Bowes was practising, she acknowledges that March 24, 72% said they did not have a contingency plan in place her business contingency plans were never actually written down, should they not be able to carry out aesthetic procedures. Of the however it had been thought about and discussed with relevant 28% who did, returning to the NHS for work was among the top parties. She says, “My medical director and I had regular conversations responses. Other plans included a focus on online product sales about how the business would continue if either of us were to fall ill. for revenue, continuing to engage with patients through education As we had others to rely on it mainly consisted of how we would take via social media, blogs and vlogs, contacting suppliers to delay any on each other’s work loads. Product supply was another thing we had payments due, claiming insurance, upskilling through online training, looked into; we knew that there were various sources of the products and potentially using time away productively, such as increasing we needed and if anything were to happen that would damage supply CPD, and improving the business. we had these contacts ready.”

The figure comes as no surprise to Mark Copsey, healthcare associate As mentioned, the number one issue businesses will likely face is director at Hamilton Fraser Cosmetic Insurance, or to business cash flow, and in usual circumstances insurance can be of huge consultant Ron Myers, director of The Consulting Room Group. “All benefit here, Myers highlights, adding, “This is what most people’s our survey participants come from a medical background so treating contingency planning involves and particular policies will help cover people is life to them, but business planning and marketing doesn’t you if you need to stop trading at a particular time, but I find that for usually come quite as naturally,” Copsey says. the majority of businesses this is as far as they get. You should also Myers adds that many individuals who run single and small consider how you might be able to keep money coming in. This could business enterprises, or those without a business or entrepreneurial include remote or video consultations, which could either be paid for background, will be less likely to have a level of future planning. He or complimentary, depending on your business model. You might also explains, “It’s certainly important for business owners to think about look to continue with sales of products that you can send directly, such potential unlikely eventualities that might lead to business disruption as skincare, nutraceuticals or at-home devices, or in some situations

News Special: Expecting the Unexpected

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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“If for any reason you are unable to practice or look after your clinic, ensure you have someone you can trust who might be able to take over from you for a length of time should something happen” Aesthetic nurse & CEO of AestheticSource Lorna McDonnell Bowes

you could look to temporarily hire suitable treatment rooms in other clinics nearby.”

Also from an insurance perspective, Copsey highlights the importance of having sufficient planning in place to be able to maintain medical malpractice insurance contracts. “Although practitioners may not be practising in the event of clinic closure, this insurance should still be in place as it covers them for medical liability and dissatisfaction claims and has to be in force at the time of the claim, not when the treatment was carried out,” he says.

Although cash flow is a major consideration, it’s not the only one. Myers says, “There are actually very important and simple components of basic planning that every clinic should have in place.

For example, how will you keep engaging with your employees? I recommend to communicate with your employees on a one-to-one basis at least once a week; give them a call and check in, ensure they feel they are updated and not forgotten about. Also, what about your patients? For example, how will you handle the phones and customer enquires? Many clinics work with call answering services like Aesthetic Response anyway, but it might be worth considering this. I have found that a number of clinics that are closed at present just have an answering machine saying that they are closed, but they risk alienating existing patients or losing new enquiries without human engagement.”

McDonnell Bowes also recommends that business owners assess each individual person in their business and determine critical roles.

“Look at these people working with you and make sure that someone else knows what’s going on with their role and how they might be able to take over if they ever need to. Important information about their role should be written down and easily accessible,” she says.

McDonnell Bowes’ top recommendation for practitioners is to ensure they have a good support network if something goes wrong. “For example, if for any reason you are unable to practice or look after your clinic, ensure you have someone you can trust who might be able to take over from you for a length of time should something happen.

Think what information they would need, such as accessing patient data – following GDPR of course – and who the critical people are to the business such as the suppliers. If this is another practitioner, perhaps a pre-arranged financial agreement could be beneficial,” she explains.

Myers also says a plan on how to deal with your immediate bookings is essential, as is accessing their details. “Do you have a CRM system that is cloud based? Or do you physically need to be in the building? If your clinic burns down then not being able to access this remotely is a huge issue,” he says. Overall though, Myers emphasises that any plan is better than none.

How COVID-19 will change business planning Myers and Copsey say that although no one was prepared for the disruption caused by COVID-19, they are certain that it will have a positive impact on many businesses’ contingency plans. “As a result of COVID-19, I think future planning will change forever with much greater thought and resource applied – this event will see business change forever on many levels and that can only be a positive thing,” explains Copsey. McDonnell Bowes adds, “I am convinced that the current COVID-19 presents us with an opportunity to learn and look at business structure, the relationships your business depends on and how these can be improved. Every experience I have had has been opportunity to learn and grow so I encourage others not to be afraid of it.”

Myers notes, “It’s forced everyone to run through many of the steps of disaster planning as they have not been able to go to their clinics, so now they have a template on what they can do in future.” He encourages practitioners to reflect on this time and assess how they managed the situation, explaining, “I suggest practitioners get their staff together when they are back and talk through what everyone has learnt, what worked well and what could have been done better.

Be sure to document this to help in the event of another business disruption. It is really important that clinics do this because we might all go back to work following COVID-19 and then a few months down the line we might be in lockdown again. Or, perhaps something else will happen that causes a business closure. It’s good to know what needs to be done to make things easier and slicker.”

Live and learn After being forced to step back from her business, McDonnell Bowes suggests that good things did actually come of it. “My business changed when I was unwell, but for the better as it made us all stronger. I found that the amount of time I spent developing relationships with my team absolutely payed dividends, and from a practitioner perspective having a strong relationship with your patients will do this too.”

Myers emphasises, “At least if you have a business contingency plan, if something happens you can go to that and say what is applicable at that time. Hopefully you have some kind of guideline or blueprint around the immediate and longer-term things that you need to do.”

Copsey concludes, “I think contingency planning has to be central to every business now and when we come out of the COVID-19 pandemic. Business will have changed, sectors will have adapted and people will be more experienced, so it is unlikely that we will be caught by surprise in such a huge way again. Life is always going to send surprises our way but we are resilient, mentally tough and will learn from the experience. I firmly believe that the sector will bounce back to life pretty quickly as it’s part of our natural being to take care of ourselves.”

REFERENCES 1. Kilgariff, S, ‘New survey highlights impacts of COVID-19’, April 3, 2020. <https://aestheticsjournal.com/ news/new-survey-highlights-impacts-of-covid-19> 2. Hamilton Fraser, What is the impact of COVID-19 on the aesthetics industry?, April 2, 2020. <https:// hamiltonfraser.co.uk/knowledge/covid-19-aesthetics-industry/>

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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Contouring a Male Jawline Practitioners advise on using hyaluronic acid to treat the lower face in men As aesthetic clinicians, you will be familiar with the increased interest from your female patients in jawline treatment over the past couple of years. Global statistics indicate that there has been a steady rise in the number of people searching the web for ‘jawline’, along with related topics such as ‘how to get a defined jawline’ and ‘sharper jawline’, while the UK and Ireland are among the top five countries where the searches are most popular on Google.1 With that said, a chiselled jawline and strong chin have always been ‘on trend’ and desired by men across the globe. A study from 2019 on the psychological desires of facial appearance amongst men indicated that, along with a straight nose, there is a high demand for a prominent jawline and gonial angle.2 This has largely been attributed to the fact that people perceive men with stronger jawlines as being more competent, successful and attractive.3-6 Aesthetic practitioner Dr Sophie Shotter explains, “Research shows that a strong, defined jawline is seen as synonymous with good leadership skills and dominance in men. A softly defined and rounded jawline is deemed to be more feminine. The reason for this is that high testosterone levels give men this underlying structure, and so subconsciously we perceive men with strong jawlines as having high testosterone levels and being more masculine.”

While surgery has been the traditional approach for lower face definition, there is now a multitude of non-surgical or minimally-invasive treatments that can offer noticeable and long-lasting results, independently or in combination with each other. Aesthetic practitioners can choose to treat their patients with a range of procedures, however this article will focus on the use of hyaluronic acid (HA).

We speak to Dr Shotter, Dr Paul Baines and Dr Armand Abraham about the products they use, their male-specific technique approaches, and how they recommend practitioners successfully manage the expectations of male patients.

Treatment demand Approximately 10% of Dr Shotter’s patients are men; a figure that has been growing year on year. The same goes for Dr Baines, whose male patients make up around 20% of his database. Men make up a significantly larger proportion of Dr Abraham’s patient base – more than 70%. He says these are mainly accumulated from word-of-mouth recommendations amongst the gay community. “Being a part of this community has meant that I’ve built my database organically and am trusted amongst my patients – it wasn’t planned but is something I’m proud of,” he says, noting that his male patients are becoming increasingly confident with seeking treatment.

All practitioners agree that while men will usually be very confident in their choice of clinician, they’re generally less informed on the types of treatment available to them. Dr Baines explains, “As a stereotype, they’ve researched who they’re going to entrust their treatment to, and then once they’re in clinic, it’s pretty much a case of, ‘I trust you as a clinician to make me look as good as you possibly can and do what you think is best’.

Dr Shotter adds, “The men I see have usually been considering treatment for a long period of time but, for the most part, are less knowledgeable about treatment options than women. They have often had a concern for many months or even years, and decided to come and see what may be done about it, but are generally less aware of a particular treatment option than my average female patient.” While this can offer more freedom to discuss a variety of options, Dr Abraham notes that it can make it more challenging for practitioners to avoid leading the patient to addressing particular concerns or undergoing certain treatments. “Men will come to clinic and ask, ‘What treatment do you think I should have?’, which one needs to approach in a very careful manner. You don’t want make them conscious of something that they’re actually comfortable with,” he says, advising, “I respond by asking questions such as, ‘What is it that you’re not comfortable with?’ And,

‘What is it that you see that you would like to improve or enhance?’.

On a positive note, Dr Baines says that male patients are a lot more loyal than female patients. “I’ve never lost a male patient or had one that shops around – when they jump in they’re all in and are generally more open to a diverse range of treatments,” he says, highlighting, “I don’t think that’s exclusive to aesthetics; men tend to be quite loyal and put their trust in things once they’ve found something that works for them. Think of barbers – men are known to keep returning to their same barber for their whole life!”

Consultation and patient selection When men attend consultation, practitioners find that their main worry with undergoing aesthetic treatment is the risk of feminisation.

“Avoiding this is their number one priority,” says Dr Baines, noting that men don’t want to look treated at all so effective communication on how you achieve this is key. Dr Shotter adds, “Treating the jawline and chin without understanding male vs. female anatomy could lead to feminisation rather than masculinisation. It’s important to study the proportions that make a face look masculine or feminine, before creating a treatment plan.” Dr Baines says that during the consultation he explains how the male face ages, how it can be masculinised and how it differs to the female face. He says, “I talk them through how the mentum is wider; approximately the whole width of the mouth rather than the central two thirds seen in women. The bigonial distance is wider as well, which means men can carry off a sharper, fuller and heavier jaw. I then outline the ageing process, discussing skin laxity and bony resorption, and how we can address this in multiple ways.” Dr Shotter notes that it is also important to take the mid-face into consideration, highlighting, “I always start by assessing the mid face – treating the cheeks will alter the jawline, and so I assess whether some mid-face support is needed first.”

As with any patient, looking at their individual facial shape is imperative. Dr Baines emphasises, “You should always be looking to enhance the features someone has already, rather than change it. It’s also all about the communication to work out what the patient wants and the best plan of action.”

Product selection When choosing appropriate products to treat patients with, Dr Baines highlights that it’s important to remember facial proportions, the

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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Male jawline anatomy and ageing Aesthetic practitioner Dr Raul Cetto detailed the anatomical features and ageing process of the male jawline in his article ‘Male Chin and Jawline Ageing’, published by Aesthetics.5 His top five tips to remember are: 1. The male chin width corresponds to the width of the mouth and female chin to the width of the alar base.

2. Male patients have a broader bigonial width, whereas the female bigonial width only increases with age.

differences in chin shape between men and women, and skin thickness in men, in order to achieve the best result most efficiently.

Dr Abraham adds that practitioners should consider the layer in which they intend to inject, as well as, of course, the reputation and safety data of the products available.

Dr Baines advocates the use of products with a high G-prime as the higher degree of thickness means it will be firmer and more contour stable. “If you’re using a product with a low G-prime, you’re likely to need much more of it; whilst this may be acceptable for some women, the volumes required for typical male treatments would be significantly higher.” His products of choice come from the Restylane range. “The high G-prime of the NASHA products mean that men will get a greater amount of lift per ml, as well as good coverage for the amount of volume placed,” he explains.

Dr Shotter says, “My preference for treating the jawline is to use Juvéderm Volux. This product was specifically designed for this area – it is a structural HA gel giving enhanced projection and lift. I find the results are beautiful, giving a better ’sculpt’ than products I previously used for this area.

Patient satisfaction is very high; both because of the results and the longevity.”

Alternatively, Dr Abraham uses the STYLAGE range. He says, “When it comes to the jawline, I have very good results using STYLAGE XL and XXL to enhance the angle of the mandible and project the chin. They give very good support for this area in men.”

Treatment When it comes to treatment, Dr Shotter says that after assessing the mid-face, she will then look at the chin. She considers whether there is retrognathia, if the chin length is in proportion to the rest of the face, and what the width of the chin is. She notes, “In a man I will aim for the chin to be approximately the width of the lips, whereas in a female I will aim

3. The jowl is the superficial fat which enlarges as part of the ageing process and disrupts the jawline; it is import to volumise away from this area of heaviness.

4. The facial artery emerges deep and anterior to the border of the masseter muscle. Injections for contouring the jawline should be placed superficially and away from the artery.

5. The contour of the chin is defined by the superficial fat, so in order to enhance the chin, deep injections are indicated in the midline to restore anterior or inferior projection. However, most of the product should be placed superficially in order to redefine and contour.

for the chin to be the width of the nose.” is noticeable, Dr Abraham sees the patient Following this, Dr Shotter explains that she again for their HA treatment. “On average will assess the width of the jaw in comparison I would use 2-2.5ml of HA on each side to the width of the cheekbones. “It is widely in men where treatment of the jawline acknowledged that in men, the bigonial width and chin goes hand in hand; I use it to should be approximately the same as the redefine the corners by injecting boluses interzygomatic width,” she explains, adding, onto the periosteum at the angle of the “I often strengthen and widen the jaw angle mandible, before using a straight linear with a bolus of product laid on bone with injecting technique along the arms of the needle.” mandible with a 23 gauge cannula, to It’s also important to assess whether there is achieve a stronger jawline and injecting a a weakness in the length of the mandible, Dr bolus of 0.3ml on the surface of the mental Shotter notes; for which she may consider processes to square the chin,” he explains, laying a second bolus with needle onto adding, “I sometimes use STYLAGE L, which the posterior aspect of the ramus of the is less viscous, and inject with a cannula very mandible. “This can give a more angular carefully subcutaneously on top of the most appearance as well as helping to reduce laterally projected part of the lower third of jowling,” she explains, adding, “I will almost the masseter muscle.” Dr Baines shares his always strengthen the anterior aspect of the approach to treating one patient in particular mandible using linear threads with a cannula (Figure 3). He explains, “This patient wanted in the subcutaneous plane. Occasionally I a more striking appearance so more product may also lay a bolus with needle on bone in was used than usual (here the volume used the pre-jowl area if there is a deficit here. If was 7mls, compared to typically 3 or 4) but it more sharpness is desired I may define along gave a very effective result. It was achieved the length of the body of the mandible using by injecting 1.5ml of Restylane Lyft into the a cannula in the subcutaneous plane.” mentum anteriorly, 1.5ml either side of the Dr Abraham will first consider whether the jawline: 0.75ml behind the jowl in a linear patient will benefit from jawline slimming fashion plus 1ml at the angle of the mandible using botulinum toxin.

Before After “Some patients will have a more rounded jawline shape as a result of a thick masseter muscle or bruxism. Relaxing the muscle first will make it appear slimmer, which will help with the overall redefinition,” he explains, adding it can also benefit indicated patients with a smaller budget as it will mean less HA is needed later. Figure 1: Before and after treatment with 0.5ml of Juvéderm Voluma to each zygomatic arch and 1ml of Juvéderm Volux at each gonial angle, with 2ml of Once the toxin has Volux to the chin. The patient was also treated with 1ml of Voluma to the nasal dorsum and tip. Images courtesy of Dr Darren McKeown and Allergan. settled and a result

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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Before

After

Figure 2: Before and after treatment with STYLAGE XL injected at the angle of the mandible and STYLAGE L injected along the lower arm of the mandible. Images courtesy of Dr Armand Abraham and Laboratories Vivacy.

placed deeply on the periosteum, followed by a final 1ml on the zygoma bilaterally to define the cheek.” Dr Baines notes that this patient particularly requested cheek definition, but reminds practitioners the risk of feminisation is higher when treating the cheeks so conservative volumes with continuous assessment is important.

Key considerations Continuing with Dr Baines’ advice on avoiding feminisation, he recommends reviewing the patient’s face throughout the procedure in a sitting position. “Inject small amounts and frequently recheck the effect while the patient is upright, involving them in the review, so you both have an understanding of the direction the treatment is heading and can stop when appropriate,” he says.

If you do realise that you’re getting too much overfill in an area, the first thing you should do is massage the product, advises Dr Baines, explaining, “You can usually flatten down the amount of lift with some firm pressure, as long as the volume you’ve placed isn’t very much.”

He continues, “Of course if that doesn’t make a difference, with HA, you always have the option of dissolution with hyaluronidase.

Whilst this is a reassuring safety-net that Before

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patients find reassuring, it should be remembered that this is an off-licence use of hyaluronidase and shouldn’t be something to rely on. Thankfully, this isn’t something that I have needed to use.”

A thorough understanding of male facial anatomy and injection techniques, combined with a thorough consultation process is vital says Dr Baines, adding, “If expectations aren’t fully met, I would recommend allowing a few days for swelling to settle and tissue integration to occur. Review at a week will usually have seen sufficient improvement to avoid the need to dissolve the HA.” Dr Armand notes that when it comes to the jawline, patients sleeping on their side can cause product redistribution. He advises patients to sleep on their back for three nights, and if they do notice this issue to lightly massage the area to reposition the filler to where it should be as he showed them after treatment. He adds, “Of course I advise them not to massage the area normally and if they notice a significant redistribution or any other problems, the patients are instructed to contact me immediately.” Normal aftercare advice and discussion of potential complications is imperative for all patients, but Dr Shotter notes that facial hair on men is a key difference that should be considered.

She says, “I ask men to refrain from shaving for 48 hours whilst the initial product swelling settles. I otherwise give the same advice – to not touch the face post treatment, to avoid massaging the face for two weeks after treatment, avoid intense exercise for 48 hours, and to avoid intense heat for two weeks. Additionally, no alcohol should be consumed on the night of treatment.” Men tend to follow aftercare advice very strictly, highlights Dr Baines, explaining, “If you give them a list of what they can and can’t do very explicitly, they tend to follow it to the letter, more so than women in my experience. Men like to have clear of list of what to look out for, any red flags, and knowing they can contact you if needed.”

After

Getting started with male treatments For those looking to develop their skills and start treating more men, Dr Armand recommends practising on friends and family, as well as taking male models on any training courses you attend, with an offer of free or consumables only cost treatment. He advises to always take high-quality before and after photographs, requesting permission from the male patient to use in your marketing.

“When describing the treatment alongside your images, I use more description for men than women as they tend to want more detail and extra reassurance that this treatment is suitable for them, as well as women,” he notes. Dr Armand adds that if practitioners have spent a long time solely treating women, they should be wary of their natural aesthetic eye. “It’s inevitable that you will approach the male face in the same way as you do the female face when you first start assessing men,” he says, explaining, “Every practitioner develops their own aesthetic eye when it comes to observing symmetries, corners and curves of the face, and if your eye is used to women’s faces then it is only natural that this will happen. Remember – it needs to be avoided. Take a step back, remind yourself of the differences in facial anatomy and reaffirm your end goal.”

He concludes, “Men will be apprehensive of treatment and may be harder to attract to your clinic, but remember it falls on us as practitioners to provide reassurance that there are indications for them, particularly with the jawline and chin, and we can help them.

There is a huge market for male patients, so we as clinicians should get out of our comfort zone and tell men that we are here for them when they need us.”

To read more on how to effectively market to men, turn to p.55.

REFERENCES 1. Google, Google Trends Jawline <https://trends.google.com/ trends/explore?date=all&q=jawline > 2. Balaji SM, Balaji P, Pyschological Desire of Facial Esthetics in Males, Ann Maxillofac Surg <https://www.ncbi.nlm.nih.gov/ pubmed/31909010> 3. Schmerler J, Your Facial Bone Structure Has a Big Influence on How People See You. Scientific American. June 2015.

4. Torodov A, Baron SG, Oosterhof OO. Evaluating face trustworthiness: a model based approach. Soc Cogn Affect Neurosci. 2008 Jun; 3(2): 119–127.

5. Cetto, R, Male Chin and Jawline Ageing, Aesthetics <https:// aestheticsjournal.com/feature/male-chin-and-jawline-ageing> 6. Russell, B, The face of success: new study reveals how your looks affect your career, Evening Standard <https://www. standard.co.uk/news/uk/the-face-of-success-new-study-revealshow-your-looks-affect-your-career-8465614.html>

Figure 3: Before and after treatment using Restylane Lyft – overview of volumes on previous page.

Images courtesy of Dr Paul Baines and Galderma.

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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Understanding the Efficacy of Mesotherapy Miss Mayoni Gooneratne explores the uses, techniques and considerations for mesotherapy treatments Mesotherapy has multiple aesthetic applications and is a popular treatment in clinic for rejuvenation, hair regrowth and localised fat reduction. However, it is vital that aesthetic practitioners gain a good understanding of both the possibilities and contraindications of the approach. There are many different techniques for administering mesotherapy and even more substances and formulations to choose between for injection. The purpose of this article is to explore mesotherapy and its applications within aesthetics. It will define and explain in depth what the treatment is, how and why it effects changes to the skin, and look at best practice in clinic. It also discusses indications for treatment including ageing skin, excess and/ or unwanted pigmentation, hair loss, acne, acne scarring, and cellulite.

The article will reference recent relevant literature and reports into the efficacy of mesotherapy treatments, while making recommendations for best practice. The article will also acknowledge that, at present, there is little supporting evidence for many of the mesotherapy treatments available.

technique, the nappage technique, the serial technique and the infiltration technique.11 These different techniques allow the practitioner to control the rate of delivery of substances and the time span that they remain in the tissue (Figure 1).6 The entry angle of the needle determines the depth of penetration. The deeper the injection, the more quickly the substance is transported away. Shallower injections mean the substance remains in the skin for longer. It is also possible to use a combination of superficial and deep techniques in the same session and on the same area of the body.11 It should be noted that injections at a depth of 1mm or less with a dose of 0.1ml or more will produce a welt on the skin. This can cause pain and will take a few hours or more to subside fully.11 There are many factors to take into account when choosing injection technique, including the location and condition to be treated, the substances to be injected, the pathology of the area to be treated and of course the condition of the skin.11 Practitioners should take a full medical history from the patient before embarking on mesotherapy – see the section on contraindications below for more details.

What is mesotherapy?

The epidermal technique This penetrates to a depth of 1mm or less.11 It causes no bleeding and can be used across large areas. This ‘dragging’ technique gives doses of just 0.01ml. The use of very fine needles, 27 to 31 gauge,4 means this technique is almost painless, and it is ideal for sensitive areas of the skin such as around the eyes and lips. The droplets of liquid on the surface of the skin are left to be absorbed by the skin.11

Mesotherapy as a technique was first developed in the 1950s to treat pain.1,2 The term ‘mesotherapy’ derives from the Greek word ‘mesos’, which refers to the mesoderm. This is the middle layer of skin during the embryonic stage of human development, between the ectoderm and the endoderm,3 which develops into connective tissue, muscle and the circulatory system.4 Mesotherapy, sometimes also known as intradermal therapy (ID), is the administration of small doses of active substances to this layer, intradermally. French practitioner Dr Michel Pistor was the first to identify different mesotherapy indications and develop treatments.5 He used the approach for the treatment of pain as well as in dentistry, dermatology and antiageing applications. In describing the therapy, he used the phrase, ‘little, rarely and in the right place’.6 It is a minimally-invasive technique; the pharmaceuticals or bioactive substances are delivered to the area of treatment in small doses via multiple intradermal or subcutaneous injections, using very fine needles. Mesotherapy is based on the principle that substances injected into the dermis directly to the target area can get to work quickly, releasing slowly into the surrounding tissue.1 This means they can be administered in smaller doses compared with intramuscular and oral methods.1 Mesotherapy combines the effects of microneedling with the delivery of substances.7 It aims to stimulate the biosynthetic ability of fibroblasts and aid the interaction between cells, increasing the production of elastin and collagen.8

The nappage technique This penetrates to a depth of 1-4mm with injections delivered at an angle of 30-60°.8,11 This is the most commonly used technique by practitioners whereby a series of injections are made at spacings of a few millimetres with a constant pressure maintained. Less than 0.1ml of substance is used per injection.8,11 The serial or point technique This injects to a depth of 2-4mm into the dermoepidermal junction.11 Less than 0.2ml of substance is used per injection at a spacing of 2-10mm, using a point-by-point technique.11 It is important to note that on thin, delicate skin such as the face, injecting to a depth of 4mm could mean the needle reaching blood vessels or even bone.

Therefore, the depth of injection and angle of entry must be adjusted.

Practitioners may pinch the skin and inject into the roll. Any visible bleeding must be compressed immediately, or this can lead to haematomas that can lead to permanent pigmentation.12

Microneedling: the four injection techniques Injections are given either manually or with an injector gun (also known as a mesotherapy gun). The benefits of a gun are more precise doses, more consistent depth and faster injections, meaning more comfort for the patient, as well as the practitioner.4 In either case, the skin should be tightly stretched by the practitioner’s free hand. There are four different injection techniques described in the literature,9,10 and each works at different depths and has different applications: the epidermal

The infiltration technique This is subcutaneous and penetrates to a depth of 4-12mm. For the reasons discussed above, this technique is not suited for thin, delicate skin. However, it is particularly suited to the treatment of excess fat and cellulite (lipolysis). Higher volumes of substances can be delivered, 0.5ml per point, at a spacing of 5-10mm. This technique targets adipose connective tissue.11

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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Mesotherapy formulations There is no standard formula for the substances that are injected during mesotherapy. Many different solutions are used, including vitamins and minerals, enzymes, hormones, prescription medicines (such as vasodilators) and herbal extracts.2 Unfortunately, detailed research into the efficacy of mesotherapy is limited. The papers that have been published are frequently based on small sample sizes, and many do not control for the effects of microneedling in and of itself. Some studies, however, have found mesotherapy to be effective in the treatment of conditions1 including musculoskeletal conditions,13 chronic venous lymphatic insufficiency (CVLI)14 and intradermal vaccination.15 A limited number of studies have also found it to be effective in aesthetic applications,1 including in skin rejuvenation,16 cellulite17 and hair loss.18 Mesotherapy is used in aesthetic clinics to treat a range of indications including sundamaged skin, superficial lines and wrinkles, dry and/or dull skin, excess or uneven pigmentation, male and female pattern hair loss, acne and acne scarring, and cellulite. It can also be used to remove fat from different areas of the body and to tackle cellulite.2

Possible angle of entry

Depth in mm

Skin layers

1 - Epidermis

Epidermis

2 - Superficial corium

Superficial corium

3 - Deep corium

Deep corium

4 - Subcutis

Subcutis

Figure 1: Mesotherapy injection techniques and depth6

Uses (indications) 1mm

Mesolift, mesoglow, mesodrain

2mm

Nappage, salve, cellulite, mesobotox

3mm

Intradermal mesotherapy, cellulite, hair loss, stretch marks

4mm

Mesoperfusion, creating â&#x20AC;&#x2DC;tension column (mesolift), cellulite

5mm to 15mm

Local fat pads, lipolysis

Epidermis

Mesotherapy for different indications As a gentle and minimally-invasive technique, not all patients will require anaesthetic cream, but it can be helpful in sensitive areas such as the forehead, eye area and the mouth.19 Single-use cooling elements such as cool packs should also be available to control reactive swellings.19 Due to the nature of the treatment, the full results will not be immediate, and patients should be made fully aware of this.

Often a course of treatments will be required, with regular top-ups necessary to maintain results for some indications.

Mesotherapy for ageing skin Skin ageing has been attributed to dermal fibroblast dysfunction; biosynthetic activity decreases as we age.20 Fibroblasts are known to play an important role in the health of extracellular connective tissue such as collagen. The principle behind mesotherapy for ageing skin is that microneedling stimulates fibroblasts to produce hyaluronic acid, collagen and elastin,21 and the addition of beneficial substances enhances this effect. The substances used in mesotherapy provide the skin with substrates that are key to fibroblast function.20 In vivo tests have shown that dysfunctional fibroblasts can be activated to produce Type I collagen.22,23 This increase in biosynthetic activity will continue over time as the substances are slowly released, meaning that the full effects of the treatment are not realised until some weeksâ&#x20AC;&#x2122; post-treatment.22 Epidermal nappage and point-by-point injections at 1-2mm for deeper lines are the recommended approach for all areas of the face, neck, dĂŠcolletage and backs of the hands.24 Mesotherapy for excess and/or uneven pigmentation To tackle uneven or unwanted pigmentation, mesotherapy delivers substances directly at the area of interest. A 2015 study tested a solution of hyaluronic acid and an antiageing antioxidant complex with amino acids, vitamins and minerals, and found that there was a clinical and statistically significant improvement of pigmentation.25 Results suggested that the injected substance could intervene at different moments of the skin pigmentation process by activating an intrinsic photoprotective mechanism and improving skin pigmentation quality.25 A separate 2019 study concluded that using vitamin C mesotherapy showed a significant improvement in pigmentation and a higher level of patient satisfaction compared with carboxy therapy and chemical peeling.26

Cutis

Subcutis

Figure 2: Mesotherapy injection uses (indications) and depth6

Mesotherapy for hair loss Mesotherapy has been used for many years to stimulate hair follicles and to boost hair growth. It is not recommended for patients who have been bald for some time, or those with high autoimmune activity, as it is unlikely to be successful.24 The aim of mesotherapy is to increase the anagen phase of hair growth, which around 80% of hairs are in at any given time, stimulating and regenerating the hair roots.24 However, there is little research to prove the efficacy of this approach and more controlled studies are required. There is some evidence to suggest that platelet-rich plasma (PRP) therapy given as mesotherapy leads to a significant increase in hair diameter and density.27 Epidermal nappage is recommended in the hairless areas, using point-by-point technique 2-4mm deep at 1cm intervals.24 Mesotherapy for cellulite When used to treat cellulite, mesotherapy is a form of injection lipolysis. As mentioned above, injections are typically given at deeper depths and therefore higher volumes of substance can be used.24 However, care must be taken here; systemic effects due to absorption are more likely when more than 20ml of substance is used in total.24 Cellulite itself is a gathering of subcutaneous fat, and various drugs have been found to be effective in treating such fat deposits, such as phosphatidylcholine, aminophylline and hyalorunidase.4 A 2017 study found that intradermal mesotherapy reduced the severity of cellulite,28 but this was a small-scale study which also recommended that further research is needed.

Mesotherapy for acne and acne scarring Mesotherapy is not recommended for cases of active acne, due to the presence of bacterial infection in the skin.29 It is also not recommended if the patient is currently taking a course

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of isotretinoin, or has done so in the last 18 months.29 There is very little research specifically relating to using mesotherapy to introduce a meso-product in order to treat acne scarring. However, there is good evidence to suggest that microneedling (the act of creating physical channels) as a technique is effective in improving acne and scarring.30 A literature review found that all patients treated with microneedling achieved some improvement in scar appearance.31 Further research is needed to determine how the introduction of substances via mesotherapy affects the results achieved when tackling acne and scarring.

Contraindications As explored in a publication published by aesthetic practitioner Dr Britta Knoll, absolute contraindications for mesotherapy are: pregnancy or breastfeeding, intolerance of or allergy to any of the substances used, predisposition to hypertrophic scars, or have suffered from keloid scars or scleroderma, epilepsy, acute bacterial or viral infections, severe cardiovascular or metabolic disorders, warfarin or steroid use that would cause excessive bleeding, acute inflammatory skin conditions, autoimmune diseases, and compromised immunity.32 Relative contraindications for mesotherapy are: pigmentation disorders (use of melanin control pre and post treatment needed) and aspirin or clopidogrel use (at practitioner’s discretion with thorough explanation to patient of risks).32

Adverse effects Adverse effects of mesotherapy are generally rare if the procedure is performed by a qualified practitioner and if patients adhere to pre- and post-treatment advice.4 Side effects can be caused either by the injection technique or the substances used. Non-specific common adverse effects include nausea, vomiting, diarrhoea, mild pain, bleeding, skin sensitivity and itching, redness (erythema), oedema, small haematomas, and tender subcutaneous nodules at the injection site.10 The deeper the injection technique, the greater the risk of haematoma.33 Mesotherapy can activate latent herpes infections (including the cold sore virus); this can be prevented with suitable medication.24 Patients must also avoid exposure to sunlight following treatment or uneven pigmentation can occur.24 They should also avoid vigorous exercise and saunas for at least 48 hours following treatment.29 Other problems such as skin and soft tissue infections can occur from poor hygiene in clinic.4 Practitioners should only work with sterile, single-use materials.34

Conclusion At present, there is a dearth of double-blind, peer-reviewed research into the efficacy of mesotherapy. More research is needed into the selection of specific substances and the results they achieve in comparison to microneedling alone. Attention should also be given to the effect of combining different substances. However, there is a growing body of evidence to indicate that the premise behind the technique has promise, albeit only on small scale projects at present. The results seen in-clinic are encouraging, and patient demand is strong.

Miss Mayoni Gooneratne is a graduate of St George’s Hospital and has been a member of the Royal College of Surgeons since 2002. She founded The Clinic by Dr Mayoni in 2016 and is an associate member of BCAM. Miss Gooneratne is a trainer for AestheticSource, OFAA and Cosmetic Courses.

Qualifications: MBBS, BSc, MRCS

REFERENCES 1. M. Mammucari, A Gatti, S Maggiori, C.A. Bartoletti, A.F. Sabato, ‘Mesotherapy, definition, rationale and clinical role: a consensus report from the Italian Society of Mesotherapy’, European Review for Medical and Pharmacological Sciences, 15 (2011) (p1-6) <https://www.europeanreview.org/wp/wp-content/ uploads/963.pdf> 2. What is mesotherapy? (healthonline.com, 2019) <https://www.healthline.com/health/mesotherapy#cost > 3. Science Direct, Mesoderm <https://www.sciencedirect.com/topics/neuroscience/mesoderm> 4. G. Sivagnanam, ‘Mesotherapy – the French connection’, Journal of Pharmacology & Pharmacotherapeutics, Volume 1 (2010) (p1) <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3142757/> 5. Author unknown, Mesotherapy: History and Presentation (Chanac, France: MI Medical Innovation) (p.1) <https://mi-medicalinnovation.com/en/content/17-mesotherapy> 6. Britta Knoll, Illustrated Atlas of Esthetic Mesotherapy (London: Quintessence Publishing, 2012), p.8 7. El-Domyati M, Abdel-Wahab H, Hossam A, ‘Combining microneedling with other minimally invasive procedures for facial rejuvenation: a split-face comparative study’, International Journal of Dermatology, Volume 57 (2018) (p1) <https://www.ncbi.nlm.nih.gov/pubmed/30105816> 8. El-Domyati M, Tarek S. El-Ammawi et al, ‘Efficacy of mesotherapy in facial rejuvenation: a histological and immunohistochemical evaluation’, International Journal of Dermatology, Volume 51 (2012) (p1) <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3513770/#> 9. Mesotherapy injection techniques (mesotherapyworldwide.com, 2006) <http://www. mesotherapyworldwide.com/images/pdf/MWInjectionTechniques.pdf> 10. Britta Knoll, Illustrated Atlas of Esthetic Mesotherapy (London: Quintessence Publishing, 2012), p36-38.

11. Britta Knoll, Illustrated Atlas of Esthetic Mesotherapy (London: Quintessence Publishing, 2012), p44-50 12. Paasc U, ‘Illustrated Guide to Injectable Fillers’ Chapter 1: The Skin, KVM- Der Medizinverlag, (p104). <https://www.kvm-medizinverlag.de/out/media/Illustrated_Guide_to_Injectable_Fillers.pdf> 13. Ferrara, Paola E et al, ‘Efficacy of mesotherapy using drugs versus normal saline solution in chronic spinal pain’, International Journal of Rehabilitation Research, Volume 40 (2017) (p1). <https://journals. lww.com/intjrehabilres/Abstract/2017/06000/Efficacy_of_mesotherapy_using_drugs_versus_ normal.12.aspx> 14. Maggiori, Enrica et al. ‘Intradermal Therapy (Mesotherapy) with Lymdiaral in Chronic Venous Insufficiency and Associated Fibrosclerotic Edema Damage: A Pilot Study’, Journal of alternative and complementary medicine,Volume 19 (2013) <https://www.researchgate.net/publication/236456675_ Intradermal_Therapy_Mesotherapy_with_Lymdiaral_in_Chronic_Venous_Insufficiency_and_ Associated_Fibrosclerotic_Edema_Damage_A_Pilot_Study> 15. Mammucari, Maggiori et al, ‘Should the General Practitioner Consider Mesotherapy (Intradermal Therapy) to Manage Localized Pain?’, Journal of Pain and Therapy, Volume 5 (2016) (p1) <https://link. springer.com/article/10.1007/s40122-016-0052-3> 16. Baspeyras, Rouvrais et al, ‘Clinical and biometrological efficacy of a hyaluronic acid-based mesotherapy product: a randomised controlled study’, Archives of Dermatological research, Volume 305 (2013) <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3778226/> 17. Sylwia & Krzysztof, ‘Efficacy of intradermal mesotherapy in cellulite reduction – Conventional and highfrequency ultrasound monitoring results’, Journal of Cosmetic and Laser Therapy’ Volume 19 (2017) <https://www.tandfonline.com/doi/abs/10.1080/14764172.2017.1334927?journalCode=ijcl20> 18. Hunter, Sayed, Hay et al, ‘Comparing the Efficacy of Mesotherapy to Topical Minoxidil in the Treatment of Female Pattern Hair Loss Using Ultrasound Biomicroscopy: A Randomized Controlled Trial’, Acta Dermatovenerologica Croatica, Volume 27 (2019) <https://www.ncbi.nlm.nih.gov/pubmed/31032783> 19. Britta Knoll, Illustrated Atlas of Esthetic Mesotherapy (London: Quintessence Publishing, 2012), p66 20. Prikhnenko S, Dalens M, ‘Polycomponent mesotherapy formulations for the treatment of skin aging and improvement of skin quality’, Clinical, Cosmetic and Investigational Dermatology, Volume 8 (2015) <https://www.dovepress.com/polycomponent-mesotherapy-formulations-for-the-treatment-of-skinaging-peer-reviewed-fulltext-article-CCID#> 21. Singh A, Yadav S, ‘Microneedling: Advances and widening horizons’, Indian Dermatology Online Journal, Volume 7 (2016) <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4976400/> 22. Quan T, Wang F et al, ‘Enhancing structural support of the dermal microenvironment activates fibroblasts, endothelial cells and keratinocytes in aged human skin in vivo’, Journal of Investigative Dermatology, Volume 133 (2013) <https://www.jidonline.org/article/S0022-202X(15)36135-2/fulltext> 23. Deglesne P et al, ‘In vitro study of RRS HA injectable mesotherapy/biorevitalization product on human skin fibroblasts and its clinical utilization’, Clinical, Cosmetic and Investigational Dermatology, Volume 9 (2016) <https://www.dovepress.com/in-vitro-study-of-rrs-ha-injectable-mesotherapybiorevitalizationprodu-peer-reviewed-article-CCID> 24. Britta Knoll, Illustrated Atlas of Esthetic Mesotherapy (London: Quintessence Publishing, 2012), p80102.

25. Sparavigna A, Tenconi B, De Ponti I, ‘Antiaging, photoprotective, and brightening activity in biorevitalisation: a new solution for aging skin’, Clinical, Cosmetic and Investigational Dermatology, Volume 8 (2015) <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4330006/> 26. Ahmed NA, Mohammed S, Fatani MI, ‘Treatment of periorbital dark circles: comparative study of carboxy therapy vs chemical peeling vs mesotherapy’, Journal of Cosmetic Dermatology, Volume 18 (2019) <https://www.ncbi.nlm.nih.gov/pubmed/29767467> 27. Garg S, Manchanda S, ‘Platelet-rich plasma – an ‘Elixir’ for treatment of alopecia: personal experience on 117 patients with review of literature’, SCI Stem Cell Investigation, Volume 4 (2017) <https://www.ncbi. nlm.nih.gov/pmc/articles/PMC5539389/> 28. Sylwia M and Krzysztof MR, ‘Efficacy of intradermal mesotherapy in cellulite reduction – Conventional and high-frequency ultrasound monitoring results’, Journal of Cosmetic Laser Therapy, Volume 6 (2017) <https://www.ncbi.nlm.nih.gov/pubmed/28590783> 29. Save Face Mesotherapy Fact Sheet, <https://www.saveface.co.uk/treatments/anti-ageing-treatments/ mesotherapy/> 30. Iriarte C et al, ‘Review of applications of microneedling in dermatology’, Clinical, Cosmetic and Investigational Dermatology, Volume 10 (2017) <https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC5556180/> 31. Kravvas G and Al-Niaimi F, ‘A systematic review of treatments for acne scarring. Part 1: Non-energybased techniques’, Scars, Burns and Healing, Volume 3 (2017) <https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC5965325/> 32. Britta Knoll, Illustrated Atlas of Esthetic Mesotherapy (London: Quintessence Publishing, 2012), p26.

33. M King, ‘The Management of Bruising following Nonsurgical Cosmetic Treatment’, The Journal of Clinical and Aesthetic Dermatology, Volume 10 (2017) pg. 1-5 <https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC5367875/> 34. Mammucari, Massimo, Vellucci, et al, ‘What is mesotherapy? Recommendations from an international consensus’, Trends in Medicine (2014) <https://www.researchgate.net/publication/267267177_What_is_ mesotherapy_Recommendations_from_an_international_consensus/citation/download>

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Finally, while generalisations about gender are useful, the process of identifying treatment goals should always focus on the individual patient, asking what their reasons are for seeking treatment, checking their mental wellbeing, and guiding expectations.

Note that it cannot be assumed that a man does not want to aim for a more flawless look or more feminised features, which will be identified in a thorough consultation.

Assessing the male face

Treating Men with Toxin Dr Ahmed El Houssieny explores the use of botulinum toxin in male facial treatments and asks, what do we know about best practice?

Botulinum toxin A (BoNT-A) is the most commonly used non-surgical aesthetic treatment in men.1 It is licensed for treatment of glabellar lines, forehead lines and lateral canthal lines (crow’s feet), but is also used off-licence in the treatment of other facial areas based on a broad consensus.2,3 Men account for around 10% of BoNT-A treatment, but its use is becoming increasingly popular with this demographic, rising 381% in the US between 2000 and 2018.1 Given this context, it is important for practitioners to be aware of key differences between men and women in their attitudes towards treatment, facial anatomy and musculature, and dosage when planning and administering a course of BoNT-A treatment.

The male perception of treatment and treatment goals At the initial consultation with a male patient, the practitioner should take a general medical history and any other relevant medical history, such as anticoagulant use or recent facial surgery as they would with any patient. When establishing the individual’s treatment goals, however, it is important to take into account that men may be less familiar with BoNT-A treatment than women. Despite the rise in numbers, fewer men undergo facial aesthetic treatments. Like treating females, to support the patient in identifying their treatment goals, the practitioner should take time prior to treatment to explain fully the procedure of neurotoxin administration, including the mechanism of action of BoNT-A, risks and benefits, and what the patient might expect in their individual case. Remember to explain everything fully and clearly; in my experience, unlike academic environments for example, where men feel more at ease and ask more questions than women, in the aesthetic medicine clinic men may be less likely than women to ask questions if they do not understand.4,5 It is important to understand that men have different reasons for undertaking cosmetic treatment to women. Men often want to address signs of a ‘tired’ face and tend to opt for more subtle rejuvenation than many women.6,7 A survey carried out by the American Academy of Facial Plastic and Reconstructive Surgery found that men cite ‘competitiveness’ and ‘workplace concerns’ as motivating factors in seeking cosmetic treatment.8 In most circumstances, aesthetic practitioners should work to ensure that men retain their masculinity without appearing to have undergone a cosmetic procedure; this can be done by ensuring that the features are not softened to the extent that is seen to be too feminising.9 These preferences point towards subtle rejuvenation that ensures men do not look fatigued or are judged to be too old to have lost any competitive edge, while still being happy to retain some signs of age and experience.

Anatomic characterisation of the male face Differences between male and female skeletal, muscular, vascular and cutaneous structures need to be accounted for when assessing the patient prior to the procedure and making a treatment plan.10 In terms of bone structure, men have a larger cranium and more prominent supraorbital ridges than women. This dictates the position of eyebrows: male eyebrows are flatter and positioned lower on the supraorbital ridge than female brows.10 Men have greater glabellar projection and a larger, wider forehead that slopes back to the hairline, which itself can recede with age, making the forehead larger.10 The lower face in men is characterised by a larger and wider chin than in women, with forward prominence11 and more prominent flexure of the mandibular ramus.12 Men have thicker skin than women and a greater density of facial blood vessels.13 The latter may be due, in part, to the presence of arteries that support facial hair in the male.14 Men also have significantly more skeletal muscle mass compared to women.10 The muscles of the glabellar complex, for example, have greater mass and strength in men but there is a great deal of individual variation.15 The greater facial muscle movement that men exercise may account for the deeper facial wrinkles that they are reported to develop.16,17 There are some exceptions to this; no difference was noted between 173 Japanese men and women in terms of upper eyelid wrinkles and in the perioral area, a cadaver study (females n=15, males n=15) found that white females typically display deeper wrinkles than white males.17,18 Over the age of 65 years, gender differences in wrinkle number and severity become less marked and women may have wrinkles of equal or greater intensity than men.17,19 Wrinkle patterns are also gender dependent; men are more likely to have a ‘V’ glabella wrinkle pattern because of a larger procerus muscle and to have a lower, rather than central or full, fan shape for lateral canthal lines.20,21

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Carrying out assessment As there is much individual as well as gender variation in facial anatomy, it is important to make a careful assessment and adjust dose and injection technique accordingly. It is imperative to assess the patientâ&#x20AC;&#x2122;s facial muscles at rest, as well as observing movements during a range of facial expressions and by palpation, looking for areas of stronger contraction, larger dynamic movement, and deeper lines. Some practitioners find assessment tools useful in supporting this process. Given the greater muscle mass in males, the Medicis Glabellar Muscle Mass Scale, for example, is a useful validated tool for the assessment of muscle mass in the glabellar region. It uses a range of measurements including the depth of wrinkles and brow depression at full contraction and change in the interbrow space from relaxation to contraction in order to guide dosage selection in BoNT-A treatments.15 A consensus paper on treating the forehead with BoNT-A (focusing on incobotulinum toxin A) sets out recommendations that include separate treatment protocols for men and women and describes a dynamic assessment method of the frontalis muscles based on sub divisions of muscle movement as kinetic, hypertonic and hyperkinetic.22

Evidence for BoNT-A use in the male face The efficacy and safety of neurotoxins have been shown in numerous clinical studies of glabellar, forehead and lateral canthal lines that include both female and male participants.14,15,23-26 However, studies with only male participants or with large numbers of men are few in number.27,28 Many studies include only small numbers of men and gender-specific data are not analysed to establish differences in treatment response between men and women.14 This raises the question of the extent to which the findings of many BoNT-A studies are applicable to males. One response to this question may be found in a 2019 analysis of demographics of men and minorities in clinical studies of non-surgical cosmetic procedure.29 The study examined 19 BoNT-A randomised controlled trials and found that numbers of men included in clinical trials reflects real-world demographics in terms of the proportion of men to women undergoing these procedures.29 However, further studies which focus on males or with sub-analysis of males would, in my opinion, be of great value in yielding further insights into optimising treatment with neurotoxins. While there

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Men have greater glabellar projection and a larger, wider forehead that slopes back to the hairline, which itself can recede with age, making the forehead larger is some published evidence for differences in male and female treatment response in the glabellar, there are no studies or subgroup analyses yet on gender differences for forehead lines or lateral canthus lines.14 BoNT-A dose in glabellar treatment Published evidence on response to BoNT-A in men in treatment of the glabellar complex consists of one study with male-only participants28 and two with subgroup analyses of gender differences.23,27 All three of these studies have shown that larger doses of both abobotulinum and onabotulinum are required in males compared with females for effective treatment of glabellar lines.23,27,28 The 2005 study of onabotulinum toxin A for treatment of glabellar rhytids (n=80) with only male participants concluded that a dose of around twice the 20U recommended dose for women was required for effective treatment in men.28 In the sub-group analysis from a 2009 phase 3 study of abobotulinum toxin A for the treatment of glabellar lines, women (n=135) were more likely to respond (investigator and subject assessments, 93% and 83%, respectively) than men (n=23; 67% and 33%, respectively) to a single 50U injection, suggesting men need an abobotulinum toxin A dose >50U.23 In the second study to offer a

Figure 1: Injection pattern for men vs women10,20

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sub-group analysis on the efficacy of abobotulinum toxin A in males, doses of 60, 70 and 80U were found to be effective and long-lasting in men.27 It is important to note that no difference between males and females was observed in treatment-emergent adverse events in these studies,23,27 nor did the incidence of adverse effects increase with dose.27,28 No increased risk of bruising was reported in male study participants, despite the greater vascularity of the male face.27,28 This may be due to treatment of the upper face, avoiding blood vessels which are associated with terminal hairs in the lower face.14 The dose recommendations provided by such studies offer useful parameters on dose when treating the glabellar complex, however a practitioner must make their own decision based on assessment of the individual patient. There is an absence of published data on optimal dose for males in treatment of the lateral canthi and frontalis, but we can refer to common practice which has suggested an increase of 10% to 25% above the standard dose for women.10 Some consensus papers also offer dose recommendations which take gender into consideration.22,30 It should be remembered that abobotulinum toxin A units are not interchangeable with those of onabotulinum toxin A or incobotulinum toxin A and must be converted appropriately.31

Considerations for successful treatment Choice of injection points, as well as awareness of interaction between muscles, is crucial to obtaining the subtle improvements that men often seek. The brows are an area of the male face that particularly require a balanced approach. The male brow is flatter in shape than the female brow and if elevated into an arch by injection of toxin, this tends to feminise the face.10 Based on advice from the literature, when injecting the frontalis, injections should be administered in rows, including the lateral aspect of the frontalis in order to avoid lateral frontalis contraction causing arching of the brows.8,22,32 When treating the glabellar, the practitioner should be aware of the interaction between the frontalis, procerus, corrugators, and orbicularis oculi and, for this reason, should consider placing 2U ona/incobotulinum or 5U abobotulinum in the lateral frontalis above the brow, using an injection pattern of seven, as opposed to the usual five points when treating the glabellar area in order to minimise the risk of raised brows in men (Figure 1).10,20 A further male facial characteristic to be aware of in the upper face is that, when treating lateral canthal lines, more than one injection point along the inferior part of the vertical fibres of the orbicularis oculi muscle may be required. This is due to the fact that the majority of men will have a downward fan pattern of wrinkles.10,21 I recommend a follow-up visit when treating men and stress its importance, based on the fact that according to one study, men are less likely than women to return if the procedure requires some adjustment.10

Conclusion Male attitudes towards non-surgical aesthetic treatment continue to develop and change but it seems likely that we will see continued growth in this patient population. While our knowledge and experience of treating the male face with BoNT-A treatment has grown, the need for further evidence to support dosing and treatment response remains. As practitioners, we need to take gender-specific differences into account both in terms of treatment aims and anatomic differences. However, while accommodating an awareness of general principles, it is the formulation of an individualised treatment plan that will govern the choice of dose and injection site, and ensure outcomes that meet the expectations of our male patients.

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

Qual: MBBCH REFERENCES 1. American Society of Plastic Surgeons. 2018 Plastic Surgery Statistics Report. ASPS. 2018. <https:// www.plasticsurgery.org/documents/News/Statistics/2018/plastic-surgery-statistics-full-report-2018.pdf> 2. Charlson P. Facial rejuvenation: Off licence applications for botulinum toxin. MIMS. 30 April 2015. <https://www.mims.co.uk/article/1339024/facial-rejuvenation-off-licence-applications-botulinum-toxin Accessed 270220> 3. Schlessinger J, Gilbert E, Coehn JL, Kaufman J. New uses of abobotulinumtoxinA in aesthetics.

Aesthet Surg J 2017;37(suppl_1):S45–S58.

4. Hinsley A, Sutherland WJ, Johnston A. Men ask more questions than women at a scientific conference. PLoS ONE 2017;12(10): e0185534.

5. Carter AJ, Croft A, Lukas D, Sandstrom GM. Women’s visibility in academic seminars: Women ask fewer questions than men. PLoS ONE 2018;13(9): e0202743.

6. Jagdeo J, Keaney T, Narurkar V et al. Facial treatment preferences among aesthetically oriented men. Dermatol Surg 2016 Oct;42(10):1155–1163.

7. Scherer MA. Specific aspects of a combined approach to male face correction: botulinum toxin A and volumetric fillers. J Cosmet Dermatol 2016;15:566–574.

8. Jones IT, Fabi SG. The use of neurotoxins in the male face. Dermatol Clin 2018;36:29–42.

9. Scheuer JF, Matarasso A, Rohrich RJ. Optimizing male periorbital rejuvenation. Dermatol Surg 2017;43:S196–S202.

10. Green JB, Keaney TC. Aesthetic treatment with botulinum toxin: approaches specific to men.

Dermatol Surg 2017;43:S153–S156.

11. Thayer ZM, Dobson SD. Sexual dimorphism in chin shape: implications for adaptive hypotheses. Am J Phys Anthropol 2010:143;417–425.

12. Donnelly S, Hens SM, Rogers NL, Schneider KL. A blind test of mandibular ramus flexure as a morphological indicator of sexual dimorphism in the human skeleton. Am J Phys Anthropol 1998;107:363–366.

13. Mayrovitz HN, Regan MB. Gender differences in facial skin blood perfusion during basal and heated conditions determined by laser Doppler flowmetry. Microvasc Res 1993;45:211–218.

14. Keaney TC, Alster TS. Botulinum toxin in men: review of relevant anatomy and clinical trial data.

Dermatol Surg 2013;39(10):1434–1443.

15. Monheit G, Lin X, Nelson D, Kane M. Consideration of muscle mass in glabellar line treatment with Botulinum Toxin Type A. J Drugs Dermatol 2012;11(9):1041–1045.

16. Weeden JC, Trotman CA, Faraway JJ. Three dimensional analysis of facial movement in normal adults: influence of sex and facial shape. Angle Orthod 2001;71:132–140.

17. Tsukahara K, Hotta M, Osanai O et al. Gender-dependent differences in degree of facial wrinkles.

Skin Res Technol 2013 Feb;19(1):e65–71.

18. Paes EC, Teepen HJ, Koop WA, Kon M. Perioral wrinkles: Histologic differences between men and women. Aesthet Surg J 2009;29(6):467–472.

19. Hamer MA, Pardo LM, Jacobs LC, et al. Lifestyle and physiological factors associated with facial wrinkling in men and women. J Investigat Dermatol 2017;137(8):1692–1699.

20. De Almeida AR, da Costa Marques ER, Banegas R, Kadunc BV. Glabellar contraction patterns: A tool to optimize botulinum toxin treatment. Dermatol Surg. 2012;38:1506–1515.

21. Kane MAC, Cox SE, Jones D, Lei X, Gallagher CJ. Heterogeneity of crow’s feet lines patterns in clinical trial subjects. Dermatol Surg 2015;41:447–456.

22. Anido J, Arenas D, Arruabarena C et al. Tailored botulinum toxin type A injections in aesthetic medicine: consensus panel recommendations for treating the forehead based on individual facial anatomy and muscle tone. Clin, Cosmet, Investig Dermatol 2017;10:413–421. <https://www.dovepress. com/tailored-botulinum-toxin-type-a-injections-in-aesthetic-medicine-conse-peer-reviewed-fulltextarticle-CCID> 23. Brandt F, Swanson N, Baumann L, Huber B. Randomized placebo-controlled study of a new botulinum toxin type A for treatment of glabellar lines: efficacy and safety. Dermatol Surg 2009;35:1893-1901.

24. Carruthers A, Bruce S, de Coninck A, et al. Efficacy and safety of onabotulinumtoxin A for the treatment of crows feet lines. Dermatol Surg 2014;40(11):1181–1190.

25. Solish N, Rivers JK, Humphrey S, Muhn C, et al. Efficacy and safety of onabotulinumtoxinA treatment of forehead lines. Dermatol Surg 2016; 42:410–419.

26. Wu Y, Zhao G, Li H, Zheng Z, et al. Botulinum toxin type A for the treatment of glabellar lines in Chinese: a double-blind, randomized, placebo-controlled study. Dermatol Surg 2010;36:102–108.

27. Kane MAC, Brandt F, Rohrich RJ et al. Evaluation of variable-dose treatment with a new U.S. botulinum toxin type A (Dysport) for correction of moderate to severe glabellar lines: results from a phase III, randomized, double-blind, placebo-controlled study. Plast Reconstr Surg 2009;124:1619–1629.

28. Carruthers A, Carruthers J. Prospective, double-blind, randomized, parallel-group, dose-ranging study of botulinum toxin type A in men with glabellar rhytids. Dermatol Surg 2005;31:1297–1303.

29. Roman J, Zampella JG. Demographics of men and minorities in cosmetic clinical trials of botulinum toxin and hyaluronic acid fillers. Dermatol Surg. 2019 Dec 11.

30. Carruthers J, Fournier N, Kerscher M, et al. The convergence of medicine and neurotoxins: a focus on botulinum toxin type A and its application in aesthetic medicine—a global, evidence-based botulinum toxin consensus education initiative. Part II: Incorporating Botulinum Toxin into Aesthetic Clinical Practice. Dermatol Surg 2013;39:510–525.

31. Yutskovskaya Y, Gubanova E, Khrustaleva I, et al. IncobotulinumtoxinA in aesthetics: Russian multidisciplinary expert consensus recommendations. Clin Cosmet Investig Dermatol 2015;8:297– 306.

32. Medicines.org.uk. Summary of Product Characteristics. BOTOX 100 units powder for solution for injection. Allergan. March 2020. <https://www.medicines.org.uk/emc/product/859/smpc>

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Using Pulsed-dye Laser for Non-vascular Indications

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Scars

Scars have a multitude of causes, including: burns, acne, trauma and surgery, and are a very common reason for dermatological consultation. The PDL can be used either early on during the proliferative phase of wounding (typically within three months Consultant dermatologist Dr Firas Al-Niaimi of surgery/trauma), where it has predominantly modulatory effects on the angiogenesis, or at outlines the various uses of pulsed-dye lasers any point of a mature scar where its effects are Lasers are fast becoming the vogue of dermatology; ranging from predominantly a wound-healing pattern that leads ultimately to ablative, non-ablative, fractional photothermolysis to vascular. collagen destruction.10-12 Numerous studies have shown the efficacy Then there are a number of vascular lasers available, including of PDL in scars either alone or in combination with other fractional potassium titanyl phosphate (KTP 532 nm), pulsed-dye laser lasers (both ablative and non-ablative).13-15 (PDL 95 nm), diode (810 nm) and Nd:YAG (1064 nm). Pulse-dye lasers One study assessed the value of early laser intervention by using (PDL) emit light from a rhodamine dye solution and were initially PDL to treat surgical scars commencing on the day of suture introduced in the 1980s for vascular malformations. Now PDL lasers removal, three weeks following the operation. The research involved represent the gold standard vascular laser, with a wealth of evidence a split-scar study and demonstrated a 44% benefit in Vancouver Scar to support their use.1 The 595 nm wavelength of PDL lasers targets Scale score with PDL as opposed to without it, indicating the benefit oxyhaemoglobin found in blood vessels. The main modes of actions of early PDL intervention for scars.16 are photothermal, including coagulation of the blood and endothelial damage, in conjunction with photochemical effects. Typical Striae vascular lesions which are treated by PDL include port wine stain, Striae, also known as stretch marks, are a common presenting haemangioma, telangiectasia, spider angioma and rosacea.1 This complaint and can either be striae rubra or alba. Striae rubra progress article focuses on the use of PDL beyond vascular malformations, to striae alba and both are often refractory to treatment.17 Striae which include acne vulgaris, scars, striae, warts, molluscum, psoriasis, rubra present as linear red plaques that evolve into linear atrophic rejuvenation, and miscellaneous dermatological indications. I have white plaques. I have previously published a literature review on had significant personal experience in the use of PDL in most of the treatment options available for striae distensae, systematically the discussed indications. The effects are either due to targeting the appraising the evidence of energy-based treatment for striae available vascular component of a condition, or through photochemical effects; to date. The results showed that striae alba are more difficult to treat simply explained as biological changes that occur in the skin as a that striae rubra and side effects of all types of laser treatment, such result of the photonic light and tissue interaction. These photochemical as post-inflammatory hyperpigmentation, were more common in changes can result in up or down-regulation of certain pathways or a higher Fitzpatrick skin types.17 In a study of 20 patients, PDL has been 2 change in a biological composition and behaviour of the disease. The shown to effectively reduce the erythema in striae rubra, as well as list of conditions which the PDL can treat is growing with more articles influencing an increase in collagen-1 expression.18 being published regularly.

Warts Acne vulgaris Acne vulgaris is one of the most common skin ailments in adolescents, with a prevalence nearing 90%.3 The mechanism of acne is well-known to be a multifactorial process and its physical and psychological sequelae have a huge impact on quality of life. Although conventional treatment is known to be beneficial in most patients, there are always recalcitrant cases or patients who cannot tolerate traditional antibiotics or isotretinoin due to their side effects. PDLâ&#x20AC;&#x2122;s mechanism of treatment in acne is by killing Cutibacterium acnes (one of the known contributory mechanisms) by inducing oxidative stress secondary to the protoporphyrin production by the bacteria, which absorbs the incoming light,4 in addition to photothermal effects on the sebaceous glands and microvasculature which lead to a reduction in the inflammation as well as seborrhoea; two key mechanisms involved in the pathogenesis.5 PDL alone and in combination with topical therapy has been demonstrated to be beneficial.6.7 Seaton et al. found that PDL versus placebo in 41 patients with inflammatory acne demonstrated a significantly better improvement in acne severity in the treatment arm versus the placebo arm at 12-week follow-up.8 Interestingly, there is no conclusive evidence regarding the exact parameters in acne; various parameters have been used with overall good improvement.9

Warts are common and present as papillomatous or hyperkeratotic papules. There is ample evidence to support the use of PDL in warts either alone or in combination with salicylic acid or cryotherapy.19 PDL is efficacious in warts and its mechanism is related partly to coagulation or destruction of the papillary vessels and partly as a thermal effect, leading to clefting of the dermo-epidermal junction in association with a localised inflammatory reaction.20 The number of sessions depends on the thickness and anatomical location of the wart, with the soles of the feet being the slowest to respond, with more sessions required.21 In general, the fluences used are high, in conjunction with a short purpuric pulse duration and no cooling. I have previously published a review paper on the evidence of PDL in warts. In my experience the PDL has a very high success rate if used properly with the correct settings and the required number of treatments. Combination treatment with salicylic acid often yields better results.22

Molluscum contagiosum Molluscum contagiosum is a common infectious dermatosis that typically affects children or those who are immunocompromised. I have again previously published a paper systematically reviewing all treatment options available to date. Included in this review are six studies from other authors on the efficacy of PDL in molluscum, demonstrating it is an efficacious and safe laser therapy, with

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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minimal treatments required.23 A study involving 1,250 lesions treated with PDL found that all treated lesions resolved and over a third of patients had no new lesions after just two treatments.24 The exact mechanism of action is unknown and is likely to be immunomodulatory.23,24

Psoriasis Psoriasis is a relatively common inflammatory skin disorder that has been successfully treated with PDL in numerous studies. Different research with assessment in both clinical and laboratory data showed a favourable response with the use of PDL, including when compared to established psoriasis treatments such as vitamin D analogues and phototherapy.

These studies included plaque psoriasis affecting the skin, as well as nail psoriasis which is an entity of psoriasis affecting the nail matrix and plate.25-27 The mechanism is largely immunomodulatory, with changes to the T-cell reactivity, as well as capillary vessels, and an alternation in specific inflammatory markers typically elevated in psoriasis such as E-selectin and substance P.28 There is no uniformity on parameters, with both purpuric and non-purpuric parameters proven effective.29

Cutaneous lupus Lupus is an autoimmune connective tissue disease which can present cutaneously as a butterfly rash on the face or as erythematous plaques and eruptions on photosensitive sites. A variant exists, which is often confined to the skin only and is called discoid lupus. Treatment depends on the subtype, and again can be refractory to conventional treatment of topical steroids or systemics such as hydroxychloroquine.30 Several studies have shown PDL to be effective both as an adjuvant therapy31 and monotherapy32,33 in cutaneous lupus. All the studies indicate that the inflammatory markers decrease post PDL, with clearance of the inflammatory aggregates typically seen histologically in cutaneous lupus.31-33

Miscellaneous PDL has also been successfully used in a number of other – less common – dermatological conditions such as angiolymphoid hyperplasia with eosinophilia,34 morphea,35 granuloma faciale,36 and cutaneous sarcoid.37 In most of these cases the series were small and consisted mainly of case reports or series with heterogeneity in terms of parameters used.

Conclusion Although a primarily vascular laser, the PDL has been used successfully in various non-primary vascular conditions in dermatology. The effects are, in part, due to the treatment of the underlying vascular component, as well as in part due to a photochemical effect; although the exact mechanism in some cases is unknown. I use the PDL regularly in many of the conditions discussed in this article and advances in this field are ongoing. It should be noted that only suitably-qualified practitioners should use PDL, especially when managing treatments they are not familiar with.

Dr Firas Al-Niaimi is a consultant dermatologist, Mohs and laser surgeon. Dr Al-Niaimi has written for more than 160 publications, 10 book chapters and his own book on preparation for dermatology specialist examination. He is also a senior research fellow in the dermatology and laser department at Aalborg University, Denmark, and is involved in clinical and translational research in the field of lasers.

Qual: MD, MSc, MRCP, EBDV REFERENCES 1. Galekas KJ. Update on lasers and light devices for the treatment of vascular lesions. Semin Cutan Med Surg 2008;27(4):276-84.

2. Erceg A, de Jong EM, van de Kerkhof PC, Seyger MM. The efficacy of pulsed dye laser treatment for inflammatory skin diseases: a systematic review. J Am Acad Dermatol. 2013;69(4):609-615.

3. Ali FR, Al-Niaimi F. Acne vulgaris. Br J Hosp Med (Lond.). 2013;74(5):C78-80.

4. Momen S. Al-Niaimi F. Acne vulgaris and light-based therapies. J Cosmet Laser Ther 2015;17(3):122 5. Nouri K, Ballard CJ. Laser therapy for acne. Clin Dermatol. 2006 Feb;24(1):26–32.

6. Yoon HJ, Lee DH, Kim SO, et al. Acne erythema improvement by long-pulsed 595-nm pulsed-dye laser treatment: a pilot study. J Dermatol Treat. 2008;19(1):38–44.

7. Alexiades-Armenakas M. Long-pulsed dye laser-mediated photodynamic therapy combined with topical therapy for mild to severe comedonal, inflammatory, or cystic acne. J Drugs Dermatol JDD. 2006;5(1):45–55.

8. Seaton ED, Charakida A, Mouser PE, et al. Pulsed-dye laser treatment for inflammatory acne vulgaris: randomized controlled trial. Lancet 2003 Oct 25;362(9393):1347–52.

9. Voravutinon N, Rojanamatin J, Sadhwani D, et al. A Comparative Split-Face Study Using Different Mild Purpuric and Subpurpuric Fluence Level of 595-nm Pulsed-Dye Laser for Treatment of Moderate to Severe Acne Vulgaris. Dermatol Surg 2016;42(3):403–9.

10. Forbat E, Ali FR, Al-Niaimi F. Treatment of keloid scars using light-, laser- and energy-based devices: a contemporary review of the literature. Lasers Med Sci. 2017; 32(9):2145-2154.

11. Kono T, Erçöçen AR, Nakazawa H, et al. The flashlamp-pumped pulsed dye laser (585 nm) treatment of hypertrophic scars in Asians. Ann Plast Surg. 2003;51(4):366–71.

12. Tierney E, Mahmoud BH, Srivastava D, et al. Treatment of Surgical Scars with Nonablative Fractional Laser Versus Pulsed Dye Laser: A Randomized Controlled Trial. Dermatol Surg. 2009;35(8):1172–80.

13. Park KY, Hyun MY, Moon NJ, et al. Combined treatment with 595-nm pulsed dye laser and 1550-nm erbium-glass fractional laser for traumatic scars. J Cosmet Laser Ther 2016;18(7):387–8.

14. Ouyang H-W, Li G-F, Lei Y, et al. Comparison of the effectiveness of pulsed dye laser vs pulsed dye laser combined with ultrapulse fractional CO2 laser in the treatment of immature red hypertrophic scars. J Cosmet Dermatol. 2018;17(1):54–60.

15. Kim DH, Ryu HJ, Choi JE, et al. A comparison of the scar prevention effect between carbon dioxide fractional laser and pulsed dye laser in surgical scars. Dermatol Surg 2014;40(9):973–8.

16. Nouri K, Jimenez GP, Harrison-Balestra C, Elgart GW. 585-nm Pulsed Dye Laser in the Treatment of Surgical Scars Starting on the Suture Removal Day. Dermatol Surg. 2003 Jan 1;29(1):65–73.

17. Forbat E, Al-Niaimi F. Treatment of striae distensae: An evidence-based approach. J Cosmet Laser Ther. 2018;1–9.

18. Shokeir H, El Bedewi A, Sayed S, Khalafawy G. Efficacy of pulsed dye laser versus intense pulsed light in the treatment of striae distensae. Dermatol Surg 2014;40(6):632-40.

19. Akarsu S, Ilknur T, Demirtasoglu M, Ozkan S. Verruca vulgaris: pulsed dye laser therapy compared with salicylic acid + pulsed dye laser therapy. J Eur Acad Dermatol Venereol. 2006;20(8):936-40.

20. Kenton-Smith J, Tan ST. Pulsed dye laser therapy for viral warts. Br J Plast Surg 1999;52(7):554-8.

21. Nguyen J, Korta DZ, Chapman LW, Kelly KM. Laser Treatment of Nongenital Verrucae: A Systematic Review. JAMA Dermatol. 2016;152(9):1025-34.

22. Veitch D, Kravvas G, Al-Niaimi F. Pulsed Dye Laser Therapy in the Treatment of Warts: A Review of the Literature. Dermatol Surg 2017;43(4):485–93.

23. Forbat E, Al-Niaimi F, Ali FR. Molluscum Contagiosum: Review and Update on Management. Pediatr Dermatol. 2017;34(5):504–15.

24. Hancox JG, Jackson J, McCagh S. Treatment of molluscum contagiosum with the pulsed dye laser over a 28-month period. Cutis. 2003;71(5):414–6.

25. Taibjee SM, Cheung S-T, Laube S, Lanigan SW. Controlled study of excimer and pulsed dye lasers in the treatment of psoriasis. Br J Dermatol. 2005;153(5):960–6.

26. Erceg A, Bovenschen HJ, van de Kerkhof PCM, Seyger MMB. Efficacy of the pulsed dye laser in the treatment of localized recalcitrant plaque psoriasis: a comparative study. Br J Dermatol.

2006;155(1):110–4.

27. Youssef NY, Saleh HM, Abdallah MA. Pulsed dye laser in the treatment of psoriatic nails: a controlled study. J Eur Acad Dermatol Venereol. 2017;31(1):e49–50.

28. Ilknur T, Akarsu S, Aktan S, Ozkan S. Comparison of the effects of pulsed dye laser, pulsed dye laser + salicylic acid, and clobetasole propionate + salicylic acid on psoriatic plaques. Dermatol Surg.

2006;32(1):49–55.

29. Treewittayapoom C, Singvahanont P, Chanprapaph K, Haneke E. The effect of different pulse durations in the treatment of nail psoriasis with 595-nm pulsed dye laser: a randomized, double-blind, intrapatient left-to-right study. J Am Acad Dermatol. 2012;66(5):807–12.

30. Blake SC, Daniel BS. Cutaneous lupus erythematosus: a review of the literature. Int J Womens Dermatol. 2019:5(5):320-329.

31. Rerknimitr P, Tekacharin N, Panchaprateep R, et al. Pulsed-dye laser as an adjuvant treatment for discoid lupus erythematosus: a randomized, controlled trial. J Dermatol Treat. 2018;10;1–6.

32. Erceg A, Bovenschen HJ, van de Kerkhof PCM, et al. Efficacy and safety of pulsed dye laser treatment for cutaneous discoid lupus erythematosus. J Am Acad Dermatol. 2009;60(4):626–32.

33. Truchuelo MT, Boixeda P, Alcántara J,et al. Pulsed dye laser as an excellent choice of treatment for lupus tumidus: a prospective study. J Eur Acad Dermatol Venereol. 2012;26(10):1272–9.

34. Macarenco RS, do Canto AL, Gonzalez S. Angiolymphoid hyperplasia with eosinophilia showing prominent granulomatous and fibrotic reaction: a morphological and immunohistochemical study. Am J Dermatopathol. 2006;28(6):514–7.

35. Eisen D, Alster TS. Use of a 585 nm pulsed dye laser for the treatment of morphea. Dermatol Surg.

2002;28(7):615–6.

36. Fikrle T, Pizinger K. Granuloma Faciale treated with 595-nm pulsed dye laser. Dermatol Surg.

2011;37(1):102-4.

37. Cliff S, Felix RH, Singh L, Harland CC. The successful treatment of lupus pernio with the flashlamp pulsed dye laser. J Cutan Laser Ther. 1999;1(1):49–52.

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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Keeping Positive During a Pandemic Aesthetics celebrates the valuable actions of those in the community throughout the COVID-19 crisis In times of crisis, it’s easy to get yourself down and become wrapped up in a negative spiral, especially with so much disheartening media coverage circulating every day. While the last month has been particularly challenging for not only the aesthetics community but the whole country, it has shone a light on the caring and supportive nature of the people in our industry. From practitioners

returning to the NHS, distributors donating products, and personal protective equipment (PPE) fundraising efforts, practitioners and aesthetic companies have been uniting to combat this global crisis.

To help keep your spirits up, Aesthetics wants to remind everyone of all the hard work our specialty has put in over the last few weeks and bring a smile to your faces.

Practitioners Equipment donations Aesthetic practitioner and clinic owner Dr Nestor Demosthenous has set up a Go Fund Me page, aimed at raising money to buy more essential PPE for the NHS. Any residual funds will be distributed to medical charities. Dr Demosthenous says, “Having spent many years in surgical training within the NHS, I know the NHS well. I understand the sacrifices my colleagues are currently making, the fear, the bravery and the compassion filling our hospitals. I have closed my clinic doors temporarily, to focus efforts on supporting my NHS colleagues during these unprecedented times.

While I have applied to NHS Scotland ‘COVID-19 recruitment’, awaiting to be placed where appropriate, I have decided to help in other ways too. With the COVID-19 pandemic rapidly escalating, I feel it is essential that we help our NHS Lothian colleagues to continue to practice safely at such a critical time.” Permanent makeup artist, medical tattooist and trainer, Karen Betts, is donating 100,000 residual stock items to support NHS staff and care homes locally and across the UK. She comments, “After visiting my warehouse earlier this week to evaluate our stock, I realised we had a huge number of face masks, gloves, hand sanitiser and disinfectant wipes. We are in unprecedented times and anything that can even slightly ease the worry and stress many are facing is hugely important, and I urge others to do the same, no matter how big or small, we can all make a difference.”

Dr Qian Xu has started a JustGiving page in order to raise funds to provide proper respirators for frontline staff. Dr Xu explains, The lack of PPE led me to catch the virus myself, and after making a recovery from it, I decided to do more to help protect others on the frontline. This is why I set up a fundraising campaign to buy better face masks for those working in high risk areas. I currently have 5,000 N95 masks en route to the UK. About 750 of those are funded by my campaign and will be directly donated to those in need.”

Transforming clinics Illuminate Skin Clinic has transformed into a GP service for general health problems. Every day there will be three non-profit appointments available for members of the community on low incomes, and the clinic will also be holding free video consultations. Clinic owner, Dr Sophie Shotter comments, “When it became clear how serious the coronavirus pandemic was becoming, I wanted to find a way we could serve the community. It was becoming clear that GP services were going to be under immense pressure, and members of the public were going to struggle to access their usual

Educating children Since the start of the pandemic, aesthetic and general practitioner Dr Simi Adedeji started a YouTube channel with patient education about COVID-19 at the fore. One of her most popular videos includes the best ways to teach your children about coronavirus – explaining the disease in simple terms for them to understand whilst still being entertained. She says, “I had a YouTube channel before COVID-19, where I discussed skin, women’s health and wellbeing and medical aesthetics. With COVID-19 came the opportunity for me to educate about an extremely important health issue. I started with factual knowledge videos and updates and then created a children’s video explaining coronavirus to preschool and school-aged children once it became clear that children were also experiencing anxiety from the new world and new rules around them.

I’ve had incredible feedback from the videos including from the public, parents and schools who have used my video to help their children understand the situation better.”

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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Coronavirus testing

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medical care. We had been planning to launch a private GP service anyway, and decided to bring this forward. This ensures that people can continue to access medical advice whilst the NHS is under strain.”

Aesthetic supplier efforts Free tests for NHS workers KLNIK, an aesthetic clinic in Wilmslow, has been conducting free COVID-19 antibody testing for all NHS workers. Dr Rosh, medical director at KLNIK, comments, “At a very difficult time for all, seeing people band together and giving back to the community is key. In just three weeks, KLNIK are proud to have completed 15% of all tests by the NHS. Our commitment to those in crisis will not falter, and together we will continue to provide an inclusive wellness service fundamental to public health protection for all. We liaise with the Public Health England (PHE) and the Department of Health and have been regarded as a partner agency, having specially-modified contactless testing protocols with trained clinical and nonclinical volunteers working collectively in this effort.”

Non-profit testing for the community Consultant plastic surgeon Mr Taimur Shoaib has introduced non-profit coronavirus testing at the Glasgow Medical Rooms, which is liaising with Public Health Scotland to make sure the government body is informed of all positive tests, so to contribute to epidemiological data. The service is available to all in the community, with priority booking for those holding a key worker status.

Mr Shoaib comments, “I got together with two other doctors, an ITU consultant and a private GP, and together we wrote several documents. We wrote patient pathways, patient information leaflets about the tests, risk assessment documents, consent forms, website information and information leaflets about test results.

We considered all the different suppliers of testing kits and we decided that we wanted to offer the service as a nonprofit venture after we saw that other doctors were charging over £300 for a test. Our priority is to ensure that patients would get the correct care rather than simply be offered a test without any counselling.”

Care packages Aesthetic distributor AestheticSource has partnered with skincare platform Get Harley to arrange for gifts to be sent to the first 50 key workers, nominated by colleagues or family members, who recently closed their aesthetic practice and returned to the NHS. Lorna McDonnell Bowes, co-founder and CEO of AestheticSource, says, “We want to personally thank everyone returning to support the NHS. We all know how challenging it is for skin to be under PPE all shift. The NeoStrata Bionic Face Cream will support skin after PPE is removed, and once the skin is washed, Clinisept+ can be applied and left to dry for 15 seconds.” Charmaine Chow, founder and CEO of Get Harley, comments, “In these unprecedented times, it is heart-warming to see many of our practitioners work with the NHS to help their communities.

It inspires us as a company to do more for them and work hard to ensure that there is business continuity for these practitioners, through our platform’s visual consultation and at-home skincare delivery offerings.”

Product donations Harpar Grace International and iS Clinical have donated 60 skincare products to the A&E department at the Royal Shrewsbury Hospital in Shropshire. The company states that this is in response to the harsh nature PPE can have on the skin after being on for a long period of time.

The company will also be donating the products to seven other hospitals in the coming weeks. Alana Marie Chalmers, director of Harpar Grace International, says, “We have been inspired by the practitioners within the industry returning to work within the NHS and also those wishing to support their colleagues on the frontline. We are fortunate to have clinical formulations that target the specific issues created by PPE and being endured by our NHS heroes currently and humbled to be able to help in any way we can.”

Private label cosmeceutical supplier 5 Squirrels has also been donating products to the NHS. Gary Conroy, co-founder of 5 Squirrels, comments, “We have worked with some of our brands to support people in the NHS with ulcerative sores caused by PPE equipment.

We have donated several thousand skincare products to more than 100 NHS hospitals and care centres, to help soothe and heal front line staffs’ faces to help them recover for future shifts. We have also donated several thousand lamination folders which we had in our office for presentation material and these have been re-purposed to make personal protection face shields for NHS front line staff. Many of our customers have returned to their original roles within the NHS and a number have volunteered so hopefully if we can all play our part we can beat this virus together and save lives!”

Medik8 Helping Hands project UK skincare manufacturer Medik8 has created hand sanitisers to supply free to local communities in response to the current high demand. “This health crisis shows how the entire human race can unite to face off a common enemy, and we all have a part to play,” comments Medik8 founder Elliot Isaacs. Named the ‘Medik8 Helping Hands’ project, the company will distribute 4,000 units of sanitiser to care homes, vulnerable individuals, the homeless and the police, among other community members. Isaacs continues, “I am grateful for the chance to use our ISO capabilities for the community, and on a personal level, to be able to deliver for those who cannot leave their homes, or locate any sanitiser locally.”

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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Clinic gifts Aesthetician and founder of West Room Aesthetics, and Black Skin Directory Dija Ayodele has created The Nightingale Treatment, which aims to help restore the skin of NHS frontline professionals when social distancing rules are relaxed. And it won’t just be available at Ayodele’s clinic – she’s encouraging others to get involved too!

The idea is that participating clinics gift a soothing and rejuvenating facial treatment to their local NHS frontline staff, with each clinic deciding upon the number of treatments to gift, the timings and dates they can be redeemed. All clinics will be provided with a digital poster to send to their local hospital HR department, with clinic details displayed on The Nightingale Treatment website and promoted across social media and traditional advertising channels via a dedicated PR agency.

Skincare brands are also encouraged to get involved, with AestheticSource already confirmed to support the efforts. Ayodele says, “Like most people, I have been impressed by the bravery and courage of frontline NHS staff. As a skin health specialist I have also been both saddened and inspired by their bruised and marked faces caused by the tight masks they have to wear as part of the personal protection equipment. It’s important to give back to this army of people who have selflessly looked after the nation and the best way I know how to do this is by using my skills to bring together colleagues and brands in the beauty industry to create this initiative – The Nightingale Experience.”

In addition, aesthetic nurse Arleana Hodnett has created a Pride of Britain facial, designed specifically for NHS frontline workers. Vouchers are being sent out to those nominated, and will be available to retrieve as soon as her clinic doors are open again.

Webinars Aesthetics is aware that many practitioners will have missed out on attending workshops, conferences and training days as a result of COVID-19. To ensure you still continue your professional development during this period, many companies are

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Ventilators Turkish laser manufacturer, Nessa Lasers, is releasing a line of ventilation machines in the coming weeks to help the NHS and general hospitals around the UK and Europe. Deren Yilmaz, network and marketing manager for Nessa, comments, “Ventilation machines available in hospitals provide approximately 500 kilohertz and 14 hours’ run-time before they need to be turned off to cool down. Our team of engineers have developed a cooling system that allows our ventilation machines to run 24 hours, seven days a week at 1.7 million megahertz. This, as you can imagine, is extremely vital for the recovery of coronavirus patients.”

Returning to the NHS Whilst most of the country has been staying at home to keep safe over the last few weeks, many aesthetic practitioners have been returning to their former jobs in the NHS, offering their time and services when the country is most in need.

It’s not easy While the return of aesthetic practitioners to the NHS reflects positively on the community and serves as an inspiration to many, it’s important not to overlook the realities of working in healthcare during COVID-19, and to consider what your friends and colleagues are enduring throughout this period. Dr Adedeji, who is working at her local general practice full time, opened up to Aesthetics about the impact of working for the NHS on herself and her colleagues at this time.

She comments, “Anxiety levels are high. Almost daily news trickles in of death of our NHS colleagues. We try not to show the desperation to staff, non-medic spouses, family and children, as we are trying to maintain some sense of normality. We are trying to stay cheerful and optimistic. This takes its toll and there are tears behind closed doors before the inevitable gathering of oneself together and continuing as normal. But, whilst life is different, it still carries on. We continue to treat and manage patients with chronic health conditions, diabetes, urine infections, anxiety, depression, the usual GP mix, and we all look forward to the end of this global pandemic.”

The brighter side Anna Kremerov Independent nurse prescriber Anna Kremerov left her work at Swindon’s Great Western Hospital in ICU 10 years ago to work in aesthetics. At the end of March, Kremerov didn’t hesitate to write to the manager of the same ICU unit, offering her services again during COVID-19. Upon returning to intensive

holding online webinars and education courses.

You can find sessions from AestheticSource, Allergan, Candela, Cynosure, Cutera, Cosmetic Courses, e-MASTR, Galderma, HA-Derma, Healthxchange, IMCAS Academy, Lynton Lasers, Sinclair Pharma, Teoxane, Venus Concept and many more on the Aesthetics website.

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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care, she commented, “Initially I did have reservations about what I would come in contact with, with worries about catching the virus and about not being up to speed after being away from the NHS for so long. However, since I have had my refresher training, I am confident that I can do the job. The ICU unit is incredibly well managed, and infection control is ingrained in every element of the ward so I feel very well protected. The systems in place mean that I don’t fear that I will bring the virus home to my family. For example, the clothes I wear on the ward never leave the hospital. This particular ICU unit is incredibly well prepared for what is to come.”

interest in aesthetic treatments from our patients remains high and though our practices are closed, our admin team have continued to receive calls. Throughout lockdown we continue to offer support to our patients through Skype consultations, offering help and practical advice, and we are also assessing potential new patients who are interested in exploring treatment. We have recently opened a waiting list to ensure we are able to prioritise patients who we unfortunately had to postpone at the start of lockdown. Current indications are that there will be high demand for facial aesthetics as soon as we are able to resume treatments.”

Miss Jennifer Doyle Miss Jennifer Doyle has also returned to working in ICU. On her transition, she states, “Whilst working in an intensive care unit couldn’t be more different from my normal role as an ophthalmic surgeon and aesthetic practitioner, as doctors we all have transferable skills that we can put to good use and help during this crisis. I am learning a lot and feel that I will be a better doctor when we come out the other side of all this. Whilst I have had the occasional patient try to convince me that their lack of botulinum toxin is genuinely a medical emergency, I have found that it has been a great opportunity to encourage my aesthetic patients to concentrate on their home skincare regimes. This is a habit I hope they continue when we come out of lockdown.”

Mr Daniel Ezra Consultant oculoplastic surgeon Mr Daniel Ezra has cancelled all non-urgent and routine appointments and treatments to focus on COVID-19 full time. He states, “It’s been amazing to see the NHS restructure their services in a record amount of time, such as changes in ways of working that would normally have taken years to integrate within the NHS. This crisis has shown that these changes can be carried out quickly and without the usual bureaucracy and I would hope that moving forward, this will become the norm. It’s as though the NHS has had to evolve and it’s starting a healthcare revolution that can only affect the public positively.”

Dr Victoria Manning and Dr Charlotte Woodward Owners of River Aesthetics clinic, Dr Victoria Manning and Dr Charlotte Woodward have closed their three aesthetics practices and have offered their services to help with the pandemic by working in GP roles, answering 111 calls and triaging patients on the phone.

They commented, “We are delighted that have been able to offer our skills and experience to help the NHS during this unprecedented time. Our original calling was as GPs and to be able to offer our services to triage patients for 111 to help with the deluge of additional calls was a no brainer.” On how this may affect their aesthetic practice in the future, they stated, “Demand and

Uniting the community While we are facing challenging times and uncertain futures, it is an inspiration to see the aesthetic community unite together, supporting one another and their community and, importantly, staying positive. Of course, these are only a few examples of the many amazing things that people in the industry have been doing, and there are lots others taking place across the country. If you have recently returned to working in healthcare, or are doing anything to support the UK community, please continue to send photos and positive messages to editorial@aestheticsjournal.com, so Aesthetics can keep sharing and supporting everyone involved.

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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Case Study: Treating a Drag Queen Aesthetic nurse Kerry Hanaphy shares her approach and recommendations for lip and skin enhancement in a male patient Consultation and considerations A 30-year-old male patient presented to my clinic requesting treatment for the first time. As the patient was in the public eye, working as a drag queen, he was particularly interested in improving his skin quality and enhancing his lips. The patient had mild signs of ageing such as fine lines and wrinkles, which were easily rectifiable with a good treatment plan.

During the consultation, I discussed the pros and cons of undergoing lip filler and botulinum toxin injections, outlining the side effects and risks that can occur while detailing their longevity and expected results. We also talked about how mesotherapy injections could be beneficial, as well as a chemical peel, to really enhance the results.

The patient explained that he was particularly conscious of a deep line on his forehead which tended to collect makeup, but was nervous that toxin treatment would make him look ‘too stiff’ – a common concern for many patients and something that was particularly relevant to this patient, with his job requiring him to have an expressive face. With this in mind, I suggested that we

start on a good skincare regime to begin improving skin quality before progressing to botulinum toxin injections. In regards to the lips, the patient said he was keen for the dermal filler result to be more dramatic, as he wanted to enhance the look created in his drag act and achieve the ‘wow factor’. After thoughtful discussion, the decision was made to start the patient on a skincare regime, before going ahead with a chemical peel and mesotherapy in one session, followed by lip filler and botulinum toxin injections at an appointment two weeks later. I believe it’s important to emphasise here that while this male patient dresses up and applies

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makeup to appear as a woman for his drag act, he is not transgender and requires a very different treatment approach from that of someone in the trans community. Drag queens identify as male and will generally want to preserve their masculine features, while transgender patients will most often be looking to create more feminine features, such as softening of the jawline and mid-face structure, through aesthetic treatment. As with any patient, each should be consulted with and treated on an individual basis. Of course, it’s imperative that practitioners carefully manage patients’ expectations and consider any risk of body dysmorphic disorder (BDD); anecdotally, most men don’t want their results to be noticeable and will specifically request subtle enhancement, whereas, in this case, the patient really wanted to see an obvious difference with his lips. He did not display any warning signals of BDD, so I was confident to go ahead with treatment. According to Dr Raj Arora in his article published by Aesthetics last year, warning signals generally consist of obsessive concerns about appearance and compulsive behaviours.1 Appropriate consent was obtained and the patient returned for treatment a couple of weeks later.

Treatment Prior to the patient’s chemical peel, he was given a resurfacing cream to use for the 10 days leading up to the treatment. This product is called resurfacing peel booster from mesoestetic and was chosen for its glycolic and salicylic properties, which aim to resurface the skin.2 On the day of the peel, I cleansed the skin using products from the same range, including the hydra milk cleanser and hydratonic facial toner, before applying the mesopeel with salicylic acid at a strength of 20%. This has a strong keratolytic and sebum-regulating effect, which was particularly beneficial for this patient.3 Finally I applied a factor 50 sunscreen and advised the patient to use this daily.

Following the peel, I performed the

Drag queens identify as male and will generally want to preserve their masculine features, while transgender patients will most often be looking to create more feminine features

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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Patient perspective Hanaphy’s patient, Paul Ryder, said…

“Following years of mistreatment, I was never happy with my skin. I’ve spent a long time wearing too much makeup for drag, without the proper care, meaning it had sagged and looked tired. There was also a massive line across my forehead which used to swallow makeup, making me look older than I am.

Upon consultation in Kerry’s clinic, I expressed concern with looking too stiff and having overinflated ‘duck lips’. Kerry reassured me that we could start on good skin treatments, before moving to injectable treatments that would work for me.

The peel was fantastic – I really noticed a difference in my skin. As my skin was a bit drier afterwards, having to moisturise really taught me to get into a good routine of taking care of my skin. For me, the mesotherapy has been the ‘holy grail’ of all my treatments – I still have them regularly and they’ve completely changed my skin over the past two years. I was also really happy with the injectables – I don’t think I noticed how small my lips were before as I was so used to accentuating them with my drag makeup. I fell in love with the result and it’s amazing how much they’ve shaped my whole face. Kerry really masters the art of creating what you want in a way that suits you as an individual.

Having aesthetic treatment has really changed my outlook – I was so used to looking at my face in drag and didn’t really take care of my own face. Following the procedures, I am way more confident about my skin for the first time in years.

The treatment plan Kerry advised was definitely the right course of action for me!

For practitioners new to treating men, I would remind them that not everyone is the same and we should be treated as individuals. It’s also good to remember to respect patients’ privacy – I am open about working as a Drag Queen and why I wanted treatment but others may not want to go into much detail, so it’s important to consider that.”

Before

After

In drag

Figure 1: Patient before and after treatment and in drag

mesotherapy treatment. For this I used a mesotherapy gun, injecting 2ml superficially all over the patient’s face. I use the Viscoderm Skinko product, which contains more than 50 elements including non-crosslinked hyaluronic acid, minerals, amino acids and vitamins.4 I find mesotherapy keeps the skin looking fresh and maintains a glow, while also improving wrinkles.

Two weeks later the patient returned to clinic for his injectable treatments. He explained that he is quite sensitive to pain, so I applied LMX4 anaesthetic cream prior to injection to numb the area. I also ensured I spoke very calmly and played music of the patient’s choice in the background to help him relax.

The patient had thin lips and of course wanted to see a noticeable difference in volume, so we decided to inject 0.8ml of Restylane Kysse to the area. I injected the product along the vermillion border, using a needle with a linear technique, which resulted in a nice volumised lip with significant structure. As this product is designed for the lips, I find that it doesn’t induce much swelling and tends to last longer – up to nine months.

Dental surgeon Dr Barry O’Driscoll then performed the botulinum toxin treatment using Azzalure. For the procedure, he injected a total of 125 units to the patient’s frontalis (30 units), glabellar (50 units) and orbicularis oris (45 units) muscles. Doing so

improved the patient’s frown lines and crow’s feet, which he was particularly happy with.

Following the treatments, I recommended that the patient visit the clinic on a monthly basis for mesotherapy injections to further enhance results.

Post procedure Following treatment I advised the patient not to apply makeup until the next day. I also had to really emphasise the importance of avoiding exercise for the next 24 hours – it was important to stress the risk of swelling as the patient is a big gym goer and could have been tempted.

He did not experience any notable side effects or adverse events. I recommended the patient use the mesoestetic skincare range moving forward, specifically the cleanser and resurfacing peel booster, which has 10% glycolic acid and 2% salicylic acid, which is great for cell renewal and removal of dead skin. I also encouraged used of hydra-vital factor k moisturiser and a good factor 50. Finally, the patient was given the crystal fibre at-home facemask, which is full of hyaluronic acid and I find can really enhance results.

The patient continues to visit the clinic for monthly mesotherapy appointments and has been delighted with the results. His confidence has increased, he has taken on more television work and has reported that he feels happier overall in his life.

As aesthetic practitioners, it is imperative that we recognise that patients can’t all be treated in the same way just because they are of the same sex. We should take the time to listen and understand their individual requirements, while taking care to ensure we manage their expectations and provide the best results possible.

Kerry Hanaphy is an aesthetic nurse based in Dublin. She spent more than 20 years working as a respiratory and chemotherapy nurse, before moving into aesthetics and opening the Kerry Hanaphy clinic. Hanaphy is a trainer for Galderma, amongst other companies, and has been titled ‘Ireland’s Lip Queen’.

Qual: RN REFERENCES 1. Arora R, Using BDD Assessment Tools (UK: Aesthetics, 2019) <https://aestheticsjournal.com/feature/using-bddassessment-tools> 2. mesoestetic professional, resurfacing peel booster <https:// www.mesoestetic.com/en-GB/resurfacing-peel-booster> 3. mesoestetic professional, mesopeel salicylic acid 20% <https://www.mesoestetic.com/en-GB/professional/ mesopeel-salicylic-20> 4. HA-Derma, Viscoderm Skinko <https://ha-derma.co.uk/ products/skinko/>

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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Managing Snoring Dr Natasha Verma outlines treatment approaches for snoring and explores the literature on using botulinum toxin as a viable option Snoring is very common and impacts many people, particularly the partners of snorers.

As a result, many will seek treatment; of which there are a number of options available.

While the concern is one which a patient would usually discuss with their GP, having knowledge of treatment options could be beneficial for aesthetic practitioners who discuss a patient’s lifestyle and sleeping habits as part of a holistic consultation.

Particularly of note for aesthetic practitioners is research on the use of botulinum toxin as a treatment approach for habitual snoring, which presents interesting reading. This article will discuss its value as a potential treatment option.

A review by Fiz et al. in 2009 detailed that there are associations between snoring and some medical conditions such as OSAS, hypertension and cardiovascular disease.4 They also found that there are many lifestyle influences that increase the risk of snoring, which include: •

•

Definitions and causes The American Academy of Sleep Medicine (AASM) defines snoring as a sound originating from the upper airway that does not occur with apnoea or hypoventilation, and that is caused by vibrations for different tissues within the pharynx. In 2003, Bigalke et al. explained that the tension of the tensor veli palatini muscle causes the vibrations and hence the snoring.1 AASM advises that unlike obstructive sleep apnoea syndrome (OSAS), simple snoring does not interfere with the patient’s sleep and does not cause excessive daytime sleepiness.2 Of the simple snorers, a person that snores for more than 10-20% of a monitored night or more than three to four nights a week is classified as a habitual snorer.3

•

•

•

Obesity: it was found that snoring reduced from 82% to 14% in a study in which patients reduced their BMI from 46 to 35kg/m2 following bariatric surgery.5 Alcohol intake: alcohol causes oropharyngeal muscle hypotonia, increased airway resistance and exacerbates snoring in habitual snorers.6,7,8 Smoking: it has been proposed that smoking contributes to inflammation, oedema and upper airway resistance.4 Medication: muscles relaxants and sedatives have been found to increase snoring severity.4 Sleeping positions: changing positions from lying on the side to a supine position can increase the loudness of the snoring by 8dB.9,10

Prior to treating habitual snoring, it would be best to address medical causes such as OSAS, hypertension and cardiovascular disease by advising the patient to consult their GP or specialist to ensure their medical condition is well-controlled.

If the patient is unsure as to if their snoring is caused by OSAS, this checklist can be useful to determine a provisional diagnosis and help you decide if this patient is a candidate for treatment within your clinic:2 • Gasping/choking noises • Dry mouth in morning • Sleepy during day despite going to sleep at a reasonable time • Abrupt awakenings with shortness of breath • Sore throat • Morning headache • Jerky or restless legs during sleep • Waking repeatedly at night These observations may have been made by their partners, so it therefore may be useful to carry out the consultation with them present.

Treatment options There are three major treatment categories for habitual snorers and the appropriate treatment option depends on the severity of the snoring and impact it has on the patient and their partner.4 1. Lifestyle changes and patientadministered interventions such as weight management, reduction or elimination of alcohol and tobacco, change in medication (with GP guidance) and change in sleeping positions. The patient can receive advice and guidance for the lifestyle changes on the NHS via their GP. 2. Non-surgical interventions such as oral devices, external and internal nasal dilators, nasal lubricants and botulinum toxin administration.

3. Surgical interventions such as nasal surgery, palatal surgery and snoreplasties.

There are studies that have shown that many non-surgical and surgical methods have reduced snoring, however there are disadvantages to many of these methods.

Nasal dilators can cause skin irritation, while dilators and lubricants can be costly when using products on a nightly basis. Mandibular advancement systems are the most common oral devices and work by repositioning the mandible forward, increasing the crosssectional area of the airway and reducing pharyngeal collapsibility. The adverse effects reported for these devices are chewing difficulty, excessive salivation, xerostomia, occlusion discomfort, discomfort of oral soft tissues, the jaw and teeth, headaches and masseter muscle pain. It has also been found

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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that there is reduced compliance as a result of the discomfort and lack of perceived benefits.11 Low-energy radiofrequency has also been considered as a safe and welltolerated therapy when used to reshape the nasal tissues enlarging the nasal valve.12 Nasal and palatal surgery for habitual snoring comes with the normal surgical risks and is also not readily available on the NHS, therefore the patient can undergo an expensive, risky procedure that may bring about result in the short-term but might not guarantee permanent benefits.13 The most common adverse effects of surgery include pain, mucus hypersecretion, throat irritation, nasal regurgitation, nasal voice, bleeding and dysphagia. Long-term complications include velopharyngeal incompetence and qualitative voice changes.13 Uvulopalatoplasties are now being carried out using lasers or radiofrequency to further improve the outcome. Laserassisted uvulopalatoplasties (LAUP) allow the surgeon to carry out the procedure conservatively, reliably, in clinic without requiring hospitalisation and is haemostatic and relatively painless. However, the American Sleep Disorders Association recommended against LAUP due to the lack of inadequate data and high costs and potential complications.14 Radiofrequencyassisted uvulopalatoplasties (RAUP), on the other hand, have been found to be minimally invasive, cost effective, and cause minimal pain and scar-induced contracture.15 Radiofrequency ablation is used to create a lesion on the area from the base of the uvula to the posterior nasal spine. The necrotic tissue will be resorbed, shortening the palate.16 However, evidence on the short-term efficacy is limited and long-term outcomes are unknown.15,16 Injection snoreplasty is a technique that involves injecting a sclerosing agent such as ethanol, doxycycline or sodium tetradecyl sulphate into the midline of the soft palate and either side of the midline. This results in scarring and contracture. As a result, the palate becomes stiffer and shorter, reducing the vibration of the palate, resolving the snoring concerns.17,18 This procedure has brought about serious secondary effects such as tissue necrosis and allergic reactions and can only be considered if the cause of snoring is caused by palatal vibration, which would therefore need to be assessed prior to considering this treatment.18,19 This is also the case for the use of botulinum toxin as a nonsurgical treatment option.

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Botulinum toxin as a treatment option for snoring In 2003, Bigalke et al. considered long-acting muscle relaxants as a treatment option as relaxed muscles do not vibrate. Therefore botulinum toxin was used to block the release of acetylcholine causing the muscles to relax; eliminating snoring. This would be an off-label use.1 A small study of eight patients was carried out in 2008 in which 20 Injection point units of botulinum toxin (Dysport) in a concentration of 50 units/ml was administered into the soft palate.20 The injection point can be seen in Figure 1.

To avoid unwanted effects, the levator veli palatini muscle was injected only on the left side.20 Injection of botulinum toxin was administered in the soft Figure 1: Injection of botulinum toxin in soft palate, palate, 1cm dorsal to the junction with 1cm dorsal to the junction with the hard palate and 1cm medial to the alveolar ridge.20 the hard palate and 1cm medial to the alveolar ridge.20 The patients and their partners reported and saline (300 picogram/ml) which was a significant improvement. A side effect administered into the tensor veli palatini using reported by 50% of the patients was dullness a curved cannula with video control. of the soft palate with no change to their Using botulinum toxin A, three people were lifestyle or function. One patient reported injected at three locations along the tensor that she was unable to speak temporarily, veli palatini. 100Âľl in person 1, 200Âľl in person however, this was deemed unrelated to 2 and 300Âľl in person 3 was administered, the study as it occurred earlier than known therefore the dosage per palate was 50pharmacological effects of botulinum toxin.

150pg (8-25 units). The muscle relation Three patients found no improvement in occurred within three to five days and snoring.20 As per Kuhnel et al., the theory sustained for three to four months. behind snoring is that an equivalent and Using botulinum toxin B, the method opposing force breaks the adhesive forces was replicated, however 15pg (1ml) between the tongue and the soft palate and, was distributed along four points of the by doing so, this causes the soft palate to tensor veli palatini of one person. As with form a convex arc such that it is further away botulinum toxin A, the results occurred from the tongue, resulting in the vibrations.20 within three to five days, however sustained Kuhnel et al. found that use of botulinum toxin for approximately six weeks. for treatment of habitual snoring is a safe, Using botulinum toxin C, the method was non-invasive and fully reversible option.20 By modified by administering 50pg (1ml) to inducing partial paralysis of the soft palate, the four locations of the tensor veli palatini and tongue and the soft palate remain juxtaposed once again, muscle relaxation occurred in for longer, creating a clear pathway for three to five days and lasted approximately inspiratory airflow.21 Partial paralysis of the 14 weeks. Bigalke et al. explained that a levator veli palatini preserves function, yet higher dosage of botulinum toxin C was weakens the muscle force and reduces risks required as it has a reduced specific toxicity of nasality and regurgitation.21 in comparison to A and B. In all cases, the Palatal tremor (palatal myoclonus) was also snoring noises occurred again, becoming treated using botulinum toxin in another increasingly louder. No swallowing or study in 2006, in which the toxin was injected speech impairments were noted during into the tensor and the levator veli palatini this investigation.1 Hence, snoring can be muscles, resolving the symptoms in four of reduced/eliminated on a short-term basis the five patients treated.22 with one treatment of botulinum toxin A, B Bigalke et al. carried out multiple experiments and C, however the best suited agent and of dosages using botulinum toxin A, B and dosage for this therapeutic use are yet to C. They used a solution of botulinum toxin be determined.

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

Summary The results of the toxin studies show promise, however further high-level evidence investigations are warranted with larger patient samples.20,21,22 Currently, there is no standardised measurement of snoring, therefore this may be required to determine a patient’s suitability for treatment and the dosage required to treat them. I would consider using botulinum toxin to treat snoring however, I would only do so when there is more recent and sufficient high level evidence and a protocol is devised ensuring standardisation, thus the safety of patients. Prior to treating a patient with snoring concerns, it is vital to determine any medical conditions, lifestyle habits and medication that may be the cause of the snoring and to ensure that the patient does not suffer from sleep apnoea. A delayed diagnosis could be dangerous for the patient. If in doubt, refer to a sleep clinic or specialist.

Dr Natasha Verma graduated from University of Newcastle upon Tyne with a Bachelor of Dental Surgery qualification. She has a background in oral and maxillofacial surgery and teaches undergraduate dental students in King’s College, London. Dr Verma has experience with numerous non-surgical procedures in several clinics in London. She is currently completing an MSc in Aesthetic Medicine at Queen Mary University of London.

Qual: BDS MFDS RCS (Eng) MJDF REFERENCES 1. Hans Bigalke, Hannover; Jirgen Frevert, Berlin, United States Patent, 2003, Patent No.: US 6,573,241 B1 (45) <https://patentimages.storage.googleapis.com/b3/cd/b5/e9fa6217538d2d/ US6573241.pdf> 2. Study explores management of snoring and sleep apnea in primary care setting 2016, American Academy of Sleep Medicine. <www.aasm.org> 3. Bearpark H, Elliot L, Grunstein R, Cullen S, Schneider H, Althans W, et al, Snoring and sleep apnea.

A population study in Australian men, Am J Respir 151 (1995): 1459-65.

4. Fiz JA, Prat JM, Jan, Treatments of patients with simple snoring, Arch Bronconeumol 45 (2009): 508-15.

5. Dixon JB, Schachter LM, O’Brien PE, Sleep disturbance and obesity changes following surgically induced weight loss, Arch Intern Med 161(2001): 102-6.

6. Robinson RW, Jamieson A, Guilleminault, Long term outcome for obstructive sleep apnea syndrome patients, Chest 94 (1985): 1200-4.

7. Mitler MM, Dawson A, Henriksen SJ, Sohers M, Bloom FE, Bedtime ethanol increases resistance of upper airways and produces sleep apnea in asymptomatic snorers, Alcohol Clin Exp Res 12 (1988):801-5.

8. Issa FG, Sullivan CE, Alcohol, snoring and sleep apnea, J Neurol Neurosurg Psychiatry 45(1982): 353-9.

9. Itasake Y, Miyazaki S, Ishikawa K, Togawa K, Intensity for snoring in patients with sleep-related breathing disorders, Psychiatry Clin Neurosci 53(1999): 299-300.

10. Nakano H, Ikeda T, Hayashi M, Ohshima E, Onizuka A, Effects of body position on snoring in apneic and non-apneic snorers, Sleep 15(2003) :169-72.

11. Hoffstein V, Review of oral appliances for treatment of sleep-disordered breathing, Sleep Breath 11(2007): 1-22.

12. Brehmer D, Bodlaj R, Gerhards F, A prospective, non-randomized evaluation of a novel low energy radiofrequency treatment for nasal obstruction and snoring, Eur Arch Otorhinolaryngol 276 (2019): 1039–47.

13. Hoffstein V, Snoring, Chest, 109 (1996): 201-22.

14. Wischhusen J, Qureshi U, Camacho M, Laser-assisted uvulopalatoplasty (LAUP) complications and side effects: a systematic review, Nat Sci Sleep 27 (2019): 59-67.

15. Samimi Ardestani SH, Dadgarnia MH, Baradaranfar MH, Mazidi M, Rabbani M, Behniafard N, Baradaranfar A, Radiofrequency Uvulopalatoplasty for Primary Snoring, Acta Med Iran 51 (2013): 530-6.

16. Main C, Liu Z, Welch K, Weiner G, Jones, SQ, Stein K, Surgical procedures and non-surgical devices for the management of non-apnoeic snoring: a systematic review of clinical effects and associated treatment costs, Health Technol Assess 13(2009): 1-208.

17. Poyrazoglu E, Dogun S, Snat B, Gngr A, Cekin E, Cincik H, Histologic effects of injection snoreplasty and radiofrequency in the rat soft palate, Otolaryngol Head Neck Surg 135 (2006) :561-4.

18. Brietzke SE, Mair FA, Injection snoreplasty: how to treat snoring without all the pain and expense, Otolaryngol Head Neck Surg 124 (2001): 503-10.

19. Brietzke SE, Mair FA, Injection snoreplasty: investigation of alternative sclerotherapy agents, Otolaryngol Head Neck Surg, 130 (2004): 47-57.

20. Khnel TS, Schulte-Mattler W, Bigalke H, Wohlfarth K, Treatment of habitual snoring with botulinum toxin: a pilot study, Sleep Breath 12 (2008):63-8.

21. Achuthan S, Medhi B, A systematic review of the pharmacological approaches against snoring: can we count on the chickens that have hatched? Sleep Breath 19 (2015): 1035-42.

22. Penney SE, Bruce IA, Saeed SR, Botulinum toxin is effective and safe for palatal tremor: a report of five cases and a review of the literature, J Neurol 253 (2006): 857-60.

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New headquarters and production ntler Croma-Pharma GmbH, is an international pharmaceutical company based in plant as a clear commitment to free Leobendorf, Austria. For over 40 years, expansion and location ures Croma has been developing and producing Due to the dynamic development of the are so innovative drugs and medicalLtd. a for long-standing licenseand and devices company, the construction expansion of hat they can be distribution agreement. the fields of ophthalmology, orthopedics the headquarters andThis anotherjoint fully automatic a lunch venture the third-largest and break) aesthetic dermatology. Croma is very withproduction facility at the Leobendorf site was proud to have made such an important initiated in 2015.

The new headquarters was ive the patient Chinese pharmaceutical company contribution to improving health and inaugurated in September ance. The expert is aimed at the approval of 2017. further quality of life for more than four decades. ferent technologies products and the nationwide Founded in 1976 by pharmacist Gerhard Innovations as a result of intensive and creates a longdistribution of these products in Prinz, Croma is now managed by his sons research and development or relationship. mainland Martin and Andreas Prinz. Since 2005, the China.

Croma is investing heavily in in-house aesthetic medicine company has been driven forward through research and development of new products ge growth potential In 2014, Sustainability and social rapid internationalisation. the to drive the company’s long-term growth strategic sale of the Ophthalmology and through innovation.

In this context, Croma uty market. In responsibility Orthopedics divisions took place, since then also promotes medical and pharmaceutical offers a steadily the company has specialised in minimally research in Austria. Today, more than 90% dinated portfolio As a family business, Croma invasive aesthetic medicine. Currently, of sales are generated from products of our goal is a “full-face pursues a corporate policy based Croma has 12 international offices in Brazil, own research. r doctors and on ecological, economic and social European Union and Switzerland and nearly solutions for allworldwide. sustainability.

For many years, Croma 500 employees Aesthetic dermatology as a a single source in dynamic future market is sponsor of the international Leading HA expert in Europe aesthetic medicine, the trend ble quality. organizationIn modern “Light for the World”.

Today Croma is a global player in the is moving from large, irreversible surgical With generous product donations dynamically growing segment of minimally lifts to smaller but more frequent, shorter Croma makes an important e course for invasive aesthetic medicine and is a leading and, above all, gentler treatments. Pain-free contributionlunchtime to the eye care in the S market European processor of hyaluronic acid. The procedures (treatments that are so poorest regions of the company sells nearly six million hyaluronic straightforward thatworld. they can be performed 8 Croma-Pharma acid syringes (injectables) annually through during a lunch break) are designed to affiliates and a network of strategic give the patient a relaxed appearance. stablishing a joint partnerships and distributors in more than 70 The expert combination of different with its long-time countries.

Production takes place exclusively technologies optimises results and creates c. to develop and at the company headquarters in Leobendorf a long-term patient-doctor relationship. ulinum toxin, HA near Vienna, Austria. Besides a broad Minimally invasive aesthetic medicine has ead products in US, Contact above-average growth potential in the range of HA fillers from the own production a and New Zealand. site, Croma markets PDO lifting threads, global beauty market. In this area, Croma s its development GmbH a Platelet Rich Plasma (PRP) CROMA-PHARMA system and a offers a steadily growing, well coordinated in its coreHöhn portfolio of products. The goal is a ‘full-face tivitiespersonalised with a skincare technology Stefanie markets. orderstrategic to prepare Cromazeile 2approach’ to offer doctors and patients the e successful market A-2100 Leobendorf gic partnership Phone: +43 676 846868 Aesthetics190 | May 2020 ntinue Croma‘s Mail: stefanie.hoehn@croma.at

best solutions for all indications from a single source in familiar and reliable quality.

Croma sets the course for entering the US market In September 2019 Croma-Pharma GmbH (Croma) establishded a joint venture company with its long-time partner Hugel, Inc. to develop and commercialise botulinum toxin, HA filler and PDO thread products in US, Canada, Australia and New Zealand.

Thus Croma unites its development and marketing activities with a strong partner in order to prepare and implement the successful market entry. The strategic partnership with Hugel will continue Croma‘s international expansion efforts and further strengthen Croma‘s market position.

Milestones product approval and joint venture in China Asia in general and China in particular are outperforming markets in aesthetic medicine.

In May 2017, the dermal filler Princess VOLUME was approved in China by the CFDA. Croma-Pharma was the first European company to do so. Almost at the same time, the company signed with Sihuan Pharma Ltd. a long-standing license and distribution agreement. This joint venture with the thirdlargest Chinese pharmaceutical company is aimed at the approval of further products and the nationwide distribution of these products in mainland China.

Sustainability and social responsibility As a family business, Croma pursues a corporate policy based on ecological, economic and social sustainability. For many years, Croma has been the sponsor of the international organisation “Light for the World”. With generous product donations Croma makes an important contribution to eye care in the poorest regions of the world.

Learn more about Croma’s products and services at croma.at Croma-Pharma GmbH Julian Popple: Country Manager UK Phone: +44 (0) 7442341 227 Email: julian.popple@cromapharma.com Orders: customerservice.uk@croma.at Website: www.croma.at This article is written and supported by Croma-Pharma 47

Higher style.

Higher power.

HIGHER iQ Laser hair removal continues to be a huge market. With over 13 million treatments expected in 2020, are you ready to offer your patients the best?1

Enter Elite iQ. Featuring Skintel®, the aesthetic industry’s only melanin reader, Elite iQ enables you to customize treatments based on objective melanin measurements, giving you ultimate confidence in the safety and effectiveness of the treatment.

To find out more visit cynosure.co.uk or call 01628 522252

1 2020 data. Energy-Based Ax Devices. Medical Insight, Inc. October 2019. *Compared to previous generation devices.

The Elite iQ aesthetic workstation is indicated for the following, but not limited to: permanent hair reduction and treatment of veins, noncancerous pigmentation, wrinkles, warts, scars and ingrown facial hairs. Common side effects include redness, swelling, crusting and scabbing. Other side effects may include blistering, burns, hives and lightening and darkening of the skin.

Like all medical procedures, not all patients are suitable for the treatment. A qualified practitioner is solely responsible for evaluating each subject’s suitability to undergo treatment and for informing those being treated about any risks involved with the treatment, pre-and postoperative care, and any other relevant information. Individual results may vary and are not guaranteed. ©2020 Cynosure, LLC. All rights reserved. Cynosure, Elite iQ and Skintel are trademarks and/or registered trademarks of Cynosure, LLC. Cynosure, LLC owns exclusive rights to photography.

Use of photography without written permission of Cynosure is prohibited. PRD_3507

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A summary of the latest clinical studies Title: Thread Lifts: A Critical Analysis of Treatment Modalities Authors: Adam A, et al.

Published: Journal of Drugs in Dermatology, April 2020 Keywords: Threads, ageing, complications Abstract: The thread lifting procedure was developed to reverse the aging process and restore youthful appearance by retightening and lifting the skin. Different models of absorbable and non-absorbable threads are universally available and promise quick results with minimum downtime. The objective was to evaluate the efficacy, safety, and cost effectiveness of the commonly used threads for facial lifting and rejuvenation using an evidence-based review. A comprehensive search of the literature was done using numerous databases. The extracted data included significant details related to the review question. Several types of threads with different designs and properties are available for facial rejuvenation, provided by many companies all over the world. Higher quality evidence was found for Contour thread (III). Available studies for the other various threads were level IV. Thread lifting procedure was found to be safe and effective, with minor and mostly self-limited complications. The longevity of results varied from months to years, with more focus related to the technique and patient selection rather than the type of thread. Comparatively high quality long-term multicentre standardized studies are required to help aesthetic doctors to choose the appropriate thread type based on optimum aesthetic outcomes.

Title: Developing a Topical Adjunct to Injectable Procedures Authors: Widgerow AD, et al.

Published: Journal of Drugs in Dermatology, April 2020 Keywords: Injectable, skin, peptides, anti-inflammatory Abstract: Injectable procedures have come to play an enormous part in everyday aesthetic medical practice. Whether its use is directed at volumizing with fillers, decreasing volume using enzymes, skin-tightening using multi-needle approaches, or neuromuscular blockade, the injectable route is the means of delivery in all these cases, making injectable procedures the most common aesthetic procedure performed. As with all procedures, expected and unexpected consequences may follow including bruising, swelling, discomfort, and the possibility of infection. This paper outlines the scientific process and validation of a product designed as an adjunct to injection therapy and the scientific deep dive needed to encompass both symptomatic and adjunctive purposes. Utilizing peptides and active agents aimed at reducing excess residual iron and stimulating macrophage absorption of red blood cells, we were able to achieve efficient resolution of bruising. In addition, peptides were included to stimulate collagen, elastin, and hyaluronic acid in synergy with the injectable. Antiinflammatory, antimicrobial, and antibiofilm agents were added to aid in the safety profile of the injectable. In vivo testing of bruising resolution demonstrated that at day 2/3, participants. Overall, 81% of subjects applying the study topical product had less bruising at day 2/3 compared to the bland moisturizer.

Title: Microneedling Treatment of Striae Distensae in Light and Dark Skin With Long-Term Follow-Up Authors: Alster TS, Li MK Published: Dermatologic Surgery, April 2020 Keywords: Striae distensae, skin, microneedling Abstract: Striae distensae have notoriously been difficult to treat due to their extensive involvement of nonfacial skin. Microneedling with its lack of thermal injury during microneedling treatment renders it a viable treatment option in darker skin tones and nonfacial regions due to the reduced risk of postinflammatory hyperpigmentation. The objective was to describe the clinical results and side effects of microneedling in a series of 25 individuals with striae distensae. Twenty-five consecutive adults (SPT I-V) with striae distensae involving the trunk and extremities were treated using a microneedling device. All striae improved at least 50% after an average of 1.8 treatments, and 28% of patients demonstrated more than 75% clinical improvement. Striae in thicker skin regions (e.g. buttocks/thighs) showed comparable clinical improvement than those in thinner skin areas (e.g. breasts) and did not require additional treatment sessions. Side effects were limited to transient erythema in all skin phototypes. No infections or dyspigmentation were observed. The clinical results obtained in this study support the safe and effective treatment of striae distensae with microneedling in light and dark skin tones in various body locations.

Title: The M.A.STE.R.S Algorithm for Acute Visual Loss Management After Facial Filler Injection Author: Graue G, et al.

Published: Journal of Cosmetic Dermatology, April 2020 Keywords: Occlusion; dermal filler, complications, injections Abstract: To propose an algorithm of treatment for sudden visual loss following filler injections and perform an Englishwritten literature search for assignment of evidence level and grade recommendation. Algorithm of treatment includes ocular physical Maneuvers, hyaluronidase administration, intravenous Steroids, intraocular pressure Reduction, and Supplemental Oxygen (M.A.STE .R.S) based on previous acute management reports. Special consideration for algorithm buildup was made for ophthalmic diseases that share physiopathological features such as central retinal artery occlusion, systemic vasculitis affecting vision, and acute glaucoma. Finally, a systematic cross-review of the reported cases with visual loss was done to identify the level of evidence and grant a recommendation grade. A search through PubMed and Medscape databases for English-written scientific papers using the terms facial filler, retinal artery occlusion, management, treatment, complications, and adverse events quoted a total of 46 papers (190 cases) which were then analyzed. A high variability on management for treatment of sudden visual loss after facial filler injections was observed. This was attributed partially to the great diversity of medical specialists performing cosmetic facial procedures.

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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losing their jobs due to COVID-19 and was then extended to include directors listed with Companies House. It is not available to sole traders, unless they are listed as an employer; they can then claim for their staff.1 HMRC states that if you have furloughed yourself or your staff you can then claim 80% of the regular salary you would normally pay your employee(s) and yourself. If you are a director, you can only claim 80% of the salary part of your income; dividends are not included, and you can claim up to £2,500 per month.

Please note that although It was previously stated by HMRC that the employees/directors must have been on the payroll scheme on/ before February 28 2020, this has now been updated to included employees/directors up to March 19 2020.1 Since the CJRS has been released it has become apparent that many accountants on behalf of directors do not run an online payroll scheme with HMRC. As such, I would suggest that you immediately register with HMRC (as a PAYE Scheme) or ask your accountant to do so if you have taken the nominal salary and you haven’t run a payroll (if you are taking the nominal salary you must be on the PAYE scheme, regardless of the CJRS). Once you have the scheme set up you will need to run late submissions for the pay periods that you physically took your salary Accountant Samantha Senior outlines the payment from the business. Note that after April grants and schemes available to clinic owners 19, however, a Early Year Adjustment will need to be submitted rather than a late submission.

As the current global pandemic unfolds, clinics are still closed Enrolling onto a PAYE scheme now may not automatically deem you and a number of medical aesthetic practitioners are back on the eligible, but I would recommend you do it anyway and explain to frontline helping support the NHS. Whilst no-one can escape the HMRC why you have made a late submission. Then submit evidence magnitude of the human cost and uncertainty of COVID-19, clinic of your salary paid into your personal account, on the same dates as owners have the extra worry of wondering, will their business survive? the late submissions.

And what kind of financial help might be available? The grants or schemes you might be entitled to will depend on whether you are a sole trader, partnership or limited company. Another factor to consider is whether you are renting/own a commercial property, have a clinic in your home, or are renting a room within a business/clinic. This article will consider what aesthetic practitioners need to know during these unprecedented times and help you find the resources and financial assistance you might need.

Understanding COVID-19 Support

Coronavirus Job Retention Scheme While many of you may have already looked into or actioned this, it may be useful to have a thorough understanding. The Coronavirus Job Retention Scheme (CJRS) is basically furloughing staff (including directors) and claiming back 80% of their regular wages.

Having not been familiar with the word until COVID-19, the explanation is evident now. The Oxford Dictionary definition of ‘furlough’ is: ‘If workers are given furlough, they are told to stay away from work for a certain period because there is not enough for them to do’. But what does the word mean for aesthetic clinics that need to close during the COVID-19 crisis? What happens to your staff, and can directors of limited companies furlough themselves?

The CJRS was introduced as a measure to protect staff from

CJRS was introduced to protect staff from losing their jobs due to COVID-19 and was then extended to include directors listed with Companies House

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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Businesses with property – Small Business Rate Grant Most aesthetic practitioners work in a clinic they rent or own directly, have part of their home converted into a clinic or rent a room in a salon/clinic. If you own/ rent your own clinic, or have part of your home converted into a clinic, it is likely you will have a rateable value. If this rateable value is less than £51,000 you will be

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eligible for the Small Business Rates Grant (SBGF). Unfortunately, if you rent a room (sub-let) from another business it is unlikely that you will be responsible for the rates of the business and, therefore, will not be eligible for the grant.12 The chancellor has now increased the SBRG from £3,000 to £10,000.12 Please remember that if you are eligible for the SBGF, it will be taxable.

Therefore, it will be treated as income on

You do not need additional payroll software to do this, you can download HMRC’s Basic Tools, which allows you to run a payroll and submit it to HMRC.2 In addition, Endeavour Law, an employment law specialist firm, highlights that a record of an employer’s furloughing communication must be kept for five years, as HMRC could investigate the validity of claims in the future. The law specialist states, ‘Employees must be told in writing and a record of that communication kept. Claims should be started from the date the employee finishes work and begins furlough – not the date they are notified of furloughed status (i.e. date of communication)’.3 After you have agreed to furlough your staff and/or yourself as a director, you must follow the guidelines from HMRC. Furloughed employees must not carry out any work for the business. Directors of limited companies that agree to be furloughed should not carry out any work for the limited company that generates revenue.4 I would recommend reading The Coronavirus Act 2020 Functions of Her Majesty’s Revenue and Customs (Coronavirus Job Retention Scheme) Direction.4 It has a lot of important detail and, of particular relevance, is the clarification that a furloughed director may only undertake work, ‘To fulfil a duty or other obligation arising by or under an Act of Parliament relating to the filing of company accounts or provision of other information relating to the administration of the director’s company’. Paragraph 6.6 gives a very narrow interpretation of the ‘work’ which can be done.4

your profit and loss account.12 To apply for the grants, local councils have updated their websites to include an online form. I would advise that you dig out the invoice of the rates and use the reference number to apply online at your local council’s website; even if you receive the small business rate relief, you will still be issued with a rate invoice (valued at 0.00) every tax year.

limited company. Just make sure you follow HMRC’s guidelines on becoming self-employed. You can read my article in the January 2020 issue of Aesthetics which shares advice on how to become selfemployed and what requirements need to be fulfilled.7 Another point to consider is that if you are in a position where you are debating to furlough or not, I would consider that for 80% of the optimum salary (for a single director company) of £719 – which equates to £575.20 per month – is it worth not furloughing and working on your business to stay ahead of the competition? Creating content, marketing material and engaging in potential patient relationships may constitute to more revenue in the long term than the income the grants provide. It is at the discretion of the individual director, but it is worth weighing up if it is beneficial to furlough or not. HMRC has promised that the first portal to claim CJRS will go live on the April 20, which is after the time of writing so is hopefully now in place.8

Statutory Sick Pay refund Employers are allowed to claim a full refund of Statutory Sick Pay (SSP) of up to two weeks for any employee including directors who are away from work due to COVID-19. This means your employees and directors may be eligible for £95.85 for up to 28 weeks.9 The Government is still working on the legislation and the scheme, and as soon as it is updated it will be included on HMRC’s website.

Coronavirus Business Interruption Loans Scheme In regards to what constitutes as generating income and what is administration, financial journalist Martin Lewis notes that it still isn’t entirely clear, giving two examples of conflicting advice from two separate departments at HMRC. When asked if a director can continue to work on marketing their business, for example preparing marketing materials at home, designing leaflets etc., one said it was acceptable, while the other said it wasn’t.5 It is clearly still a grey area, so I would recommend reading the Coronavirus Act 2020 para 6.6 carefully and consider HMRC’s statement: ‘Where furloughed directors need to carry out particular duties to fulfil the statutory obligations they owe to their company, they may do so provided they do no more than would be judged reasonably necessary for the purposes, i.e. they should not do work of a kind they would carry out in normal circumstances to generate commercial revenue or provides services to or on behalf of their company’.4 It is also worth noting that if you are furloughed as an employee or director you are not able to work for your business/ limited company that is furloughing you, BUT you can work elsewhere – if you are able too.5 This also includes freelancing.

As long as it adheres to the social distancing guidelines there is no reason why you can’t freelance your skills; maybe as an online tutor to other practitioners to create an income unrelated to your

On March 17, the Chancellor announced an unprecedented package of Government-backed and guaranteed loans to support businesses, making available an initial £330 billion of guarantees – equivalent to 15% of GDP.10 The Coronavirus Business Interruption Loan Scheme (CBILS) are loans for businesses that do not fit the criteria for normal borrowings, and the Government will pay the interest for the first 12 months.11 I would speak to your accountant and your financial advisor before looking at a loan. The loans can be obtained directly via your own business bank or from various lenders. For those businesses that use a separate personal account for their business, I would recommend opening a separate business bank account as soon as possible as per the requirements.

Sole traders/partnerships Self Employment Income Support Scheme The Self Employment Income Support Scheme (SEISS) is 80% of the Average Monthly Trading Profit. According to HMRC’s website the criteria is as follows; sole traders and partnerships can claim the SEISS and you will be eligible if you:13 • Have submitted your income tax self-assessment tax return for the tax year 2018-19

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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• • • •

Traded in the tax year 2019-20 Are trading when you apply, or would be if it weren’t for COVID-19 Intend to continue to trade in the tax year 2020-21 Have lost trading/partnership trading profits due to COVID-19

Your self-employed trading profits must also be less than £50,000 and more than half of your income from self-employment. This is determined by at least one of the following conditions being true:13 • Having trading profits/partnership trading profits in 2018-19 of less than £50,000 and these profits constituting more than half of your total taxable income • Having average trading profits in 2016-17, 2017-18, and 2018-19 of less than £50,000 and these profits constituting more than half of your average taxable income in the same period If you have not submitted your income tax self-assessment tax return for the tax year 2018-19, you must have done so by 23 April 2020.

This was an extra breather from HMRC, as the 2018-19 Tax Return was due on January 31 2020 so there is unlikely to be a further extension.13 HMRC will use data on 2018-19 returns already submitted to identify those eligible and will risk-assess any late income tax returns filed before the 23 April 2020 deadline in the usual way. It important to note that at present there is nowhere to apply for SEISS – HMRC has stated that you will be contacted accordingly and the grant will be paid automatically in June. If you are eligible and wish to calculate your grant amount, you need to collate your tax calculations for the relevant tax years. If you have not traded in the full three years, you only need the tax calculations for the years that you have traded/ submitted (and work the calculation based on the years you have).

To find your tax calculation: • If you filed your own self-assessment tax return, you can log on to your Tax Account at gov.uk and in the ‘Tax Years Options’ you will be able to click on the relevant years and print out your tax calculations.

• If your accountant filed your tax returns and used a HMRC agent account to do so, you should be able to print out the returns as above.

• If an accountant filed your tax returns using third-party software you should have a copy of your tax calculation sent to you by your accountant before and after it was submitted – if you can’t find this your accountant should have a copy.

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If you are furloughed as an employee or director you are not able to work for your business/limited company that is furloughing you, BUT you can work elsewhere company. Another point to mention is that for the SEISS, you can carry on working for your business (unlike furloughed employees or furloughed directors) as long as it adheres to the Government guidelines on social distancing.13 Deferral of self-assessment payments on accounts and VAT payments This section is relevant to individuals who pay their tax on account.

For example, if you had more than £1,000 of tax to pay for the last tax year, you will automatically have been asked to make a payment for the following tax year, which is an estimate based on the previous year’s tax due. This payment on account is normally due by July 31, which has been deferred to January 31 2021, and can be paid in full or via a payment plan. No penalties or interest will be charged on the deferred payment.14 The same goes for VAT payments; if you owe VAT, you will be able to defer the payment. The period covered by the VAT deferral is March 20 to June 30 2020, and the payment can be deferred until March 31, 2021.15 I would recommend that if you pay by direct debit, you cancel this immediately to create some cashflow.

You will still need to complete and submit your VAT returns as normal.

Universal credit This is available for anyone (unless you are already claiming working/ child tax credits) who is self-employed or is a furloughed director.

HMRC has removed the minimum income floor. individuals who do not have more than £16,000 of capital can claim.16 Claiming is all completed online and there is an option for a hardship fund, which

The figure that you need from your tax calculation is ‘Profits from Self Employment’, which is the same as what the Chancellor is calling ‘Trading Profits’. See Figure 1 for an example.

Tax year Profits from self-employment Please note, if your profits are in the same region as the example detailed, it is likely that you will have been 2016/2017 £25,000 advised to set up a limited company for the tax-saving 2017/2018 £35,000 benefit. In this scenario, as the eligibility for the SEISS £51,000 (note that even though this one year is above the 2018/2019 is that you continue to trade (as self-employed) in £50,000 cut off it is not the average for the three years) 2019/2020 and continue to trade in 2020/2021, you Total profits from self-employment = £111,000 will need to ensure that your self-employment income Average (divide by 3) = £37,000 Monthly average (divide by 12) = £3,083.33 is more than your employment income (and dividends) Monthly grant (80%) = £2,466.66 from your limited company, or you will not be eligible 13 Therefore, the three-month payment in June will be £2,466.66 x 3 = £7,399.99 for the SEISS grant. I would recommend contacting your accountant and ask them to advise the best route Figure 1: Example of how to calculate your possible grant amount for the Self Employment Income Support Scheme in regards to continuing as a sole trader or a limited

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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can pay out on the same day.16 I would refer to Universal Credits directly to complete its online calculator to see if you are eligible, which will be dependent on your personal circumstances and savings. The LITRG has free advice and resources in regards to Universal Credit.17

Samantha Senior is the founder of SAS Accounting, which was established in 2004. She is a member of the Association of Accounting Technicians and has experience in accounting for small and medium businesses, as well as large limited companies. Senior is currently running a support group to enable small businesses to have access to accurate advice throughout the COVID-19 pandemic.

Limited companies

REFERENCES 1. Gov.uk, Check if your employer can use the Coronavirus Job Retention Scheme <https://www.gov.uk/ guidance/check-if-you-could-be-covered-by-the-coronavirus-job-retention-scheme> 2. Gov.uk, Download HMRC’s Basic PAYE Tools < https://www.gov.uk/basic-paye-tools> 3. Reeves, L, Further furlough guidance for employers, Endeavour Law <https://endeavour.law/blog/ further-furlough-guidance-for-employers/> 4. Gov.uk, The Coronavirus Act 2020 Functions of Her Majesty’s Revenue and Customs (Coronavirus Job Retention Scheme) Direction <https://assets.publishing.service.gov.uk/government/uploads/ system/uploads/attachment_data/file/879484/200414_CJRS_DIRECTION_-_33_FINAL_Signed.pdf> 5. Facebook, Martin Lewis, <https://www.facebook.com/mrmartinlewis> 6. Gov.uk, Claim for your employees’ wages through the Coronavirus Job Retention Scheme <https:// www.gov.uk/guidance/claim-for-wage-costs-through-the-coronavirus-job-retention-scheme> 7. Senior, S, Understanding Tax Requirements, Aesthetics <https://aestheticsjournal.com/feature/ understanding-tax-requirements> 8. Gov.uk, COVID-19: guidance for employees <https://www.gov.uk/government/publications/guidanceto-employers-and-businesses-about-covid-19/covid-19-guidance-for-employees> 9. Gov.uk, Statutory Sick Pay (SSP) <https://www.gov.uk/statutory-sick-pay> 10. Gov.uk, Support for those affected by COVID-19 <https://www.gov.uk/government/publications/ support-for-those-affected-by-covid-19/support-for-those-affected-by-covid-19> 11. The CBI, Coronavirus Business Interruption Loans Scheme <https://www.cbi.org.uk/articles/thecoronavirus-business-interruption-loans-scheme/> 12. Gov.uk, Coronavirus (COVID-19) guidance on business support grant funding <https://www.gov.uk/ government/publications/coronavirus-covid-19-guidance-on-business-support-grant-funding> 13. Gov.uk, Claim a grant through the Coronavirus (COVID-19) self-employment income support scheme <https://www.gov.uk/guidance/claim-a-grant-through-the-coronavirus-covid-19-self-employmentincome-support-scheme> 14. Gov.uk, Coronavirus (COVID-19): what to do if you’re self-employed and getting less work or no work <https://www.gov.uk/guidance/coronavirus-covid-19-what-to-do-if-youre-self-employed-and-gettingless-work-or-no-work> 15. Gov.uk, Deferral of VAT payments to coronavirus (COVID-19) <https://www.gov.uk/guidance/deferralof-vat-payments-due-to-coronavirus-covid-19> 16. Gov.uk, Apply for Universal Credit <https://www.gov.uk/apply-universal-credit> 17. LITRG, Coronavirus guidance <https://www.litrg.org.uk/tax-guides/coronavirus-guidance> 18. Gov.uk, Apply for more time to file your company’s accounts <https://www.gov.uk/guidance/apply-formore-time-to-file-your-companys-accounts> 19. Wilson Field, Wrongful Trading <https://www.wilsonfield.co.uk/wrongful-fraudulent-insolvent-trading/ wrongful-trading/> 20. Gov.uk, Regulations temporarily suspended to fast-track supplies of PPE to NHS staff and protect companies hit by COVID-19 <https://www.gov.uk/government/news/regulations-temporarilysuspended-to-fast-track-supplies-of-ppe-to-nhs-staff-and-protect-companies-hit-by-covid-19>

Extended deadline for filing company accounts The Government has extended the deadline for filing company accounts for three months. To apply for this extension, you will need to complete an online form at the Companies House website. It will be fast-tracked and automatically accepted during the pandemic.18 Suspension of wrongful trading rules Wrongful trading is when a director enters into a financial agreement with a creditor knowing the company has no money.

There are strict guidelines in regards to wrongful trading, and it has severe repercussions for directors as it is a civil offence.19 In these unprecedented times, the wrongful training rules have been suspended, taking the pressure from the director of the business, and the Government is trying to ensure that limited companies emerge intact from the pandemic, giving them breathing space from creditors.20 Further details on the suspension of wrongful trading will need to be announced to ensure that it is not abused.

Nevertheless, businesses genuinely struggling due to the lockdown will have some reassurance.

Moving forward During these times of uncertainty, I suggest you follow HMRC and Low Income Tax Reform Group (LITRG) websites for accurate advice. In regards to furloughing staff and directors, I would recommend that you get legal advice from the Advisory, Conciliation and Arbitration Service (ACAS) or an employment lawyer. I would also suggest that you contact your own local council or Local Enterprise Partnership (LEP) Growth Hubs to access a wealth of free information and guidance. Some local councils/LEPs have funds of their own to distribute to businesses that need help, which are shared at their discretion.

NOTE: The help available and cited in this article is correct at the time of writing, however some changes may have occurred at your time of reading.

AESTH ETICS AWARDS ENTRY OP E NS JUNE 1 Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

1 + 2 OCTOBER 2020 | EXCEL LONDON, UK

The UK’s largest gathering of medical aesthetic practitioners

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

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5,873 Attendees

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

Nancy Ghattas, Associate Vice President Country Manager, Allergan

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

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Dr Marwa Ali, Harrods Wellness Centre

Book your stand now www.ccrlondon.com

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it would lead to 50/50 splits in aesthetic clinic patient lists. So, without pandering to stereotypes, how do we build a male database?

Treatments ‘for men’?

Attracting Male Patients Digital specialist Alex Bugg and branding professional Russell Turner explore how to increase the number of men visiting your clinic for treatment It was lad culture in the 90s, in came the metrosexual in the 00s, now we have ‘the modern man’. Typically seen as being confident to acknowledge he cares about how he looks, the modern man is willing to adapt to new things, technologies, styles, trends and skills, according to a recent Huffington Post article.1 Yet, despite this, building a male clientele is always going to require more work than a female one. Anecdotal evidence suggests that this is largely due to general uptake, perception of aesthetics as ‘beauty’, and acceptance amongst peers. Accurate information on non-surgical treatment audits is harder to find than surgical data.

The British Association of Aesthetic Plastic Surgeons’ annual survey of cosmetic surgery indicated that nearly 27,000 procedures took place in 2019, but only 7.9% of these were on male patients.2 Could this data correlate into the nonsurgical side of aesthetics? It could certainly be possible.

Aesthetic practitioner Dr Munir Somji of Dr MediSpa clinic says that in his seven years in medical aesthetics he has seen male patients go from one in 50 patients to 33% of his database. When asked does being a man influence his success, he says, “I think there is an advantage as a male practitioner because I am able to give immediate visual feedback to prospective male patients to dispel common misconceptions of having aesthetic treatments. I find that most men fear the ‘feminine’ look and when they see that actually the opposite can be achieved, they are more comforted by this.”

It is important to note that there has been a backlash against gendered marketing.

Cosmetic products have been especially scrutinised, which has come about from price gouging for female razors, identical products being sold in pink and blue packaging, or what is known as the ‘pink tax’.3 If this backlash was successful though,

The untapped male market is clearly vast.

To build your male database, you must firstly make it clear in your messaging – through your online presence and in-clinic marketing – that you A) treat men and B) have offerings tailored to their needs. Demonstrate that you understand before you are understood; it is important to present treatments using terminology men relate to.

Pivoting your current offering to service male patients is as simple as evaluating it and identifying treatments that they could benefit from. This could be a single treatment, or creating combination therapies which address complaints. Even if the treatment offers exactly the same results for women, demonstrating how they can also benefit men is step one into building your male database.

For example, consider: • Fillers: can be used for masculinisation, to look less tired, or for correction of a single point e.g. non-surgical rhinoplasty • Anti-wrinkle injections: the same messages you use for women should also apply; e.g. to look fresher, younger, less tired, or to treat sweating • Facials: instead of ‘facials’ position them as ‘face treatments’ and use terminology such as ‘chill-out time’ instead of words such as ‘relaxation’ as you normally would for women • Hair treatments: as discussed later, both surgical and non-surgical hair restoration is becoming increasingly popular with men and promoting this demonstrates that you can support them in their journey • Acne treatments, scarring treatments and minor surgery: will all be applicable to men

Male profiling Creating personas is the key part of branding businesses and services – male and female patients alike – and is a good place to start when you begin to think about attracting more men to your clinic. Knowing your target audience is integral. It is useful to create an avatar of your ideal male patient – and understand that this is who you are talking to.

Develop your understanding of his sexuality, age, race, language, likes, hobbies, work, interests outside of work, taste in music, films and food, as well as his cultural influences.

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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You should also ask yourself questions such as: • How old are they?

• How much do they spend on personal care a month?

• Who are they influenced by?

• Are they into sport and if so what sports?

• What communication style do they relate to?

• What car do they drive?

• What TV shows do they like?

These are some of the factors you should know about any patient and if you have done your job properly, you will already know all of this about your female patients. Do the same for your male patients and if you do not know – then start brainstorming and researching.

Branding and use of colour Should you de-feminise the aesthetic clinic?

Gendered marketing may be considered old fashioned, yet still, aesthetic clinics generally see almost all of their patients as female, and use colours and messages that we have been conditioned to associate with women since marketing began.

Is a pink and purple clinic going to attract men at scale? If you don’t want that market then fine, but do consider colour as part of your overall message. Dr Somji says, “Your website is a shop window, so if it looks like a nail salon and is branded in pinks and purples then men will be apprehensive to enter.”

Colour is often an undervalued, non-verbal communication tool, with brand owners often choosing their favourite colour, ignoring research and so missing a key strategy. The Shutterstock Guide to Colour in Design is a great introduction to colour theory, the psychology behind it and how to use colour

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in branding.4 Cool colours, hot colours and soft colours all relate to familiar items, surroundings and can communicate a mood.

In our professional experience, medicalgrade skincare benefits from coming in clean, neutral packaging with minimal colour, but the online branding does lead to femininity in some cases. Remember to stick to neutral colours online too.

Imagery We buy when we feel connected and potential male patients will feel more connected to your service offerings if they see images of other men when browsing your social media platforms and website.

Have a section on your website dedicated to male interpretations and include imagery on there of men of all ages and ethnicities.

Before and after images with male case studies will be especially powerful here.

For men in particular, considerations should be made when promoting body contouring treatments such as the newly-popular muscle stimulation, or fat freezing procedures due to body dysmorphic disorder (BDD). Social pressures to build the perfect gym body are becoming increasingly common in men5 and clinics should remember to consider the risks before using images of men who are way beyond average build or who may have used performance-enhancing drugs to get their physique. The fitness conscious would also see these treatments as cheating, so these types of treatments should be sold as addressing the last stubborn areas that tough workouts won’t shift. For the already body beautiful, focus on the face, as these guys will likely be keen to enhance their facial features too. Images of sharp, chiselled jawlines and cheekbones, associated with male models and superheroes, are the aspiration.

Pivoting your current offering to service male patients is a simple as evaluating it and identifying treatments they could benefit from

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Your range of male imagery is easy to achieve with stock; getting your own photography with a cohort of male patients is perhaps harder to arrange, but you have complete control.

Wording Your choice of language when writing your male content could be different – if you’re choosing to have a male and female segment, rather than de-feminising or looking to improve inclusion for men in your marketing, consider the following: • Focus on benefits such as ‘younger, stronger, long-lasting’ • Use facts and statistics to support your marketing messages • Solve problems (e.g. treat a receding hairline, eliminate stubborn fat, remove unwanted tattoos compared to feel more nourished, moisturised and confident) • Move away from outdated, stereotyped messaging such as ‘macho, masculine, win the girl’ and think about terminology that will appeal to all, such as ‘strong, confident and self-care’ Again, testing these messages with male patients, or male family/friends, allows an insight – especially if you are a female practitioner!

Reviews and referrals On your website and social media, you must include social proof in the form of reviews or patient testimonials. Words are good, videos are even better. Included in these should be reviews from male patients. But do men want to share even less than women do about having treatments? We do not know the answer to this until we ask our male patients. Privacy in aesthetics should always be respected, but simply not asking men to appear in video testimonials, treatment videos or even just written content due to this fear is unwise. Word-of-mouth recommendations come as the best form of organic (free) enquiries. Dr Somji says, “Referrals from female partners and friends is one of the largest avenues we have found for building Dr MediSpa’s male database. Once men see that their partners/friends look refreshed they feel a lot more confident to come in.” Dr Somji also advises to offer promotions or gifts for referred patients, specifically male patients if that is your current focus. He says, “Setting up partner referral schemes is always beneficial

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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Knowing your audience How hair treatments can attract male patients to your clinic Hair restoration, both surgical and non-surgical, is a growing market. It is estimated that 60% of men and 40% of women experience some hair loss, and the global market is expected to be worth US $30 billion (£24.3 billion) by 2025.6 Danny Large, director of DSL Consulting, which runs the annual Business of Hair seminar on adding hair restoration services to clinics, says, “Attracting male patients is a part of the aesthetics market which is undervalued, but is growing. Hair restoration has recently seen an improvement in techniques and technology. Many men have been made aware of hair restoration by celebrities, particularly footballers, who have lost hair and have wanted it back. The most famous of these was Wayne Rooney, who really bought hair restoration into the mainstream.”

He adds, “When men see something work for someone else it attracts them; especially if they see a common trait in the article or image, so make great case studies to showcase.”

Thus, offering hair loss treatments at your clinic could be a great way of bringing more men through your doors. You don’t have to train as a hair surgeon; other trichology treatments include low-level laser therapy, medication and scalp tricopigmentation, are available provided you undergo the relevant training or employ a suitably-qualified member of staff in your team. Then, use your marketing messages to suggest further aesthetic treatments that you think might interest them.

and helps open the aesthetic world to men. Even if it’s just for a quick skincare consultation or facial.” Of course, bear in mind advertising guidelines on appropriate use of promotions.

to do this digitally include Google Forms or SurveyMonkey; TypeForm offers a ‘people-friendly’ experience and deeper integration with your other business apps, if you’re prepared to pay.

Database segmentation

Print advertising

Email marketing is still an excellent way to bring current patients back into clinic. Often a ‘broad brush’ email is sent out on a schedule – bi-weekly, monthly, seasonally – regardless of the demographics (of which gender is a part) in the database. Rarely do clinics send a ‘male’ email to their male patients, and then separate ‘female’ communication.

Doing so could be a great way of forging deeper relationships with your male patients.

Start a segmented male database with five patients, for example. Test your ‘men only’ email on them. See if they open the email, see if they click any of your links from your ‘masculine’ email and note what they seem to be interested in. You can use your specific male marketing messages, such as ‘dermal fillers for a more masculine jawline’, or, ‘male hairline restoration’ in these emails and refine your message based on the open and click-through rates you get. To refine your message even further, why not survey, whether formally or informally, your current male patients and ask them what they want to see? What drew them to your clinic? Good free tools

If you have budget, print advertising could correlate to your male persona. A great place to find the ideal male patient is possibly in the gym, so advertising in fitness magazines or through posters/leaflets at your local gym could be of real benefit. You will have an audience that cares enough about how they look to do something about it. If they are prepared to feel the burn in the gym your biggest challenge will be convincing them they need help – that’s where knowledge of male fitness magazines is key.

Additionally, magazines know their readership inside out, so you should take inspiration from them. A flick through the magazines will reveal immediately the tone of voice, and personality of the messaging. Men who buy these publications lap it up so it would be foolish to ignore.

Your clinic needs to be able to demonstrate that you know men as well as you do women, and want to treat and help them rather than just capitalise on an untapped market.

Building a male database could be as simple as starting with what you have. You can update or re-purpose the marketing materials you already have into malefocused messaging, or you could neutralise them. Utilise your current audience, encourage male referrals and then ask them to join your clinic newsletter mailing list. Knowing your target audience is key to success and remember to treat men as you would any customer – as individuals.

Alex Bugg has worked with the Web Marketing Clinic since 2012 and has a key interest in developing strategies for cosmetic clinics and biotechnology firms across the UK and abroad. Bugg also has a Masters’ in chronic disease and immunity from University of Leicester, graduating in 2016.

Russell Turner is the founder of RWT Creative and has more than 30 years’ experience in branding and design. Having worked with brands such as The White Company, Hotel Chocolat and AstraZeneca, Turner now works with cosmetic clinics and brands, aiming to put emotional brand development at the core to build meaningful and lasting relationships.

REFERENCES 1. Sanders S, The Modern Man, Huffington Post <https://www. huffpost.com/entry/the-modern-man_b_13542212> 2. BAAPS, Cosmetic Surgery Trends (UK: 2020) <https://baaps. org.uk/media/press_releases/1807/cosmetic_surgery_trends_ reduction_in_overall_numbers_as_industry_associations_ campaign_for_education_and_tighter_regulation> 3. Elliot C, The Pink Tax, Listen Money Matters <https://www. listenmoneymatters.com/the-pink-tax/> 4. Clem A, Complete Guide to Color in Design: Color Meaning, Color Theory and More, Shutterstock Blog <https://www. shutterstock.com/blog/complete-guide-color-in-design> 5. Body Dysmorphia among male teenagers and men, American Addiction Centres <https://americanaddictioncenters.org/maleeating-disorders/body-dysmorphia> 6. Research and Markets, Global Hair Transplant Market Projected to Reach $30 Billion by the End of 2025 <https://www. businesswire.com/news/home/20190906005396/en/GlobalHair-Transplant-Market-Projected-Reach-30>

Print advertising, especially in nationallydistributed magazines, does come with a cost. So as well as at gyms and in your clinic, consider distributing leaflets and posters on local notice boards and coffee shops to attract more brand awareness.

These are cheaper and more targeted at your local area.

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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Conducting a Successful Video Consultation Aesthetics provides advice for holding patient consultations online With COVID-19 causing aesthetic clinics to close across the country, many practitioners are now turning to video consultations to stay in touch with their patients and keep their business going. However, for some, it can be quite daunting to set up and organise.

For those new to virtual consultations, Aesthetics outlines key considerations to ensure that your patients get the most out of their time with you, and help your consultation go as smoothly as possible.

Organisation Remote consultations can be used for a variety of patients and appointment topics.

According to research and guidance from the University of Oxford, it is possible to conduct limited physical examination via a virtual consult, however you must carry out a physical examination of patients before prescribing the patient any injectable cosmetic medicines.1,2 When setting up an online consultation with a patient for the first time, it’s important to ensure that both patient and practitioner are prepared. You can do this by: • Sending an email or text confirmation of the appointment, with a time and date as you would when setting up a normal consultation • Letting the patient know how the consultation will take place and if there are any particular programs or apps they need to download, with the link required to access the session, for example via Skype, Microsoft Teams, Zoom, Doxy.me, as well as others.

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conducting video consultations, updating information previously given on general online appointments.4,5 Although working outside your usual clinical environment, the NHS states that practitioners should make sure that the background of their video consultation remains professional and that there is privacy.

This will avoid distractions for both practitioner and patient, helping patients to feel at ease to discuss any issues with you and ensure patient confidentiality.4 In theory, the consultation itself should be no different to a face-to-face meeting, although the video quality may cause the picture to be blurry. To avoid this, the NHS recommend that, if the patient wishes you to observe something, for example a skin rash or acne, it would be beneficial to encourage them to send you clear photos prior to or during the consultation; of course in a suitable manner that abides by data protection regulations.4

Setting up

Conducting the consultation

According to new guidance for video consultations for GPs published by the University of Oxford, dependable and a good technical connection (to avoid reduced speed) are important.2 If technical connection is high-quality, it enables practitioners and patients to communicate in a similar way to face-to-face consultations. It is suggested that using ethernet cables can increase internet speeds, so these can be considered to maximise video quality.3 It is also recommended for all parties to restart their computer or device before a call, so that no other software can interfere with the video or microphone.3 In response to COVID-19, the NHS released a set of guidelines for

Throughout the consultation practitioners should take written records, the same as you would in a standard consultation, to ensure that you stay aligned with medical best practice, and ensure that these are kept securely in line with data protection requirements, as with any images shared.6,2 Dr Toby Makmel, aesthetic practitioner and co-founder of aesthetic software company Clinicminds, which features a virtual consultation function, shared some words of advice with Aesthetics. He says, “It’s very important to bear in mind that the majority of patients are not used to doing these kind of appointments, so practitioners will need to make sure they guide their patient through

Top tips for video consultations American plastic surgeon Dr Samir Pancholi, has been conducting video consultations since long before COVID-19. He comments, “Virtual consults are fun and provide a great initial interaction and bond. Maybe it’s because patients are more relaxed in their home vs. the clinic or maybe it’s because it feels more focused for a one-on-one interaction.” When asked what his top tip is for making the consultation run smoothly, he replies, “It can be difficult for patients to focus with this medium. Ask them to try their best to create a calm atmosphere for their consultation. In the office, we can control quite a bit. At home, anything from the dog and kids to ambient traffic noises can interrupt the flow of the consultation. It’s a good idea to have them prepare for a solid 30-45 minute window of uninterrupted time to have the consultation and patient care coordinator meetings.” He continues, “Also, get the lighting right! Avoid sitting with your back to a bright window, though do make use of soft, natural lighting when available.

You can set up simple two-point lighting by sitting near a window and putting a lamp 180 degrees apart from it. Take a look at yourself on camera and make sure you have even lighting from the front without being too washed out. Too much from the back and you will get the ‘angel’ halo effect, while too much from the top can make you look ominous like the villain in a movie.”

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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the process. Instruct them well and take things more slowly – leave longer pauses to account for potential delays and don’t speak too quickly in case the patient can’t catch what you’re saying. You need to give the patient the chance to really take in what you outline, and then give them the opportunity to respond.” If experiencing any technical difficulties during your consultation, telemedicine site doxy.me recommends lowering the resolution of your video. By doing this it requires less bandwidth and computer power, resulting in less disruption during your call. It is also suggested that practitioners could try using headphones to eliminate echo or audio feedback.3 When doing these consultations it’s important to abide by guidance from individual regulatory bodies on remote consultation and prescribing.7,8,9

Closing the consultation To ensure that both parties have all the correct information, the NHS recommends that practitioners should summarise the outcome of the consultation at the end of the call, and ask the patient if they want to ask any final questions before signing off.4

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Following the end of the consultation, practitioners should send a written summary of advice given in the video, and provide the opportunity for patients to book a follow-up appointment. Feedback questionnaires for staff and patients, sent digitally, are helpful so that improvements can be made where necessary. While practitioners may have these already, these can be adapted specifically for video consultations. For example, whether they felt the consultation was kept at a professional level.4

The future of video consultations While video consultations are being used during the COVID-19 lockdown, their use may become common practice in the future. Dr Makmel notes that video consultations can be a good way to encourage new patients to get in touch. He highlights, “For some people, the anxiety of going into a clinic and having a face-to-face appointment stops them from attending. Patients may feel more comfortable to have the first point of contact via virtual means and they can really get more confidence from that. I believe that this makes it more likely for them to come to

your clinic and visit for a second or followup consultation, when they can.” Dr Pacholi agrees, commenting, “I think they are here to stay. They are personable and there is a great translation of information.”

REFERENCES 1. University of Oxford, 2020, <https://elearning.rcgp.org.uk/pluginfile.php/148915/mod_resource/content/3/NHS_VC_Info%20 for%20GPs_v06.pdf> 2. General Medical Council, 2020, <https://www.gmc-uk.org/-/ media/documents/guidance-for-doctors-who-offer-cosmetic-interventions-210316_pdf-65254111.pdf?la=en&hash=B08BAC23313D96E848950838154B5132303F75A5> 3. General Medical Council, <https://www.gmc-uk.org/-/media/ documents/good-medical-practice---english-20200128_pdf51527435.pdf?la=en&hash=DA1263358CCA88F298785FE2BD7610EB4EE9A530> 4. NHS, 2020, <https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/C0044-Specialty-Guide-Virtual-Working-and-Coronavirus-27-March-20.pdf> 5. NHS, 2020, <https://www.england.nhs.uk/wp-content/ uploads/2020/01/online-consultations-implementation-toolkit-v1.1-updated.pdf> 6. General Dental Council, <https://www.gdc-uk.org/docs/ default-source/guidance-documents/high-level-principles-remote-consultations-and-prescribing.pdf> 7. General Dental Council, https://www.gdc-uk.org/docs/ default-source/guidance-documents/high-level-principles-remote-consultations-and-prescribing.pdf 8. Nursing and Midwifery Council, <https://www.nmc.org.uk/ globalassets/sitedocuments/other-publications/high-level-principles-for-remote-prescribing-.pdf> 9. General Medical Council, <https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/prescribing-and-managing-medicines-and-devices/remote-prescribing-via-telephonevideo-link-or-online>

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Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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Becoming a Prescriber Nurse prescriber and clinical academic educator Donna Barleycorn outlines key points to consider before embarking on a prescribing course Many practitioners, especially those who are new to aesthetics, may not be prescribers, however prescribing is an additional skill you may wish to consider to augment your autonomous aesthetic practice and patient management. This article aims to share the considerations to make before becoming an independent prescriber. It also discusses the background to independent prescribing, benefits of being a prescriber, recent national guidance, guidance for prescribing mentors, and practical advice including top tips to consider before embarking on the V300 prescribing course.

Background Since legislation changes in 2006, nurses and pharmacists have been permitted to independently prescribe within their area of competence. Further legal changes over the following six years allowed the prescribing of unlicensed drugs and controlled drugs (with some exceptions) within the nurse/midwife scope of competence.1 From this successful implementation, registered professions to independently prescribe (not including supplementary prescribing) has grown and now includes: nurses, midwives, pharmacists, physiotherapists, optometrists, podiatrists and, most recently, therapeutic radiographers and advanced paramedics.2 But can all these professions prescribe in aesthetics? The Nursing and Midwifery Council (NMC) states, ‘If you hold a prescribing qualification, you must prescribe in line with the requirements of the Code and your individual scope of practice. This applies to all forms of prescribing including remote prescribing, and nonsurgical medicinal products being used for cosmetic and aesthetic purposes, such as Botox’.3 The General Pharmaceutical Council (GPhC) advocates, ‘Pharmacist prescribers who prescribe and

administer non-surgical cosmetic medicinal products must be appropriately trained, they must prescribe and administer nonsurgical cosmetic medicinal products only in line with good practice guidelines, and only after there has been a physical examination of the person’.4 However, the regulations around prescribing in aesthetics does have diversities; the Health and Care Professions Council (HCPC) covers different professions who can prescribe (physiotherapists, optometrists, podiatrists, therapeutic radiographers and advanced paramedics), but there may be limitations for aesthetics and respective scope of practice.

For example, physiotherapists cannot prescribe medicines for purely cosmetic purposes.5 There are also further restrictions on prescribing unlicensed medicines and ‘off-label’ prescribing and control drugs for certain HCPC professions.6 As this is still an evolving field and prescribing for selected HCPC professions is in its infancy, it is beyond the scope of this article to discuss.

Those with questions should contact their regulatory body for up-to-date guidance.

It should also be noted that a number of training courses do not train all HCPC professions in medical aesthetics.

Benefits of independent prescribing The benefits of independent prescribing are widely documented and it has allowed the development of new roles, genuine autonomous practice, better access to medicines and has overall benefited services and patients.7 As an aesthetic practitioner, being able to independently prescribe prescription-only medicines (POMs) including botulinum toxins, first and second-line emergency drugs, reversal agents and anti-microbial drugs is advantageous in terms of patient management, time and autonomous holistic practice.

Undertaking the prescribing course may feel daunting, but the benefits to you personally and professionally, in my opinion, are significant. These include enhancing your consultation skills and assessments, critical thinking, clinical decision making and autonomous practitioner abilities.

New prescribing standards New educational standards for non-medical prescribing are now available and are currently being implemented: Nursing and Midwifery Council Standards for prescribing programmes (NMC 2018),8 Health and Care Professions Council Standards for Prescribing (HCPC 2019)6 and the General Pharmaceutical Council Education and Training Standards for Pharmacist Independent Prescribers (GPhC 2019).9 Due to the complexities of the NMC, HCPC, GPhC regulatory bodies and different entry criteria for prescribing, this article can only provide sign-posting guidance regarding the prescribing standards.6,8,9 For example, under the new NMC standards,8 entry onto a prescribing programme is assessed on evidence of the necessary skills, knowledge and experience.

Practitioners will need to evidence they have the right skills in clinical and health assessment, diagnostics, care management,

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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Top tips This may feel like a lot of information, so here are some top tips to help. → Read the regulatory guidance from each body → Do your homework and research the AEI criteria → Ensure you can attend all the study days and complete the clinical hours → Enquire about a DPP (as discussed previously) – can they offer you varied dedicated clinical supervision and sign off on your hours? Set regular meetings to meet your outcomes. Ensure they are familiar with the sign off documents you’ll be provided with. Ensure you both know the hand-in dates for completion and work towards this → Pharmacology – if this is an area in which you have less knowledge, I would suggest reading and learning before the course. For non-pharmacists, my book recommendations to start with basic pharmacology are referenced below at the end13,14 → Essay writing if this is relevant – you will get academic support and library support but give yourself enough time to prepare the essay or case study and to get an essay draft reviewed → IT – if you have not already, ensure you have access to a reliable computer or laptop → Collect any examples of patient reflections and interesting topics or evidence base practice → Calculations – if this is an area of weakness I would suggest practising daily, there are many online resources that can help too. The pressure to attain 100% pass mark can put more stress on you; in my experience, I have had prescribing students who felt they couldn’t achieve this or worried they could not pass the course. These students were supported and encouraged, they worked so hard to achieve their goal and ultimately passed with the highest grades. → Remember that this course is achievable with time and preparation – you don’t have to be a superhero, but be organised

and the planning and evaluation of care. At the time of publication, all approved education institutions (AEI) are going through the revalidation process of the regulatory bodies to implement the new educational standards, which is due to be completed by September 2020.6,8,9 Some AEIs have been through this and offer the new validated courses and entry criteria, but others are still awaiting revalidation.

All programmes should be operating under the revised standards by September 2020.

The below is an example of some of the entry criteria for the new standards:6,8,9 • Nurses and midwives at least one-year post-registration experience and in the role in which they will prescribe for at least one year • Advanced paramedics at least three years’ relevant postqualification experience in the clinical area in which they will be prescribing and have undertaken or are working towards an advanced practice qualification (as defined by Health Education England, usually an MSc) • Pharmacists at least two years’ appropriate patient-orientated experience post registration, in a relevant UK practice setting • Physiotherapists, podiatrists, and therapeutic radiographers must normally have been practising for at least two years at an advanced level

Choosing the right AEI Although the NMC has changed the entry criteria from three years’ post-registration experience to one-year post registration, pertinently, universities may still add extra stipulations to entry onto the V300 prescribing course for each profession to ensure governance.8

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This may vary from each educational establishment. Ultimately, entry onto the V300 prescribing course is down to the educational establishment’s criteria and validated course requirements. The NMC states the selection process is often a partnership between you, your employer (if you’re employed), the AEI and their practice placement partners.8 Furthermore, not all AEIs offer the course to aesthetic practitioners (but many do) and some may add an extra entry criterion for the aesthetic setting. This may include, for example, being able to demonstrate Level 7 PG Cert in cosmetic/ aesthetic medicine and practice in a private healthcare environment that is regulated by the Care Quality Commission. However, not all AEIs have this extra requirement. Another pre-requisite for all professions onto the prescribing course may include an advanced history taking and physical assessment course. In my personal view and experience of pathway lead for the prescribing course, I would highly recommend undertaking this if you’re not already practising at this level.

This is because the course will prepare you for the prescribing module and augment your autonomous practice.

Deciding on academic levels The next step is deciding on an academic level. In general, the NMC courses can run at both Level 6 (L6) and Level 7 (L7). Allied healthcare professionals and most pharmacist prescribing courses are only validated at L7 and advanced paramedics can only take the course at L7, so this may influence your choice.6,9 This is only a guide so please confer with your chosen AEI as there may be some individual differences at local levels. So, have you already been awarded a degree or diploma? In broad terms, to study at Level 6 (degree level) you will have an advanced diploma, DipHE or equivalent. For Level 7 (Master’s level) you will have a BSc (Hons), unclassified BSc or equivalent.10 The AEI may have further requirements on academic grades acquired for the corresponding award, so please review the academic criteria. If you are eligible

Undertaking the prescribing course may feel daunting, but the benefits to you personally and professionally are significant

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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to study at L7, I would ask, do you require the academic credits, are you on a pathway, or are you going on to complete a full MSc pathway? Please be aware you can use recognition of prior learning, which is normally a module of up to five years into a pathway.10 If you plan to undertake a MSc in the next two years, it may be worth doing L7, so futureproof yourself and discuss this with your chosen AEI. Another consideration is the length of the course. There is a slight variation in the academic credits for the prescribing course, ranging from 30, 40 or 60 credits depending on the location. In addition, obviously L7 will have a slightly higher marking grade to pass. Still unsure? Ultimately the prescribing qualification on the register is the same if you undertake the L6 or L7. So, if you are eligible and you need the academic credits then do L7, if not and you just require the prescribing qualification (assuming is it offered at this level for your profession) then you could complete the course at L6.

Designated prescribing practitioners (DPPs) Alongside the new standards there is updated guidance for those taking on the supervisory and assessing role for prescribing students.

Regulatory changes mean that experienced non-medical prescribers can become responsible for a trainee prescriber’s period of learning in practice in a similar way to Designated Medical Practitioners (DMP).11 In this guidance, the Royal Pharmaceutical Society (RPS) refers to those fulfilling this new role collectively as Designated Prescribing Practitioners (DPPs).11 Terminology generally used by each of the bodies is as follows: • The HCPC uses the term Practice Educator • The NMC standards describe two roles key to learning in practice: Practice Assessor and Practice Supervisor (this must be two different practitioners unless exceptional circumstances apply8) • The GPhC uses the term Designated Prescribing Practitioner (DPP) as the title for this role All three regulators have slightly different requirements which need to be considered. For eligibility of the DPP role, please also review the AEI criteria.

Assessments Assessments for the prescribing course will vary depending on the individual validated AEI programme, however, this could include case studies, clinical management plans (for supplementary prescribing), practice assessments, clinical decision making, patient reflections or an essay. The NMC standards require passing a pharmacology exam with a minimum score of 80%, and passing a numeracy assessment related to prescribing and calculation of medicines (this must be passed with a score of 100%).8 A portfolio of supervised prescribing hours and evidence of mapping to the ‘RPS Competency Framework for all Prescribers’, is also generally required.12 All the new prescribing programmes6,8,9 will deliver outcomes which meet the ‘RPS Competency Framework for all Prescribers’.12 This framework is supported by all three of the regulatory bodies.

for each of the professions and some do not offer the course to independent aesthetic practitioners, but many do, so be prepared to travel if necessary. Ensure you can complete all the clinical hours and have a dedicated DPP, practice supervisor/assessor or educator.

Finally, the key to success here is to plan ahead, have good time management and dedication. It maybe time consuming, even stressful at times, but it’s doable. You can do it, and it will be the best course you will do in terms of patient management and knowledge, professionally and personally, and I promise you won’t regret it.

Note: the above is guidance only and is understood to be correct at the time of writing. Criteria and requirements as stated are subject to change.

Donna Barleycorn is an aesthetic nurse prescriber and clinical academic educator. She has a BSc honours nurse practitioner specialist degree and MSc in clinical education. Barleycorn’s background includes emergency care, medico-legal, professional development and senior lecturer for MSc advanced practice and prescribing pathways. She reviews academic international journals and is a published clinical author.

Qual: MSc BSc Hons DipHE PGcert REFERENCES 1. Cope, L et al. (2016) Nonmedical prescribing: where are we now? Ther Adv Drug Saf 7(4): 165–172 <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4959632/> 2. National Health Service (NHS) England (2016) Allied Health Professions Medicines Project. London: <https://www.england.nhs.uk/ourwork/qual-clin-lead/ahp-2/> 3. Nursing & Midwifery Council (2019) Useful information for prescribers. <https://www.nmc.org. uk/standards/standards-for-post-registration/standards-for-prescribers/useful-information-forprescribers/> 4. General Pharmaceutical Council (2019) Consultation on guidance for pharmacist prescribers. <https://www.pharmacyregulation.org/sites/default/files/document/consultation_on_guidance_for_ pharmacist_prescribers_march_2019_0.pdf> 5. Charted Society of Physiotherapy (2020) Medicines, prescribing and injection therapy. <https://www. csp.org.uk/professional-clinical/professional-guidance/medicines-prescribing-injections> 6. Health & Care Professions Council (2019) Standards for prescribing. <https://www.hcpc-uk.org/ standards/standards-relevant-to-education-and-training/standards-for-prescribing/> 7. Dowden, A. (2006) The expanding role of nurse prescribers. <https://www.prescriber.co.uk/article/ expanding-role-nurse-prescribers/> 8. Nursing & Midwifery Council (2018) Part 3: Standards for prescribing programmes, 2018. <https:// www.nmc.org.uk/globalassets/sitedocuments/education-standards/programme-standardsprescribing.pdf> 9. General Pharmaceutical Council (2019) Standards for the education and training of pharmacist independent prescribers. <https://www.pharmacyregulation.org/sites/default/files/document/ standards-for-the-education-and-training-of-pharmacist-independent-prescribers-january-19.pdf> 10. UK Quality Code for Higher Education (2014) Part A: Setting and Maintaining Academic Standards.

The Frameworks for Higher Education Qualifications of UK Degree-Awarding Bodies. <https://www. qaa.ac.uk/docs/qaa/quality-code/qualifications-frameworks.pdf> 11. Royal Pharmaceutical Society (2019) Competency framework for Designated Prescribing Practitioners. <https://www.rpharms.com/recognition/all-our-campaigns/competency-framework-fordesignated-prescribing-practitioners> 12. Royal Pharmaceutical Society (2016) The Prescribing Competency Framework for all prescribers. <https://www.rpharms.com/resources/frameworks/prescribers-competency-framework> 13. McGavock, H. (2015) How Drugs Work: Basic Pharmacology for Health Professionals, Fourth Edition London, Taylor & Francis Ltd. 14. Page, C, (2018) CrashCourse Pharmacology, 5th Edition London, Elsevier

Moving forward This article has aimed to provided factual and sign-posting information and suggestions regarding the independent prescribing course. Importantly, read the appropriate regulatory guidance.

Research the right AEI for you; not all deliver the prescribing course

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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Boosting Your Profile Learn how you can become better known and respected amongst your peers in the aesthetic specialty A common question many Aesthetics readers ask is, ‘How can I boost my profile in the industry?’ The aesthetics community is small and there are many ‘big’ and ‘famous’ aesthetic practitioners in our field who are known by pretty much everyone. So how do you boost your profile, achieve professional satisfaction and respect amongst Aesthetic nurse prescriber Sharon Bennett has been working in the aesthetic industry for more than 25 years, is the chair of the British Association of Cosmetic Nurses and a key opinion leader for Galderma.

your colleagues? Aesthetics speaks to Mr Dalvi Humzah and Sharon Bennett – two practitioners and Aesthetics Media Clinical Advisory Board members who are exceptionally well-known and respected amongst their peers in the specialty – to gain their insights and tips on how to grow your profile.

Consultant plastic, reconstructive and aesthetic surgeon Mr Dalvi Humzah has been working in the aesthetic field since 1996. He is a regular speaker at national and international events and runs the award-winning Dalvi Humzah Aesthetic Training.

What your profile says about you

Join industry associations, groups and committees

So, you want to be known, but why do you want to be known, and what do you want to be known for? Bennett notes that if you simply want to be famous within your field then you need a fresh perspective.

She explains, “Firstly you need to think about who you want to be, and what you want to achieve. For most, boosting your profile within this industry doesn’t happen overnight and it means working hard, becoming an expert in something and sharing that with the community.

The leading lights you see ‘effortlessly’ presenting on stage put so much work and study into their field and that’s how they got there; they are organised and focused.” When Bennett and Mr Humzah reflect upon their careers, they note that they didn’t actively set out to boost their profiles, although they do acknowledge that much of what they did in the past achieved just that. Mr Humzah jokes, “If someone asks me how to do it, I often just say, don’t try. A good mentor once told me to just develop as much as you can and be good at what you do – develop a professionalism and then people will recognise your abilities.” Bennett suggests that being known and respected across the field does come with its benefits. “You get a lot of professional satisfaction when your peers respect you, come to you for advice, or for mentoring or shadowing. Having this profile and respect is exceptionally valuable for your patients too. It can give your patients faith that they have chosen the right practitioner,” she says. Mr Humzah adds, “As a professional, especially in a medical field, everyone wants to be respected in their specialty and it’s a great feeling when you believe you have accomplished this.”

Associations such as the British College of Aesthetic Medicine (BCAM) and the British Association of Cosmetic Nurses (BACN) are among many industry-specific groups that can aid your professional career, and help raise your profile. Bennett says, “In my experience, being a representative of an association can really open doors. With the BACN I have found myself sitting around a table with Government ministers, advising trade publications and representing the association in Europe, which has absolutely helped my professional profile.” However, you don’t need to be on the committee to benefit from these associations notes Mr Humzah, who is currently assisting BCAM by writing its membership exam. “These groups are a place where you can be a member, but that is all you will be unless you take the next step of getting involved. This means attending their events and annual meetings from a local level, putting your hand up to speak, or helping out at local level events.” An overview of the different industry associations can be found on the Aesthetics website.1

Educate yourself, then educate yourself again Mr Humzah acknowledges that it’s important for practitioners to be on top of their game by knowing as much as they can about their particular subject area. He also says that learning never ends.

“You need to be constantly adapting, continuing your learning and developing over time. If I was still doing the same thing 10 years ago I wouldn’t be very known or respected in my field as things have changed and are completely different now.” Bennett echoes this, noting that formal education, such as the Level 7 Master’s in Aesthetics, will give practitioners a further authoritative voice.

Write for trade publications Both Bennett and Mr Humzah are on the Aesthetics Media Clinical Advisory Board and have been active authors in the field, something which they encourage others to get involved in.

Bennett notes, “When you write, especially about something that is new, interesting and different, it gives you the opportunity to demonstrate that you know your subject and it will often present you with other opportunities. There is no point in writing something you know nothing about, so be sure you know the subject matter well, do your research and reference where appropriate. You might want to start by writing about your opinions – people are interested in other’s opinions, whether they feel they are right or wrong.” Mr Humzah adds, “Approaching trade publications in the sector shows you are actively involved in research and developing the future of your specialty. Writing is kind of like the chicken and the egg; the more you write in specialty journals the more journals start to work with you.”

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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Lecture at events We all know the importance of attending industry events such as the ACE and CCR conferences for networking and learning opportunities.

However, they can also be opportunities to boost your profile, provided you have something interesting or different to say to help further the learning of others. Speaking and lecturing in front of your peers is a good way to get your name out there. Many practitioners will be approached to present, however you can also actively approach event organisers and companies to show you are eager to talk, remembering to be clear on what subjects will be valuable to others and why you’re qualified to speak on them. Bennett says, “Like writing, it’s hard to deliver a great presentation when you don’t know your subject so you should know it inside and out. We encourage our BACN members to present at their regional meetings as they have a really friendly and forgiving audience, so it is great practise.

You need to not only practice your presentation, but how you stand, what you wear, how you look and come across to send the right messages to the audience.” Mr Humzah adds that people need to find their own style when it comes to lecturing, “Don’t be anyone but yourself. If you are apprehensive you can seek training to improve.”

Become involved with an aesthetic company Aesthetic manufacturers and suppliers frequently seek spokespeople to educate their clients and endorse their products and it can be a great opportunity to boost one’s profile if you’re particularly knowledgeable about certain brands. Bennett says, “In my experience, most companies want people who know the products well and can demonstrate a skillset in using them. This comes before their presenting skills for example, because that is something that is more easily taught. The bigger companies generally invest a lot in training their key opinion leaders and will do a lot of promotion for you, provided you work hard for them too. As a representative for companies you may become one of the faces of their brand and be able to speak at events they host or sponsor and train others so I recommend to stay loyal to them.” Mr Humzah advises that practitioners should carefully consider who they work with. “Work with a company that you believe in and never compromise your integrity – always be professional and true to that. Remember that the company has an agenda and you need to be prepared to work within that while still maintaining your boundaries,” he explains.

Be active with industry awards Bennett and Mr Humzah have been very active in both entering and judging industry awards such as the annual Aesthetics Awards.

Bennett explains, “Entering awards can really up your profile and I have found that they can make a big difference both personally and for your clinic amongst both your peers and patients. It draws attention to you – if you win a category such as Aesthetic Nurse of the Year it brings opportunities that might not have come their way before. Even being shortlisted is a great achievement too.” Mr Humzah and Bennett note that becoming a judge can also help with your professional profile as judges will be promoted on the award body’s website and social media. Again, many people will often get approached to become a judge, but sometimes it’s up to the practitioner to actively show their interest and demonstrate why they are of value and suitable for the role.

Overcoming challenges of having a high profile Although being well known in the specialty can present with many advantages, practitioners should be mindful of certain challenges.

“As a professional, especially in a medical field, everyone wants to be respected in their specialty and it’s a great feeling when you believe you have accomplished this” Mr Dalvi Humzah

“Don’t think for a moment that having a profile is all sunny,” Bennett emphasises. Mr Humzah notes that when you have a high profile, you are more exposed to criticism. He says, “You will be challenged when giving a talk for example, but dealing with this falls back to your knowledge base and keeping up with the latest new ideas, studies and what’s happening in the sector.” Bennett adds, “Some people within the aesthetics industry can be unkind – especially on social media rather than face to face – and I have experienced it a number of times. Regardless of if you believe you are doing the right thing, remember that not everybody thinks the way you do. You need to recognise that you will face this challenge and I find that having my good loyal friends in the industry by my side helps me deal with any negativity.” Mr Humzah acknowledges that sometimes difficulty arises in maintaining your profile and being consistent. He says, “I think people need to be careful of being a ‘butterfly’ in the industry – people who flutter about with different companies or groups of people one week, then they are with someone else the next week. This might get you a quick overnight profile, but there is no consistency and I think they risk becoming famous for being famous!”

Mr Humzah adds, “It’s also important that you maintain a degree of professionalism, which can easily slip the more comfortable you become. Remember, it’s very hard to build your reputation but very easy to lose that in one night.” Bennett emphasises, “You must never forget you are a medical practitioner before you are a salesperson. If you are going to be taken seriously in this industry – or specialism – by your peers then you need to maintain a medical focus.”

Be yourself Mr Humzah and Bennett both agree that although there are some ‘overnight stars’ in the field, having a high profile usually follows hard work over a long period of time. Bennett says, “Just be genuine and work hard. Becoming an expert takes time, and you should focus on an area of practice you are genuinely interested in spending time on and are passionate about and then share that with the community – I think you will then get a lot of opportunities.” Mr Humzah concludes, “You have to be who you are and stay true to yourself. Doing what you do well will get you noticed. Then, remember you should be ready to grab the good opportunities that come your way.”

REFERENCES 1. Carver, H, Connecting Practitioners Through Industry Associations, Aesthetics, March 2020. <https:// aestheticsjournal.com/feature/connecting-practitioners-through-industry-associations>

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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Reflecting on Your Business Nurse Tracey Jones provides an introduction to the importance of business evaluation when running your own aesthetic clinic Running an aesthetic business can be both personally and financially rewarding, with many clinics becoming highly accomplished as a result of the strong reputation of their practitioners and services. However, when a clinic is well established with a busy diary, it can be easy to let things continue to run as they are, rather than question what aspects of the business could be improved. It can be constructive to critique and assess your current practices, as well as to incorporate more strategic planning in order to stay ahead of the competition and encourage future success. Practitioners should embrace business reflection and evaluation, which can take place at any point, but should become a regular feature of your business strategy moving forward. This article highlights several areas that aesthetic practitioners can prioritise during the review process, both allowing your business to grow, whilst meeting the expectations of the healthcare regulator such as the Care Quality Commission.

Risk Any business that offers patient care must and should place the assessment of risk at the highest point of priority. Most clinics already place a large focus on this; however, cases reported in both academic literature and the media demonstrate that mistakes continue to occur and cannot be avoided completely.1-5 By reviewing potential risks can ensure that mechanisms are in place to minimise the adverse outcomes should anything go wrong.

Examples of risk factors that need to be considered in an aesthetic clinic might include the collapse of a patient; do you have mechanisms in place to deal with an event such as this, do your team have life support training, equipment on-site or emergency drugs to hand? Or, perhaps another risk factor could be an emergency dermal filler complication such as a vascular occlusion; do you and your staff all have training in this scenario? Do you have an emergency kit that

Keeping a risk register, and being honest about what can be deemed as a risk in your service, can be the most active way of evaluating and improving your care delivery

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is stocked, in date and available at all times?

All your strategies will be deemed as being risk adverse as an emergency has been pre-empted and management planned. Less obvious risks to consider include mechanisms to protect lone workers. Ultimately, the aim for any healthcare practitioner is risk prevention.

This can be achieved by ensuring that your service is safe and effective. A busy clinic is ultimately the goal, however in any healthcare environment patient load is monitored as risk increases the busier the medical team become.6 To determine where your individual risks lie, you must look at your service from fresh eyes. Examine the service you are providing and if anything goes wrong, question if there is an occurring theme that might be causing this to happen. Do the results from your annual patient feedback survey show any negative trends? Is this data measured and then advertised to your wider team so they are aware? Encourage your team to be open and transparent about any issues they have encountered and provide support should it be required. Being open and honest has been a significant thread throughout the National Health Service over recent years and must be integrated into private practice too. Practitioners should assure their employees that reporting mistakes is a positive way of learning.

Keeping a risk register, and being honest about what can be deemed as a risk in your service, can be the most active way of evaluating and improving your care delivery.

Alam (2016) offers a succinct guidance regarding why a risk register is important in healthcare. He clarifies how the underlying causes of medical errors can be related to communication problems, inadequate information flow, human-related problems and inadequate policies and procedures. By examining your own service related to these areas, you can often start to recognise where your risks appear. I would then recommend having a structured system in place where you rate risks and plan your actions to amend them, in order to demonstrate safe practice and good governance.7

Environment A good standard of care and attention to detail at every stage of the patient journey has proven to be a benefit to any organisation.8 When did you last view your clinic environment with a critical eye? Take a moment to walk the walk of your patients and understand how your whole environment might feel to them. Practitioners should reflect on whether there are areas that they

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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can improve, and question their team to see if there is anything they would like to change. Start by entering the clinic through the door your patients use and see how you are greeted by the reception staff. Sit in the waiting area for a few moments and listen to what your patient might hear.9 Is the environment not only pleasant to look at, but comfortable? Are there refreshments in this area and are you telling your patients about your additional services and the positive feedback you have received by other patients? This can all be displayed in the waiting area and is an important feature of any clinic working towards registration with the healthcare regulator as it demonstrates transparency. Advertising your patient feedback enables you to promote your good service to offer assurance to patients waiting for treatment.

Medicine management and safety In all areas of healthcare, the management of medicines is one of the most important aspects of a service. Practitioners can be called to account by their employer, registering body and independent healthcare regulator when there are not processes in place to demonstrate safe practice. Therefore, it is imperative for clinic owners to have a system in hand that is both safe and efficient. For example, clinics must ensure that medicines are accounted for at all times; this can be achieved through regular audits and clear documentation when medicines are received and destroyed. Safety mechanisms, such as firm security related to the storage of medicines, must also be in place, alongside evidence of training in the area of medicine management. When working for any large healthcare organisation it is an expectation that regular mandatory training will take place, which should involve medicine management. This should also be common practice in a smaller aesthetic clinic.10 This not only assures the healthcare regulator of good governance, but also enables practitioners to put time aside for learning and reflection, empowering practitioners to question and implement change.

Policies, guidelines and continuous learning Ensuring that the clinic team embraces learning and continues to develop is another area that can often be overlooked. It takes a lot of effort, commitment and financial input to ensure staff remain continually professionally developed, but it is crucial for keeping

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patients safe as well as for the growth of your clinic.11 Inadequate or inappropriate policies can result in poor practice, so making an evaluation of your current clinical guidelines, governance and human resource processes should be an important aspect of the business assessment. There should be policies and guidelines in place within the clinic that can be a reference point for the whole team, not just the clinical staff. The administration and reception teams should also be able to access and understand this documentation. Note that lengthy documents do not demonstrate clear guidance, so make it extremely clear and fit for purpose. These should be reviewed annually and updated with any new guidance and evidence.11 This documentation should be clear enough for another practitioner to walk into your clinic, and be able to carry out the service continually being assured that safe systems are in place. The most important benefit of clinical guidelines and policies are their potential to improve both the quality and safety of the care being provided. Alongside policy is team learning, ensuring that all of the team can demonstrate and understand the fundamental areas of health provision, such as safeguarding vulnerable adults or information governance.

Fresh eyes Assessing and reviewing your risk, environment, medicine management, safety, and policies and guidelines should be the responsibility of the clinic owner or assigned to a clinic manager. However, sometimes it can be hard to constructively criticise something that is so personal and see it objectively, so a fresh pair of external eyes might be beneficial, such as a fellow professional. It can also be useful to invest in an external review of your clinic as this offers an objective report critiquing your service.

When appointing a company to critique your business, it would be advantageous to ensure that they specialise in aesthetic medicine, or at least the healthcare sector.

Opportunity for change It can be easy within the area of private practice to become insular in many areas, which can really impact patient safety and the growth of your business. An evaluation of your aesthetic business can offer an opportunity for positive change. This is especially true when you recruit staff, create departments within the business, appoint managers or directors and become distanced from the everyday running of the clinic.

Reflection should be a foundation to any evaluation model, as it is key in highlighting areas that need to be improved.

Disclosure: Tracey Jones is the co-owner of Inspire to Outstand, which assists clinics with CQC registration and preparation for inspection.

Tracey Jones is a registered nurse with more than 25 years’ experience, working as a senior nurse with in the NHS. She is currently a senior lecturer at the University of Manchester for nursing and a senior fellow of the higher education academy. Jones is educated to Master’s level and is a published book author.

REFERENCES 1. Funt, D. Pavicic, T. Dermal Fillers in aesthetics: an overview of adverse events and treatment approaches. Clin Cosmet Investig Dermatol; 2013; 6: 296-316.

2. Jordan, D.R. Stoica, B. Filler Migration: A Number of Mechanisms to Consider. Ophthalmic Plast Reconstr Surg. 2015 Jul-Aug; 31(4):257-62.

3. Kim H, Cho SH, Lee JD, Kim HS. Delayed onset filler complication: Two case reports and literature review. Dermatol Ther. 2017 Sep; 30(5). Epub 2017 Jun 6.

4. The Sun Newspaper (2020) Had Our Fill Campaign. <https:// www.thesun.co.uk/fabulous/10804760/were-determined-tohelp-make-the-cosmetic-fillers-industry-safer-why-our-celebsupporters-are-backing-had-our-fill/> 5. Merkle, Walter. Risk Management in Medicine. Berlin, Heidelberg: Springer Berlin Heidelberg: Imprint: Springer, (2016).

6. Schmitz-Rixen, Thomas. Keese, Thomas. (2016) Team-TimeOut: Before It’s Too Late. In Merkle, Walter (Ed) (2016) Risk Management in Medicine. Berlin, Heidelberg: Springer Berlin Heidelberg: Imprint: Springer.

7. Alam, Ali Yawar. Steps in the Process of Risk Management in Healthcare. Journal of Epidemiology and Preventative Medicine (2016). <https://www.elynsgroup.com/journal/article/stepsin-the-process-of-risk-management-in-healthcare Accessed 29/3/2020> 8. Wolf, Jason A. PhD, CPXP; Niederhauser, Victoria Dr PH, RN; Marshburn, Dianne PhD, RN, NE-BC; and LaVela, Sherri L. PhD, MPH, MBA (2014) “Defining Patient Experience,” Patient Experience Journal: Vol. 1 : Iss. 1, Article 3. DOI: 10.35680/23720247.1004 <https://pxjournal.org/journal/vol1/iss1/3> 9. Sachdev, M. Britto, G. R. Essential Requirements to Setting up an Aesthetic Practice, (2014). <https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC4271299/#> 10. Guinan, L. (2019) Back to basics: stepping into aesthetics and continuing professional development. Journal of Aesthetic NURSING Volume 8 Issue 8, October 2019.

11. General Medical Council (GMC) The reflective practitioner. <https://www.gmc-uk.org/education/standards-guidance-and-curricula/guidance/reflective-practice> FURTHER READING • Carthey, J. de Leval, M. Reason, J. Institutional resilience in healthcare systems. BMJ Qual Saf 2001;10:29–32.doi:10.1136/ qhc.10.1.29.

• Ferrolino, M, L. (2018) The economics of aesthetics, Business World. June 19, 2018. <https://www.bworldonline.com/the-economics-of-aesthetics/> • General Medical Council, Guidance for Doctors who offer cosmetic surgery interventions (2016). <https://www.gmc-uk. org/-/media/documents/Guidance_for_doctors_who_offer_cosmetic_interventions_210316.pdf_65254111.pdf> • Singh, H (2019) From information to income: the five ‘I’s for business success. Journal of Aesthetic Nursing Vol. 8, No. 10 Practice Management.

• Wondergem, F. (2019) Building an ethical bridge to quality in aesthetics. Journal of Aesthetic Nursing April 2019, Volume 8 Issue 3.

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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“This is a field that requires a lot of dedication, so you need to stay focused” Dr Vincent Wong tells Aesthetics why he started the first LGBT campaign in the industry, and what he finds most challenging about his career As an aesthetic practitioner and owner of VinDoc clinics in London, Dr Vincent Wong is well known for his work on celebrity faces and has now become a regular speaker at global conferences. So, where did it all begin? Born and raised in Malaysia, he grew up in a culture that was very competitive.

He recalls many of his friends’ parents pushing their children into becoming doctors or lawyers. But for Dr Wong, entering the medical sector was all his decision.

“Contrary to normal stereotypes, I was the one who told my parents I wanted to be a doctor!” laughs Dr Wong. “I was heavily influenced by my godfather, and medicine is what I’ve always been passionate about.

From that point on I worked really hard so that I could make it happen. I did my A-levels in Singapore, and then I decided to move to the UK to complete my medical degree,” he says.

After studying in the UK, Dr Wong achieved a Bachelor of Science and Medicine from the University of St Andrews, and a Bachelor of Medicine and Surgery from the University of Aberdeen in 2010. He comments, “I wanted to study here because the education is highly respected and recognised worldwide. I also wanted to move somewhere that wasn’t very hot after living in Malaysia, so strangely enough I guess you could say I moved to the UK for the weather!”

Dr Wong says he knew early on that he wanted to be involved in the aesthetics field.

“After I left uni, I worked for the NHS for a few years doing general surgery and respiratory medicine, but I’d already started to look into aesthetics on the side. In 2011 I started undertaking specialised aesthetics training with aesthetic practitioner Dr Kate Goldie on her MedicsDirect course. She was the person who created me! Even after training had stopped, I regularly emailed her or her team and kept in contact when I had any questions.

I still view Dr Goldie as my mentor and teacher even when I see her at conferences now – I don’t think that will ever change!

She’s someone who I really look up to.”

Now a clinic owner, Dr Wong offers botulinum toxin, fillers, threads and body sculpting. In the last three years, he has started to specialise in the masculinisation and feminisation of the face for transgender patients. He states, “With trans patients, who they are on the inside often differs from what their external appearance is. The aesthetics specialty offers them a way to change that and become more themselves.”

Dr Wong has been involved with the LGBT community for many years and has since started his own campaign called #IAMME, the first LGBT campaign in medical aesthetics. It involves him interviewing prominent figures in the LGBT community about issues they have faced, and the aesthetic procedures they have had.

He explains, “I first started to become involved in the LGBT community by attending Pride every year. I always liked to be involved in some way – even if it was just being on stage dancing with Sinitta! Through attending these kind of events I met so many people, especially in the trans community, and a lot of them expressed to me that they had always wanted to try things out in aesthetics but they didn’t know where to go to or who to trust.”

Dr Wong explains that he was inspired to try and make a difference. “I wanted to start

something to help and demonstrate how aesthetics can be used in a positive way.

Through this, the LGBT community can learn about what procedures they can get and what practitioners they can go to that will deliver what they want without them having to fear prejudice. It also benefits the practitioners because they are able to learn about the thought processes of, and get an insight into, the trans community.”

Having a career in aesthetics hasn’t always been easy, Dr Wong explains, as the social stigma surrounding aesthetic treatments can sometimes be difficult to break. He comments, “It’s hard dealing with people who have a negative perception of the industry.

Some people are very much against any kind of aesthetic treatments, and because of that I find I get judged by people because of how I look and my choice of career. I’ve also found that some people think that aesthetic doctors aren’t as skilled as ‘real doctors’, which is hard as I’ve put a lot of work into getting where I am.” When asked what advice he would give to anyone entering the industry, he states, “The key thing is to constantly keep updated in aesthetics and see what is actually working for patients.

This is a field that requires a lot of dedication so you need to stay focused. Keep being you, and don’t let anyone alter that!”

What is your biggest achievement?

I had cancer two years ago, and that really put everything into perspective for me. So, my biggest achievement is overcoming that, being able to continue to run my business and being about to realise what life really has to offer.

Tell us your favourite treatment to perform?

That would definitely be dermal fillers. Especially for facial balancing.

Do you have advice for other practitioners?

Don’t give up, have fun and be fearless!

What’s something people don’t know about you?

I’m very good at creative gift wrapping. When I was younger and it came to Christmas or birthdays, I always found that other people could wrap presents better than me, so I learnt by watching videos. Now, people come to me over Christmas to help them gift wrap!

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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The Last Word Dr Preema Vig explores the concerns men have around having facial aesthetic treatments and presents her views on how it can be improved Male patients make up a dedicated, and potentially growing, percentage of an aesthetic practice database. However, despite the established, and ongoing growth in the number of male patients undertaking facial aesthetic treatments such as dermal fillers or botulinum toxin,1,2 some men feel there is still a social stigma attached to having non-surgical facial cosmetic procedures and either do not agree with them or feel the need to hide having such treatments. So, where does this stigma come from? What issues might this present to us practitioners, and is there anything that can be done about it?

Facing the stigma Although I do agree that men are becoming more in-tune with aesthetic procedures, in my experience, many are still not comfortable with vocalising that they have had treatment or think it’s unacceptable for men to have treatment. This could be due to the perception that men who seek and undergo treatments are labelled as vain, weak or insecure, or perhaps they believe it goes against the grain of ‘being a grownup’ and ‘manly’ and that it’s only a feminine domain. Due to media reports of botched or over-done procedures, men may also believe that only unnatural and fake results are achieved, or they may think they will be judged by their family, friends and peers for some or all of the above reasons. It’s no surprise that the social stigma greatly changes among generations, peer groups and their exposure and interaction with the media and social media. Celebrity facialist Gavin McLeod-Valentine, director of studio services at skincare company Intraceuticals, told me that he finds that compared to millennial men, older men of the baby boomer generation are far less likely to partake in aesthetic treatments, including hair loss therapy, due to social media influences.

Menswear and grooming blogger Lucas Armitage highlighted that one reason men may have issues with cosmetic treatments are that men’s peer groups are not always as open in discussing emotional issues, such as unhappiness with one’s appearance. He notes, “I think there is a stigma for men, more

so than women, and there is a certain level of banter a man would endure in admitting treatments.” So, what does this stigma mean for you as an aesthetic practitioner? In my opinion, it not only prevents male patients from openly talking about skin concerns and seeking non-surgical solutions, but also prevents the opportunity to openly research and discuss treatment options with friends, family and peers, and can even hinder identifying specialist practitioners to make an informed choice when selecting a nonsurgical treatment. In addition, it also may impact a wider patient base as it likely that this stigma may be driving existing patients to hide, and feel that their aesthetic practitioner visits are a ‘guilty secret’, while at the same time preventing others such as a friend or a female partner, exploring the possibilities of treatment for themselves.

Breaking the stigma I think if we as a collective industry can make improvements, we can potentially not only gain more patients, but also create a more respected and accepted specialty. First and foremost, I believe it falls upon the practitioner to educate their patients, both male and female, to dispel misinformation and myths surrounding facial aesthetic treatments, emphasising that there is a proven link between healthy positive body image and mental health.3 These conversations can start in your own practice through appropriate consultations, acceptable patient suitability and correct, natural enhancements for not only male patients, but females too. This, I think, will help dispel some of the fears regarding bad or disfiguring aesthetic work.

I agree with McLeod-Valentine when he highlighted that if we can get men to start talking about their insecurities and perhaps the treatments they have or are thinking about having, it will have a positive impact on all. To help facilitate this, I think practitioners should consider collaborating with a relevant or compatible and established third party brand to co-host a male educational/demo event (preferably in real life but a virtual event could also be an option) to bring the topic of non-surgical aesthetic solutions into the open. Additional ideas to consider

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include producing a tailored leaflet or brochure designed with a male patient in mind, which brings up common skin and aesthetic concerns and the solutions available for them. This can be developed further into video or visual digital assets to utilise across social media platforms or websites. Improvements can also take place through practice marketing, which digital consultant Alex Bugg explores in more detail on p.55; tailoring on and offline marketing material in a tone and language that is malespecific can also engage and encourage a conversation with a potential male patient.

Asking your male patients if they can act as case studies to showcase your exceptional results can go a long way to making others feel comfortable in getting treatments as well as understanding that natural results can be achieved. In addition, I believe the ambiance and ‘look/feel’ of your clinic, as well as the journey patients take during their time with you, can greatly contribute to their overall experience and lasting impression of your practice. Dr Preema London clinic has a gender neutral colour scheme in the treatment rooms and our new clinic space has a dedicated ‘Men’s Room’, which has been designed to have a real male feel with different colours and textures to have an urban ‘gentleman’s club’ look.

Summary The opposition many men have when it comes to facial aesthetic treatments may prevent them from presenting to your clinic.

It may even be having an impact on your current patient base. It is worth bearing in mind that the objective is not to encourage an unhealthy dependence on non-surgical treatments, but making visits to an aesthetic practice acceptable to men. This, in turn, can open the door to healthy open conversations about the ageing concerns men have and the treatments available to address them.

Dr Preema Vig is the owner and medical director of Dr Preema London Clinic. Graduating in 1997, Dr Vig has extensive medical and surgical experience at a number of London hospitals.

Qual: MBBS, MRCGP, MBCAM REFERENCES 1. BAAPS, Cosmetic surgery stats, 2019. <https://baaps.org. uk/about/news/1708/cosmetic_surgery_stats_number_of_ surgeries_remains_stable_amid_calls_for_greater_regulation_ of_quick_fix_solutions> 2. ASAPS, Cosmetic Surgery National Data Bank STATISTICS, 2017. <https://www.surgery.org/sites/default/files/ASAPSStats2017.pdf> 3. Mental Health Foundation, Body image report, 2019. <https:// www.mentalhealth.org.uk/publications/body-image-report/ exec-summary>

Reproduced from Aesthetics | Volume 7/Issue 6 - May 2020

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