NOVEMBER 2023: The Face Issue by Aesthetics & CCR

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VOLUME 10/ISSUE 12 - NOVEMBER 2023

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CPD: Exploring Benefits of CBD Dr Shirin Lakhani investigates the potential use of CBD in aesthetics

Perfecting Non-Surgical Rhinoplasties

Practitioners discuss best practice when treating the nose

Treating Facial Palsy in Aesthetics

Michelle McLean provides insight into facial palsy treatment

Implementing Wellness Services Dr David Eccleston outlines the benefits of wellness services

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Contents • November 2023 08 News

The latest product and industry news

16 News Special: New Ultrasound Guidance Clarifies Best Practice in Aesthetics Aesthetics reports on the new guidelines released by the British Medical Ultrasound Society

21 Unrivalled Education and Networking at CCR 2023 CCR’s 10th anniversary went off with a bang

CLINICAL PRACTICE 27 Special Feature: Perfecting Non-Surgical Rhinoplasties Practitioners discuss best practice when treating the nose with fillers

News Special: Ultrasound Guidance Clarifies Best Practice in Aesthetics Page 16

33 CPD: Exploring CBD in Medical Aesthetics

Dr Shirin Lakhani investigates the potential use of CBD in aesthetics

37 Understanding Facial Palsy

Michelle McLean provides insight into facial palsy treatment options

43 Case Study: Correcting Eyelid Ptosis with Toxin

Dr Alexander Parys and Dr Steven Land present two eyelid ptosis cases

46 Treating Asian Patients

Dr Souphi Samizadeh discusses aesthetic treatments in Asian patients

49 Introducing the new SmartXide Handpieces

Unleash the potential of the SmartXide Punto CO2 laser with new handpieces

50 Case Study: Using Threads in the Nose

Special Feature: Perfecting Non-Surgical Rhinoplasties Page 27

Dr Mahsa Saleki shares a case study utilising PDO threads in the nose

Clinical Contributors

55 Past, Present and Future of Chemical Peels

Dr Xavier Goodarzian summarises the development of chemical peels

58 Contour and Shape Your Way to the Next Generation HA

Revanesse Contour and Shape help to restore and restructure facial volume

59 Abstracts

Michelle McLean is the founder and medical lead for CQC-registered clinic Aesthetically You. She has more than 12 years of aesthetics experience and is a regional leader for the BACN. McLean is currently completing a second Master’s in Cosmetic Medicine.

A round-up and summary of useful clinical papers

IN PRACTICE 60 Creating Referral Pathways for Your Patients

Dr Olha Vorodukhina delves into the importance of referral pathways

63 Implementing Wellness Services In-Clinic

Dr David Eccleston outlines why the wellness sector is gaining popularity

66 Employing Patient-Centric Marketing Strategies

Marketing professional Reena Sandhu provides advice for those seeking to excel in patient engagement

69 In The Life Of Mr James Olding

Mr James Olding shares his typical days in the NHS, aesthetics and running a training academy

70 The Last Word: Should You Add a Defibrillator to Your Clinic?

Dr Elle Reid and Dr Chloe Aucott debate whether defibrillators should be a necessity in aesthetic clinics

NEXT MONTH IN FOCUS: EVOLUTION • Biological Ageing • Polynucleotide Treatments

Dr Shirin Lakhani is a cosmetic practitioner specialising in intimate health and HRT for men and women. Dr Lakhani regularly contributes to articles and conferences in the UK and internationally. She is involved with the APPG for menopause.

Dr Alexander Parys is an aesthetic doctor and founder of SONÜ Medical Aesthetics. He authored an aesthetic textbook chapter, Decision Making in Aesthetic Practice, in 2021. Dr Parys was the Aesthetics Awards Winner for Rising Star of the Year 2021. Dr Steven Land trained in medicine, surgery, plastic surgery and emergency medicine before becoming an aesthetics doctor. He is the clinical director of Novellus Aesthetics. He also runs his own training academy and is a KOL for Neauvia, Nuceiva and Nuchido. Dr Souphi Samizadeh is a visiting associate professor, founder of the Great British Academy of Aesthetic Medicine and clinical director of Revivify London Clinic. She is an honorary clinical teacher at King’s College London and an honorary clinical teacher at UCL. Dr Mahsa Saleki is a former London surgical trainee in cardiothoracic surgery. She has been practising aesthetics for the past 10 years and is the medical director of CQC-registered SAS Aesthetics where she specialises in advanced thread lifts and training. Dr Xavier Goodarzian is the medical director and co-owner of Xavier G. Clinic in Southampton. He has postgraduate degrees in clinical dermatology and cosmetic medicine. He is also the author of the book Chemical Peels in Clinical Practice.

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Editor’s letter If you weren’t at the UK’s largest aesthetics event on October 19-20 you are going to wish you were! CCR 2023 was honestly the best and biggest event I’ve been to in the UK. It all seems like such a blur now, but it was so great to catch up with 3,800+ aesthetic professionals Shannon Kilgariff for two days of collaboration, education and Editor & Event networking. Some of my personal highlights Manager include the Research Round-up and live @shannonkilgariff injectable demonstrations in the Aesthetics Arena, as well as the launch of the Medical Longevity Summit – the future of our industry. Thank you to everyone who made CCR such a success, from our esteemed speakers and partners to our exhibitors and especially our sponsors. In the Aesthetics journal this month our articles have an emphasis on treating the face safely and effectively. Central to the face is of course the nose, so we delve into how to beautify this with dermal fillers on p.27 and a lesser-known technique using threads on p.50. We also look at treating facial palsy with aesthetic interventions (p.37), eyelid

ptosis correction on p.43, and treating Asian faces on p.46. It’s important to read about the new guidance on ultrasound in medical aesthetics – an emerging technology which is becoming increasingly common in practices for optimising dermal filler safety and managing complications. Read our News Special on p.16. I hope your entries for The Aesthetics Awards are going well – I know it’s always a bit of a stressful time to get your entries in, but do allocate enough time to put together an entry you and your team can be proud of. Remember the deadline is November 6! Do get in touch with myself or the team if you have any last-minute questions about your submission or if you’d like any top tips for writing a successful entry. Finally, do remember that ACE 2024 on March 15-16 is our next event! Pop this in your diary and stay tuned for more information. We are also launching an exclusive new masterclass before ACE, where we bring some leading international thought leaders to the UK to facilitate international collaboration. See more details on p.11. As always, please do get in touch if you’re interested in writing for the journal, or would like to tell us what you want to learn next via @aestheticsjournaluk on Instagram.

Clinical Advisory Board

Leading figures from the medical aesthetic community have joined the Aesthetics Advisory Board to help steer the direction of our educational, clinical and business content Sharon Bennett is chair of the British Association of Cosmetic Nurses (BACN), previous UK lead of the BSI committee for aesthetic non-surgical standards, and member of the Clinical Advisory Group for the JCCP. She is a trainer and registered university mentor in cosmetic medical practice, and is finishing her MSc at Northumbria University. Bennett has won the Aesthetics Award for Nurse Practitioner of the Year and the Award for Outstanding Achievement.

HELP PROGRESS MEDICAL AESTHETICS! WRITE FOR THE JOURNAL Do you have any techniques to share, case studies to showcase or knowledge to impart? Email: editorial@aestheticsjournal.com

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

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

Dr Anjali Mahto is one of the UK’s leading consultant dermatologists. She is a Fellow of the Royal College of Physicians, member of the Royal Society of Medicine and a spokesperson for The British Skin Foundation. In 2023 Dr Mahto opened Self London, a dermatology and lifestyle clinic aimed at managing skin conditions holistically.

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

Jackie Partridge is an independent nurse prescriber. She is the clinical director and owner of Dermal Clinic in Edinburgh and a KOL for Galderma. She holds an MSc in Non-surgical Aesthetic Practice and a BSc in Dermatology. Partridge is a stakeholder group member with Scottish Government/HIS, Honorary BACN member and JCCP Fitness to Practice Nurse.

Dr Tapan Patel is the founder and medical director of PHI Clinic, and has more than 20 years’ experience performing aesthetic treatments. He is a KOL for Allergan Aesthetics and Cutera, and is passionate about high standards in aesthetic medicine. In 2023, Dr Patel received The Aesthetics Award for Outstanding Achievement in Medical Aesthetics.

Mr Adrian Richards is a plastic and cosmetic surgeon with over 30 years’ experience. He is the clinical director of the aesthetic training provider Cosmetic Courses and surgeon at The Private Clinic. He is also a member of the British Association of Plastic and Reconstructive and Aesthetic Surgeons and the British Association of Aesthetic Plastic Surgeons.

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

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

ARTICLE PDFs AND REPRO

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Complications

Talk #Aesthetics Follow us on Instagram @aestheticsjournaluk

#CCR Caroline Hall @randraesthetics Such an amazing first day at CCR 2023 catching up with lots of friends and meeting some fabulous new faces too!

#Conference Dr Caroline Wilde @drcwilde So nice catching up with these incredible women at BCAM conference – all so inspiring in their unique ways.

#Education Dr Wassim Taktouk @drwassimtaktouk I loved hosting the first ever SkinCeuticals European Master Physician in London this week!

#Roadshow Dr Benji Dhillon @drbenjidhillon Two cities. Three days. A truckload of anatomy, techniques and education. Thank you Teoxane!

#Learning Dr Raquel Amado @drraquelamado CMAC Conference was a great opportunity to learn more from leading experts on different complications in aesthetic treatments.

BCAM annual audit reveals leap in complication rates The British College of Aesthetic Medicine’s (BCAM) Annual Clinical Review has revealed a rising number of complications being dealt with by medical aesthetic practitioners in the UK. The associations audit of 357 members showed that in 2023, the total number of complications treated rose to 3,523 from 3,323 in 2022. A total of 82% of all members surveyed said they had dealt with a complication caused by another practitioner in the past year. Practitioners revealed 69% of these complications had been caused by non-medically qualified professionals like beauticians, therapists and podiatrists, up from 60% last year. Dermal filler was the most frequent cause of complications (44%), followed by botulinum toxin (30%), threads (12%) and lasers/ energy-based devices (9%). BCAM president Dr Catherine Fairris said, “We have found that dermal fillers continue to be the treatment with the largest number of complications from non-medical practitioners, which confirms how dangerous dermal fillers can be in the wrong hands. Notably, members report that these complications are often more severe and require specialised treatments. We strongly welcome the public consultation for a licensing scheme of aesthetic treatments, which will hopefully reduce the rate of complications and put patient safety first in the coming years.” Injectables

Merz Aesthetics’ dermal filler receives further FDA approval Belotero Balance hyaluronic acid (HA) dermal filler from pharmaceutical company Merz Aesthetics has received US Food and Drug Administration (FDA) approval for under-eye treatments. The product has now been approved for use in the infraorbital hollows in adults over the age of 21, with the company saying this development means the filler can be used to address under-eye concerns. A study conducted in June 2023 saw 150 patients with moderate to severe infraorbital hollows separated into a control group and a Belotero Balance group. At week eight, the estimated average responder rate for the Belotero Balance group was 80.6%, while the estimated average responder rate in the control group was 1.9%. Patrick Urban, president of Merz Aesthetics in North America, said “We’re so excited to be able to offer this new Belotero Balance indication to healthcare professionals, and consumers are thrilled with the promising results that we’ve seen to date through our studies. At Merz Aesthetics, we hold ourselves to the standard of always continuing to innovate and offer the best possible treatments for our customers to bring to their patients.”

Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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Awards

Entry closes this month for The Aesthetics Awards 2024 Entry for The Aesthetics Awards 2024 officially closes on November 6, with Finalists being announced in the January issue of the Aesthetics journal. This year there are 24 categories to choose from, so practitioners, clinic owners, companies, training providers, products and more can showcase their achievements and developments over the past year. We are also excited to announce that aesthetic treatment company Hydrafacial will be sponsoring the Award for Best New Clinic, UK & Ireland; medical-grade skincare brand AlumierMD will be supporting the Rising Star of the Year Award; and aesthetic manufacturer Crown Aesthetics will be sponsoring the Award for Best Non-Surgical Result. Shannon Kilgariff, editor and event manager of Aesthetics, said, “Known as the ‘Oscars’ of Aesthetics, the Aesthetics Awards are the ideal opportunity for the medical aesthetics industry to come together and celebrate the fantastic achievements over the past year. With plenty of categories to choose from, the Awards are available for everyone, whether you are just getting started in aesthetics or have been in the industry for years, don’t miss out on this fantastic opportunity.” Entry for The Aesthetics Awards closes on November 6. Full Members of Aesthetics can enter for free. Head to the Aesthetics Awards website to enter now! Skincare

Galderma debuts Alastin skincare line Pharmaceutical company Galderma has launched its new skincare line Alastin, providing a collection of products for optimal procedure results and daily skincare regimens. According to Galderma, the products are formulated with TriHex technology, a patented blend of peptides that work with the skin to help cleanse damaged skin cells, while supporting the skin’s natural ability to produce new, healthy elastin and collagen. One of the products Skin Nectar is a pre- and post-procedure product that complements aesthetic treatments including laser, microneedling, chemical peels and facial surgery to help support recovery and improve results. Jackie Tuzee, head of marketing for Aesthetics UK&I, said, “Alastin has finally landed on UK shores! Alastin is the most preferred pre- and post-procedure brand in the US and is formulated with unique TriHex technology which helps to restore the appearance of the collagen and elastin in depleted skin. We are so excited to bring Alastin to the UK!” Alastin was included in the CCR Innovation Trail 2023. Find out more in the Aesthetics Product Launches Report 2023, which is online now.

Vital Statistics Of all melanoma skin cancer cases in the UK, 87% are preventable (Cancer Research UK, 2023)

Of 3,750 men, 6% were more likely than women to choose to have treatments due to their profession (Curated Digital/RARE: Group, 2023)

A total of 1-2% of the UK population is currently suﬀering from body dysmorphic disorder (BDD Foundation, 2023)

Of 13,000 women of colour surveyed, 90% said their top skin concern was hyperpigmentation (4.5.6 Skin, 2023)

Over five years, menopausal women lose on average 30% of the collagen in their bodies (American Academy of Dermatology Association, 2023)

In a survey of 1,000 suﬀerers of an inﬂammatory skin condition, 27% said they felt self-conscious wearing more clothes than others to cover-up (Prospectus Global, 2023)

Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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Events diary 4 -5 November th

FACExpo and FACExpert Conference 9th-11th November BACD Annual Conference 11th November AUCC Conference 25th November IAAFA Conference 2023 15th-16th March ACE Conference 2024 16th March The Aesthetics Awards 2024

IN T H E ME D I A What’s trending in the consumer press

DIY filler trends on social media An alarming trend is emerging on some social media platforms – that of DIY filler. Social media pages across platforms like TikTok are seeing non-medical users posting content about filler which can be administered at home, either between friends or even to oneself. The treatment option is often presented as a cheaper alternative to being injected in a clinical environment. Dr Asha Chhaya, aesthetic practitioner at sk:n Clinics, says, “I have been performing aesthetic treatments for almost eight years, and I still find lips the trickiest area to treat, so to see that DIY lip filler is trending on social media platforms is highly concerning.” Ariana Grande opens up about treatment past Worldwide popstar Ariana Grande has shared that she has had ‘a ton of lip filler over the years and Botox’, but she stopped in 2018. She says that she ‘felt like hiding’ behind the treatments, alongside heavy make-up and hairstyles, to create a ‘disguise’ for herself. She added that she might go back to treatments ‘one day’, because ‘people should do whatever makes them feel beautiful’.

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Ambassador

Dr Sabika Karim becomes KOL for Erchonia Aesthetic device company Erchonia has announced Dr Sabika Karim as its new key opinion leader. According to the company, Dr Karim will be carrying out treatments using the Emerald Laser at her Northwood Clinic and consultations in her Harley Street Clinic. Dr Karim has 17 years of experience in non-surgical and laser procedures, facial rejuvenation and body contouring, notes the company. Dr Karim comments, “Most of us want to maintain a healthy lifestyle and do our best to eat well and maintain a regular exercise regime. However, some patients struggle with stubborn body fat which simply will not budge, despite making healthy lifestyle changes. It was a no brainer for me to choose Emerald and I am so excited for my patients to experience this technology.” Eye Treatment

Obagi Medical releases new Nu-Cil eyelash serum Skincare company Obagi Medical has announced the release of the new Nu-Cil Eyelash Enhancing Serum. According to the company, the serum contains biotin, proprietary liquid compound, sodium hyaluronate, hyaluronic acid and vitamin B5 to enrich the lashes. The product uses patented NouriFlex technology to target lashes during the growth phase. In a 16-week double-blind clinical study of the product, 93% of participants said their eyelashes showed visible improvement, 89% said their eyelashes looked thicker and 89% of participants said they looked more densely packed. Dr Laurence Dryer, executive vice-president of research and development at Obagi, said “By delivering the right blend of ingredients, Nu-Cil Eyelash Enhancing Serum targets the anagen phase of the lash cycle to support overall improvement in the appearance of lashes in as little as eight weeks.” Device

Sculpt Pro Aesthetics unveils e-Magnescence device Aesthetic device company Sculpt Pro Aesthetics has released the new e-Magnescence device, combining three rejuvenating technologies. According to the company, e-Magnescence incorporates three technologies into one handpiece: radiofrequency, HI-EMS and HI-TENS. The technologies can be used to target all layers of the skin, aiming to tighten, sculpt muscles and minimise cellulite. Monopolar, tripolar and fractional RF are all available, providing treatment options for a variety of indications, notes the company. e-Magnescence was included in the CCR Innovation Trail 2023. Find out more in the Aesthetics Product Launches Report 2023, online now.

Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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Advanced Education

Renowned global speakers to lead exclusive masterclass UK aesthetic practitioners will learn advanced injection techniques from three international leaders at an exclusive one-day masterclass on March 14, 2024. Taking place on day zero, before ACE 2024 opens in London, the CPD-verified event, organised by Aesthetics, aims to bring international thought leaders and master injectors to the UK. This will facilitate a global exchange of learning and collaboration through live discussions, mentoring and injecting. Internationally renowned Australian plastic surgeon and global leader in cosmetic facial enhancement techniques Dr Steven Liew will be showcasing his newest approaches through anatomical learning and live treatment demonstrations. Accompanying him will be internationally respected speaker and trainer on advanced cosmetic dermatology Dr Tatjana Pavicic, who will explore the latest learnings and techniques from Germany. The third speaker and facilitating the event will be Dr Tapan Patel, who will bring his latest techniques and approaches for safe, holistic results. With the masterclass taking place at the beautiful Bulgari Hotel in Knightsbridge, it will be both intimate and luxurious, allowing advanced practitioners to have direct access to the world-leading practitioners. It will include live injectable demonstrations, opportunities to get difficult cases examined, as well as delicious Bulgari cuisine. Practitioners will then relax in a lavish setting, connect with speakers, and build a valuable network over drinks, providing limitless networking opportunities. Divisional managing director of Aesthetics, Alison Willis, commented, “Taking place before ACE, this intimate, ticketed event will allow practitioners exclusive access to master global techniques to unleash excellence in their clinical practice. As well as unparalleled learning, practitioners will network with world-class speakers and connect with other like-minded advanced professionals. If you are an experienced practitioner, this event is one to attend!” The agenda will be released soon. To receive your exclusive invite, turn to p.36 – places are limited. Device

Lynton launches handpieces Aesthetic device company Lynton has introduced two new handpieces for the SmartXide PUNTO CO2 laser, in partnership with Deka. The company explains that the SCAR3 handpiece will offer deep CO2 treatment, targeting thick scars such as acne, surgical and burn scars. Despite the depth, the risk of hyper- and hypopigmentation is reduced due to the handpiece’s smaller spot size, Lynton says. The Dermascan handpiece is a CO2 scanner for use in surgical dermatology, enhancing the device’s vaporisation capability with maximum precision, according to Lynton. Hayley Jones, commercial director at Lynton, said, “We are thrilled to extend the advantages of Moveo technology to our valued clinic partners throughout the UK and Ireland. By combining this cutting-edge technology with the renowned Motus AY, our practitioners can now offer top-tier skin rejuvenation as well as pain-free hair removal services.” Turn to p.49 to read more about the new handpieces.

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

BACN REGIONAL MEETINGS Throughout October, BACN members gathered in various regions of the UK for insightful regional meetings. These gatherings exemplified the essence of the BACN’s mission, where knowledge sharing and collaboration among dedicated aesthetic nurses takes centre stage. Meetings in 2024 will be taking place across the UK, and members are encouraged to find out about regional events via the BACN events page by scanning the QR code below.

EDUCATION AND TRAINING COMMITTEE The BACN Education and Training (E&T) Committee has been reformed under the leadership of BACN Management Committee Member Rachel Goddard. E&T Committee Members are responsible for approving and overseeing internal policies implemented by the BACN. It is imperative for the Committee to maintain alignment with the BACN’s governing documents and the association’s overarching objectives. Transparency and accountability are fundamental aspects of the Committee’s work, ensuring that their actions are conducted openly and responsibly. In addition, Committee Members are entrusted with the critical task of maintaining strict fiscal discipline within the Education & Training budget. As advocates of the association, Committee Members actively engage in promoting the BACN’s mission and vision. Minutes and updates will be provided to members via the BACN newsletter and general updates.

BACN CHRISTMAS MEALS The BACN encourages all members to celebrate the forthcoming festive season by attending Christmas meals and festivities within their local areas! These gatherings serve as the ideal backdrop for connecting with fellow aesthetic nurses and developing relationships. Members can find out about their local meals by contacting Regional Leaders in their area or accessing their local WhatsApp groups. More info can be found by contacting BACN HQ at admin@bacn.org.uk. This column is written and supported by the BACN

Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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Skincare

Cosmeditech unveils new skin analysis system Aesthetic supplier Cosmeditech has introduced the SOFT FX to its portfolio. According to the company, the new skin analysis system offers bespoke consultations for both facial and bodily treatments. The system generates shareable reports and recommendations to patients’ phones whilst operating a traffic light system, pinpointing areas of concern and improvement. The SOFT FX can investigate a range of skin conditions with accuracy, including hydration, elasticity, pH, sebum and pigmentation. The systems HD micro cameras can also look at wrinkles, skin texture, keratin levels, cellulite, redness and pores, notes Cosmeditech. Peter McGuinness, managing director at Cosmeditech, said, “The SOFT FX incorporates clinical laboratory technology in a compact easy to use device that can provide the most in depth analysis of every aspect of skin, hair and body analysis.” Body

New injectable to treat cellulite launches in UK

AlumierMD introduces new at-home kit Medical-grade skincare brand AlumierMD has launched a new at-home kit, Radiance Reveal A.C.E. The limited-edition kit aims to help skincare professionals empower their patients by providing a preventative and corrective product duo, notes the company. The Radiance Reveal A.C.E contains AlumierMD’s Everactive C&E + Peptide and AHA Renewal Serum which helps to reduce the appearance of fine lines and wrinkles, even out skin tone, improve skin texture and lock in moisture and radiance, adds AlumierMD. The new kit can be combined with in-clinic treatment plans, including laser resurfacing, chemical peels and injectable treatments. To examine the efficacy of the new kit, AlumierMD conducted an in-clinic study of 50 patients with Fitzpatrick skin types I-VI. The study was conducted over a two- and four-week period during July to demonstrate the efficacy of Radiant Reveal A.C.E in both stabilising and improving skin conditions before an in-clinic treatment. The study found that Radiance Reveal A.C.E. reduced wrinkle appearance up to 431%, visible redness by 282%, appearance of dark spots by 165%, skin texture by 152% and spots by 78%. Dr Sonia Khorana, aesthetic practitioner at MediZen Clinic, said, “Prevention skincare makes perfect sense for younger patients – they will see better results while improving clinical outcomes, and it’s becoming very common to see now. What’s more, focusing on essential dermatological ingredients like vitamins C and E and AHA will help revitalise skin whatever your patients’ age. With Radiance Reveal A.C.E., professionals have the opportunity to engage with wider demographics of patients, in turn supporting a growing recognition that prevention is better than cure.” Training

Marllor Biomedical, the Italian manufacturer of Aqualyx, is hosting an event in London to officially launch Alidya. The company explains that Alidya is the first class III, CE marked, medical device specifically developed to treat cellulite. The injectable was first released in Italy in 2012 and is present in 50 countries to treat grade 1 and 2 cellulite effectively. Alidya can be used as a stand alone treatment or in combination with other modalities such as carboxytherapy or energy-based devices. Matteo Fabbri, business development director of Marllor Biomedical, said, “Alidya fills an existing gap in treating cellulite, still one of the most intolerable aesthetic concerns for women. We are very excited to launch Alidya in the UK, as part of our expansion strategy, and we are convinced this will be a game changer for both practitioners and patients alike.” The event is to be held at Café Royal in Regent Street, London on December 3 and will feature speakers from different countries that will share their experiences with Alidya. 12

Prollenium collaborates with Harley Academy Aesthetic manufacturer Prollenium UK has announced its collaboration with training provider Harley Academy. The company explains that the collaboration will deliver an innovative practical training programme for healthcare professionals wanting to elevate their techniques with the Revanesse and Softfil product ranges. The modular programme will include online pre-learning delivered via Harley Academy’s learning management system, followed by hands-on practical sessions at Harley Academy’s facilities in London, notes Prollenium. Models will be provided for the delegates in order to focus on patient assessment and treatment strategies. Natalie Colbourne, general manager at Prollenium UK, commented, “Harley Academy is forward thinking and innovative, just like our organisation. I’m delighted to offer this opportunity to our valued customers to support their development with our products.” To find out more about the Revanesse products, turn to p.58.

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Dr Anjali Mahto becomes newest member of Clinical Advisory Board Consultant dermatologist Dr Anjali Mahto is the newest member to join the Aesthetics Clinical Advisory Board. Based in Harley Street, London, Dr Mahto provides consultations for a wide range of medical and cosmetic conditions including acne, acne scarring, rosacea, moles and aesthetic concerns. She is affiliated with esteemed professional organisations including the British Cosmetic Dermatology Group, the British Association of Dermatologists, the Royal College of Physicians and the Royal Society of Medicine. Dr Mahto will join clinical lead nurse prescriber Sharon Bennett, nurse prescriber Jackie Partridge, plastic surgeons Mr Adrian Richards and Mr Naveen Cavale, ophthalmologist and oculoplastic surgeon Miss Elizabeth Hawkes, dental surgeon Dr Souphi Samizadeh, aesthetic practitioners Dr Tapan Patel and Dr Mayoni Gooneratne and dermatologist Dr Stefanie Williams. Dr Mahto commented, “I’m very excited to be joining the Aesthetics Clinical Advisory Board and look forward to putting together dermatology content for future meetings as well as working alongside some fabulous colleagues!” Shannon Kilgariff, editor and event manager at Aesthetics, said, “I’m delighted to welcome Dr Mahto to our esteemed Advisory Board. As skin health is an important topic in aesthetics, I’m looking forward to learning from Dr Mahto’s expertise and ensuring that the industry receives the latest vital dermatology updates to improve their knowledge.” Distribution

ABC Medical partners with three new companies Aesthetic distributor ABC Medical has announced three new distribution partnerships with Cynosure, Deleo and EMA Aesthetics Ltd. The company says this expansion of its portfolio represents a diversification in its offerings and aims to provide each brand with unparalleled support, resources, and training to boost growth and market share in the competitive aesthetics space. Cynosure offers a range of aesthetic devices, with treatments including radiofrequency, microneedling and hair removal. Deleo also provides a variety of aesthetic devices, addressing concerns such as body contouring and fat dissolving for the face and body. Finally, EMA Aesthetics Ltd offers the Préime DermaFacial to even skin tone and boost collagen, according to the company. Managing director at ABC Medical Alastair Sawyer comments, “ABC’s heritage in the UK is working with premium medical aesthetic brands, so we are extremely proud to be partnering with three companies which are just that. Each of our new brands offers something unique to the medical aesthetic industry, so we are optimistic and looking forward to growing their presence in the UK.”

Headline Sponsor

ACE 2024 is Your Next Aesthetics Event

Register now for top class education and networking. After the success of CCR last month, it’s time to look forward to your next aesthetics event – ACE, taking place on March 15 and 16 at the Business Design Centre. As the leading event for non-surgical aesthetic professionals, ACE is the only UK aesthetics show to bring together all the top pharmaceutical companies. What can you expect? With five educational conferences to choose from, there is something to suit all of your educational needs. From clinical education to business insights and live demonstrations, you can learn all the latest in medical aesthetics. There will also be a chance to advance your clinical skills with Headline Sponsor TEOXANE’s line up of expert KOLs. All content at ACE is free to attend, so stay tuned for our agenda updates over the next few months! There will also be plenty of networking opportunities throughout the two days, concluding with The Aesthetics Awards ceremony after Day 2. Entries close on November 6, so if you haven’t entered already, you still have a few days to do so! NEW exclusive international masterclass As if ACE wasn’t enough, this year we’re introducing a brand-new advanced masterclass featuring worldleading education from three of the top international aesthetic leaders. Dr Tapan Patel, Dr Steven Liew and Dr Tatjana Pavicic will bring 120 delegates exclusive live demonstrations and the chance to access them directly for questions and advice. Taking place the day before ACE, attendees will get VIP access to the conference, making it the perfect three days to really expand your knowledge base and develop your skills. Scan the QR code to register now!

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Julie Horne’s Expert Insights Julie Horne is a world-famous aesthetic nurse prescriber based in Oslo, Norway. She has travelled all over the world, sharing teaching on how to achieve exemplary injectable techniques. Here, Aesthetics shares some of Horne’s insights into creating injectable perfection… Your key pointers for perfect lip results… Choose the right filler for each and every lip – rheology matters. Take your time, work with precision and respect the natural anatomy of the lips. Don’t forget about the chin: always do a proper assessment from all angles to be sure the lips will harmonise with the rest of the face. What’s your advice to mitigate filler migration? Inject in the more closed compartment of the lips – only in the pink, below the white roll, in front of the orbicularis oris muscle and above the fascia in the wet dry junction. The delicate structures of connective tissue and fascia are not made of steel. Do not overfill, because if you do, you will create high pressure and the filler can travel over time. Top tips for ensuring natural injectable results... Less is always more when it comes to injectables. Injectors should focus on restoring volume loss and creating natural balance. It’s important to have knowledge of treating patients with different ethnicities, due to variations in anatomical structures and perceptions of beauty. I believe in starting slow and steady and establishing a good professional relationship with the patient so you can create the best results over time. When it comes to botulinum toxin, we have to avoid ‘freezing’ the face. Treating more areas with smaller doses looks more natural than overtreating specific areas and creating unnatural overcompensation. Skincare recommendations for a fresh face? Medical-grade skincare regimens should be customised for each patient, especially if they have any skin conditions. For younger patients, I would focus on keeping the skin hydrated and protecting it from the sun; Hydrafacials four to six times per year are great for this. From mid-30s onwards, patients can gradually start using more active ingredients such as retinol and alpha hydroxy acids. Microneedling, peels, platelet-rich plasma and CO2 are other good options for signs of ageing. What are your top three areas of the face to treat? I really enjoy treating most areas, but I have to say that the lower face is my favourite, including the lips, perioral region, chin and jawline. It’s all about creating balance, and the lower face is where I see this transformation have the most positive impact.

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Skincare

PCA Skin debuts Pro-Max Age Renewal serum Skincare company PCA Skin has unveiled its newest product – the Pro-Max Age Renewal Serum. The company says that the product contains patent-pending Micro Growth Factor Technology (MGF), which combines a combination of growth factors to promote collagen production and reduce the appearance of sagging and fine lines. These ingredients include: palmitoyl sh-tripeptide-3 amide, palmitoyl sh-tripeptide-1 amide, acetyl tripeptide-54 amide and acetyl tripeptide-74 amide. According to a PCA Skin’s 24-week clinical study with 47 subjects, the serum is proven to lift and firm the appearance of skin by 60%, improve facial plumping by 58% and reduce the appearance of visible lines by 40%. Lizzie Shaw, PCA Skin UK brand manager, shared, “We’re so excited to welcome the incredible Pro-Max Age Renewal Serum to our range of clinically-proven, medically-backed products. The serum uses PCA Skin’s patent-pending MGF which penetrates the skin deeper than conventional growth factors, supporting collagen production and reducing the appearance of sagging, loss of volume, lack of firmness and wrinkles. The serum also combines botanical extracts and unique biopolymer ingredients to instantly plump and smooth the skin.” On the Scene

Harpar Grace celebrates 10th anniversary at Natural History Museum Aesthetic distributor Harpar Grace International (HGI) celebrated its 10th anniversary with a black-tie party at the Natural History Museum, London. According to the company, the 200-strong guest list featured aesthetic practitioners, press, influencers and brand founders for the evening. On the night, HGI’s new charitable initiative was announced, establishing the brand’s commitment to tackling climate change. Announcements about brands iS CLINICAL, Déesse PRO and RevitaLash were also made, including iS CLINCAL’s new Retinol Emulsion+ range. The event featured a performance from aerial artist La Luna and a set from DJ Phoebe d’Abo. Alana Marie Chalmers, HGI’s founder and CEO, reflected, “We are committed to giving back in an unprecedented way to our partners and our wider world. The work and brand promises we shared at our 10-year event echo our unique and driven business ethos that see us determined to underpin these world-class brands with an approach to business growth and profits we can all be proud of.”

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Adverse Events

Complication management at the forefront at CMAC conference On October 6, the Complications in Medical Aesthetics Collaborative (CMAC) hosted its annual conference at the IET London with delegates from 25 countries attending. On day one, the three common areas of filler complications: the periorbital, lips and superficial musculoaponeurotic system (SMAS) were discussed. Dr Leonie Schelke outlined the effect on dynamic muscle movement when injecting into the SMAS. Therefore, accurate placement and avoiding the SMAS is key to better outcomes. Dr Steven Harris discussed a surgical/non-surgical approach to a lip complication, noting that mucosa spread can be classified into four classes. Dr Harris explained his technique and treatment to correct the complication. Further examples of complications were showcased by Dr Tom Decantes, Mr John Blythe and Dr Patricia Barrera with complex cases being presented that highlighted the need for good assessment, accurate and prompt management. The second day of the conference discussed vision loss, the use of hyaluronidase, and the use of devices and imaging techniques to manage complications. Aesthetic nurse Mike Clague has previously reversed blindness, and presented the Australian protocol from beside to (and including) hospital based management. The CMAC UK Board, including Dr Lee Walker, Gillian Murray, Emma Davies, Dr Cormac Convery and Dr Harris, noted, “We welcomed delegates from 25 countries and expert speakers from all corners of the globe. Case reports and evidence were presented ahead of publication, and cutting edge protocols for management of complications.” Conference Report

BCAM showcases safety and wellness at 2023 conference On September 30, the British College of Aesthetic Medicine hosted the annual BCAM Conference 2023 at Church House, Westminster. At the venue, a stone’s throw from Westminster Abbey, BCAM hosted a full day of clinical and business content for more than 250 delegates. Kicking off the day was a content stream on face and body treatments, focusing on ground-breaking options. Some sessions included introducing AviClear with Dr Priya Verma and independent nurse prescriber Sarah Gaughan; polynucleotides and platelet-rich plasma as an alternative to hyaluronic acid with Dr Munir Somji; and topical adjunctive therapies to reduce risk with Dr Dev Patel. The clinic management stream offered business advice, including setting up a skincare brand with Dr Victoria Manning and Gary Conroy; digital building blocks for scaling your aesthetic business with Rick O’Neill; and managing your reputation with Dr Sophie Shotter. After a networking lunch break, safety became the focus with a complications stream. Some topics included dermal filler blindness with Dr Patrick Treacy and ultrasound for precise filler placement with Dr Steven Harris. Dr Sophie Shotter, BCAM board trustee and event director, commented, “We are delighted with the success of this year’s BCAM Conference. We aimed to provide a TED-X style of educational content, with shorter, sharper presentations delivering high-impact education. Our speakers did a fantastic job, and the initial feedback has been extremely positive.”

News in Brief Ivanmed partners with Map My Mole Aesthetic and medical supplier Ivanmed has collaborated with skin health technology company Map My Mole. The partnership represents a significant step forward in the company’s commitment to providing comprehensive and innovative solutions for skin care and health, notes Ivanmed. Map My Mole’s mobile application allows users to monitor and track changes in their moles and skin conditions conveniently by sending them for virtual analysis from a consultant dermatologist, and can be facilitated within aesthetic clinics. Wigmore Medical announces partnership with Dermaroller UK-based aesthetic distributor Wigmore Medical has acquired a minority stake in the UK entity of Dermaroller. The company explains that a cornerstone of this partnership is the exclusive distribution rights for XCellarisPro and XCellarisPro TWIST in the UK market. Wigmore Medical will also non-exclusively retail Dermaroller’s skincare range, New Natural Line, through its pharmacy and e-commerce platforms in the UK. Michael Tomerius, CEO and executive partner of Dermaroller, said, “This collaboration transcends mere business interests. It represents an alignment of vision, values and a mutual acknowledgement of the immense potential of the Dermaroller brand within the UK.” New UK distributor officially launches UK distributor Cure Medical has officially launched, exclusively distributing AgeJET and EndyMed in the UK and Ireland. Led by managing director Adam Bashir, Cure Medical was formed to provide high-end medical equipment across the UK and specialises in energy-based, medical machinery, notes the company. The company has a growing team of eight staff members, after less than 12 months of trading. Bashir commented, “Cure Medical recognises that each clinic has a different set of requirements and goals, but our experienced medical team will help you to find the right device and specification for your needs, taking your business to the next level.” Black Skin Directory unveils new website Online resource for patients with skin of colour, Black Skin Directory (BSD), has launched a brand-new website. The platform will feature skincare articles alongside updated glossaries of treatments. The website also outlines skin conditions and ingredients aimed at educating the skin of colour consumer.

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New Ultrasound Guidance Clarifies Best Practice in Aesthetics Aesthetics reports on the new guidelines released by the British Medical Ultrasound Society for medical aesthetic diagnostics The use of ultrasound in aesthetic medicine is a growing practice. It is increasingly being regarded as a valuable technology in ensuring safe practice and enhancing results.1 To reflect this, the British Medical Ultrasound Society (BMUS) has released brand new Guidelines for Professional Diagnostic Ultrasound Practice in Medical Aesthetics.1 The guidelines are the first tailored towards medical professionals utilising ultrasound in aesthetics, ensuring practitioners understand the technology’s safety parameters for effective use. Hazel Edwards, BMUS professional officer, comments, “We anticipate that these guidelines will inform and educate users, and enhance safety for patients. As an organisation, we support all healthcare professionals using ultrasound if they seek proper training and adhere to relevant governance and safety standards.” Aesthetics speaks to consultant plastic surgeon and co-author of the guidelines Mr Dalvi Humzah, as well as dentist and aesthetic practitioner Dr Zainab Al-Mukhtar, about what this means for the aesthetics specialty.

ultrasound guidance’.1 Mr Humzah believes this guidance was needed because although aesthetic practitioners are embracing the technology, they are not necessarily looking at how best practice should be adhered to. Dr Al-Mukhtar emphasises that although adopting ultrasound into your practice can seem daunting, it is very valuable, especially when used prior to treating high-risk areas such as the nose and forehead. She shares, “Ultrasound facilitates vascular mapping before treatment, allowing you to see the position of vessels in complex areas. On several occasions, ultrasound has identified unexpected vascular variation in my patients, which helped me change the course of my treatment to keep them safe.”2-4 She continues, “In a climate where there are unfortunately increasing numbers of complications in the UK due to lack of regulation, I think practitioners will find it useful to be able to help patients through these experiences with the assistance of ultrasound. It’s great that there are now guidelines which clearly answer some of the questions practitioners might have whilst doing this.”

The need for guidance

Key points of attention

The guide, authored by Mr Humzah, Dr Elizabeth Raymond-Brown and Telisha Jenkinson, begins by stating, ‘There is increasing evidence that the accuracy and outcome of many aesthetic procedures are greatly improved when performed under

The importance of ultrasound training is highlighted in the report: ‘Aesthetic practitioners must complete appropriate education and training programmes on the clinical use of ultrasound in aesthetic practice before introducing diagnostic ultrasound

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into their clinical practice’.1 It also states that practitioners must have ‘sufficient education and training to recognise normal anatomical structures and differentiate between the appearance of normal and abnormal ultrasound images’.1 Dr Al-Mukhtar further emphasises that although extensive training and practice is required to become an expert in ultrasound, “These BMUS guidelines are useful in that they provide a linear methodology for practitioners to refer back to.” Mr Humzah identifies two other key aspects of the guidance for practitioners to note. Firstly, the safety parameters required for use of the technology. He says, “It’s crucial to understand the effect ultrasound can have on soft and nervous tissues, the bones and eyes, particularly if you’re doing a lot of long-term ultrasound treatments. It should not be overused.” Secondly, he draws attention to the correct gel to use during ultrasound assessments in the realm of aesthetics. “It hasn’t really been discussed much in the past,” he says, “but normal ultrasound gel – such as the kind used during pregnancy scans – should not be used before injection as the skin shouldn’t be breached for 48 hours after normal gel is used.1 Instead, sterile ultrasound gel should be used prior to any injectable treatments.” He explains that this comes straight from the NHS Safety Executive, so using the wrong kind of gel is breaking NHS protocol.5 He shares that sterile ultrasound gel or antiseptic gel (NatraSan/ MediChlorG) may be acceptable.

Ultrasound in aesthetics Dr Al-Mukhtar believes the growing ultrasound phenomenon is a positive move in the aesthetics space, saying, “I think the integration of imaging in aesthetic settings should be encouraged to create more predictable and safer outcomes. We are fortunate that we have the opportunity to do this with ultrasound, and if we take a responsible approach when learning this new skill, it can hugely elevate our practice.” Mr Humzah concludes that the guidelines can be used as a framework to ensure all ultrasound use is reproducible and safe. He says, “Any practitioners using ultrasound in their clinics will already be following a lot of the guidelines laid out in this document, but it’s a good reference point to do a professional check of best practice in this area.” VIEW THE REFERENCES AT AESTHETICSJOURNAL.COM

Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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Unrivalled Education and Networking at CCR 2023

CCR’s 10th anniversary went off with a bang Headline Sponsor

Last month saw the return of the UK’s largest medical aesthetics conference – CCR. And this year marked something extra special – its 10-year anniversary! For the last decade, CCR has strived to share knowledge, connect all areas of the aesthetics specialty, promote high standards and drive best practice – and this instalment did not disappoint. Across October 19 & 20, CCR welcomed 3,800+ delegates, 140+ exhibitors and 120+ speakers to CCR 2023 at the ExCeL, making it the busiest CCR to date! Shannon Kilgariff, editor and event manager of the Aesthetics portfolio, commented, “It was amazing to return to the ExCeL for another incredible two days of networking, learning and discovery. This year was our 10year anniversary, and the quality of the scientific clinical and business education, exhibition and companies were better than ever. Thank you to all our speakers for delivering exceptional insights, research and live demonstrations across the two days. I also want to thank all our sponsors, exhibitors, and partners for helping to make this event a success every year. I can’t wait to see you all again at our next event, ACE in March!”

Educational highlights from Headline Sponsor Galderma Pharmaceutical company Galderma returned as Headline Sponsor for the third year in a row, delivering unmissable new insights and live demonstrations. The symposiums focused on the company’s Holistic Individualised Treatments (HITs) protocol, with Day 1 looking at The Balanced Profile, and Day 2 on Bright 20

Eyes. Over the two days, delegates learnt from the company’s top key opinion leaders Mr Jeff Downie, Dr Yusra AI-Mukhtar, Dr Lara Watson, Dr Munir Somji and Dr Priya Chadha. Galderma also ran the wonderful Networking Lounge across the two days, providing delegates with refreshments in between talks. Joanna Neal, brand manager at Galderma, commented, “We had our most successful year ever exhibiting and Headline Sponsoring CCR with a record number of visitors to our stand and attendance at our symposiums. We continue to support this event to help bring the latest innovation and educational opportunities Galderma has to offer to the aesthetics community. We can’t wait to be back next year!”

Injectable insights in the Aesthetics Arena Bringing the Aesthetics journal to life, the Aesthetics Arena was the go-to place for independent educational content. Highlights of Day 1 included a live demonstration from Dr Raul Cetto and Professor Francesco Bernardini treating the eyes and lips; as well as a new Research Round-up where five professionals took to the stage to discuss their latest research and clinical trials from combatting dark circles to regenerative medicine. On Day 2, Dr Zainab Al-Mukhtar and Mr Dalvi Humzah noted the key developments of using ultrasound in aesthetic practice; Alexandra Mills and Professor Syed Haq provided an introduction to polynucleotides; and

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Dr Sophie Shotter performed a live demonstration of a male full-face rejuvenation. Many other speakers also took to the stage, presenting delegates with incredible insights, training and education.

Discovering the latest innovations The Innovation Stage delivered in-depth guidance for developing your clinic offering using devices through 30-minute workshops and live demos. Session highlights included How to Prevent Ageing with Non-Invasive ‘Facelift’ EMFACE with BTL Aesthetics, Safely Treating Skin of Colour with CO2 Laser & Energy-Based Devices with Cutera, and Imposter Syndrome: Me and My First Laser with Lynton Lasers.

Demonstrations at the Symposium Stage The industry’s top brands showcased the latest techniques in one-hour live treatment demonstrations at the Symposium Stage. Highlights from the two days included Understanding Exosomes in Aesthetics by Dermapenworld and Introducing AviClear – The Future of Acne Treatment by Cutera. Both days also included a lunchtime takeover from Allergan Aesthetics, an Abbvie company. During these sessions, Dr Manav Bawa and Dr Tapan Patel provided a live mother-and-daughter transformation, giving delegates valuable knowledge and insights to approach treating ageing patients with the Allergan Aesthetics product portfolio. Cheryl Pitcher, associate director of communications and public relations UK&I, commented, “At Allergan Aesthetics, we are dedicated to offering value-added services to our customers beyond just our products, helping to build their businesses whilst in tandem driving the highest levels of clinical excellence and patient safety. CCR is a key platform that supports us to do this. Its real power is in helping build real world connections that last long beyond the event itself and supports our industry to move forwards through the sharing of expertise, ideas and collaboration. Our lunchtime takeover sessions hosted by the Allergan Medical Institute give our customers the opportunity to see firsthand and experience what our portfolio of products can do, whilst learning injection techniques and skills from some of the best practitioners in the industry.”

Uncovering business insights at the In Practice Theatre As well as unmatched clinical talks, CCR provided delegates with business education from leading clinic service providers and established business owners at the In Practice Theatre, sponsored by SkinCeuticals. The first day kicked off with a morning dedicated to Getting Started in Aesthetics, featuring talks from Dr Tristan Mehta, Dr Emily Mehta, Dr Marcus Mehta, Natalie Haswell and Dr Mariam Michail. Other highlights included an update on the Government’s proposed licensing scheme, fraud and cybercrime awareness, and a panel discussion on women in business.

The second day focused on prioritising patient care, bringing your business to the forefront and marketing to diverse patients. The theatre closed with the launch of a new concept in aesthetic medicine: Gloves Off by Aesthetics! Featuring Dr Steven Land, Dr Catherine Fairris, Sharon Bennett and Shannon Kilgariff, the session provided the opportunity for those in the aesthetics specialty to watch industry leaders debate, as well as discuss and engage with the most controversial and trending topics in aesthetic medicine. Anton Petrov, SkinCeuticals brand business director, commented, “We are delighted to have been a part of this year’s CCR, connecting with industry players and customers, forming new relationships and delivering educational speaker sessions and live demonstrations by our award-winning practitioners. Integrating our scientifically backed products with high-quality treatments is at the core of SkinCeuticals, so we are proud to be a sponsor of the UK’s leading educational aesthetics event.”

Introducing Medical Longevity to the aesthetics specialty This year saw the introduction of a BRAND-NEW feature and concept to CCR – the Medical Longevity Summit. Curated alongside Dr Mayoni Gooneratne, the two-day agenda focused on how to promote a healthier and longer healthspan for patients, while enhancing aesthetic outcomes by utilising functional, integrative, regenerative, lifestyle and wellness treatment approaches. Sessions included How to Integrate Testing Services Into Practice for Enhancing

CCR’s award winners After its success at ACE 2023, Aesthetics returned with the much-anticipated Stand Awards at this year’s CCR. We’re delighted to announce our CCR 2023 winners: • Award for Best Stand – Galderma • Award for Best Stand Hospitality – Alma • Award for Best Marketing Campaign – Cosmetic Courses • Award for Most Sustainable Stand and Company – CellDerma To commend the speakers for their efforts in delivering top-quality education, we also introduced the CCR 2023 Most Influential Speaker Competition. Dr Mayoni Gooneratne was the proud winner due to receiving the highest number of visitor registrations through her network. She received a well-deserved trophy and bottle of bubbly!

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Patient Health and Results with Dr Indra Barathan; How to Introduce Supplements into Your Clinic with Tracy Dennison; Supporting Patient Health and Wellbeing Through Weight Loss Programmes and How to Implement into Practice with Dr Kam Lally and many more! Attendees also had the chance to meet longevity brands and discover more about their products just outside the theatre, making it the perfect hub for everything new in holistic healthcare.

“This year was our 10-year anniversary, and the quality of the scientific clinical and business education, exhibition and companies were better than ever” Shannon Kilgariff

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Dr Gooneratne commented, “I was blown away by the response! Although I had hoped it would be of interest to people, I had no idea it would be so well received. We had some great feedback from visitors, speakers and exhibitors, and I really believe this is the start of a new era in Aesthetics. It was amazing to be witness to this change, and it was a massive honour to be a part of it!”

Exclusive masterclasses with industry leaders Dr Tapan Patel returned to host an exclusive masterclass at CCR. Over the course of Day 1, 80 delegates got to learn best practices for taking a patient from consultation to aftercare, as well as witness two unmissable live treatment demonstrations by Dr Patel himself. The day also featured talks from Dr Priya Verma, Jack Gibson, Dr Anneka Shah, Sarah Guaghan, Dr Amanda Penny and Dr Manav Bawa. On Day 2, Dr Raul Cetto and Professor Francesco Bernardini held a masterclass guiding delegates through the comprehensive assessment and treatment of the eyes and lips using dermal fillers. Attendees watched live demonstrations and received hands-on practical training.

Uniting the community As well five theatres showcasing outstanding clinical and business education, CCR brought together the aesthetics specialty through its unparalleled networking opportunities. Day 1 ended with the annual networking drinks, sponsored by Deleo. Members of the community had the chance to congregate, discuss the key learnings of the day and catch up with peers

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Aesthetics

Newest trends unveiled at the press conference CCR presented to 20 consumer and trade press at this year’s press event, held at the Sunborn Hotel on the morning of Day 1.

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Sponsored by BIOJUVE, Crown Aesthetics, the event unveiled this year’s Product Launches Report and Trends Report. Press heard from Reena Sandhu, Dr Priya Chadha, Dr Kam Lally,

Dr Martin Nimmo, and Dr Mayoni Gooneratne who presented on the year’s most innovative advancements, launches and trends. Visit ccrlondon.com to read the full reports.

"I really believe this is the start of a new era in Aesthetics" Dr Mayoni Gooneratne

and colleagues over complimentary drinks and a 10-year CCR anniversary cupcake. Day 2 saw the introduction of the BACN Nurses breakfast, giving all aesthetic nurses an opportunity to get to know like-minded colleagues and build up a support network of professionals. This was a great way to start Day 2 of CCR and was supported by Dermapenworld. Across the two days, CCR speakers, Aesthetics Awards Finalists, and Full Aesthetics Members gathered in the VIP lounge sponsored by Hydrafacial. Drinks and refreshments were served throughout the day, providing delegates the perfect opportunity to unwind and connect.

CCR Charity Diwali After Party The official CCR Charity After Party returned for the second year running, taking place at the Trinity Bouy Wharf after the networking drinks on Day 1. Hosted alongside Dr Tapan Patel, the event once again raised money for The Childhood Trust Charity. Over £23,000 was raised for the charity

in ticket sales alone so we would like to extend a huge thank you to all who were involved, attended, and donated. Attendees enjoyed Indian fusion food, drinks, live Indian dancers, a saxophonist, and a DJ playing party classics into the late hours of the night. Dr Tapan Patel said, “The evening was a wonderful way to get

together, network, celebrate and give back. I would like to personally thank gold sponsors BTL Aesthetics and Sinclair, as well as silver sponsors Asclepion Laser Technologies, Cutera, Hamilton Fraser, and Lira Clinical for their support of the event. This generosity will directly help hundreds of children in London living in poverty.”

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This year’s top innovations The innovation trail returned for the second year, showcasing innovations, solutions and services coming out to help better the medical aesthetics field and provide clinics with new and game-changing treatments for their patients. This year featured: • • • • • • • • • •

Alastin (Galderma) Ameela (Amedica) AviClear (Cutera) BIOJUVE (Crown Aesthetics) Celluma RESTORE (Celluma/BioPhotas) e-Magnescence (Sculpt Pro Aesthetics) EMFACE (BTL Aesthetics) LGx Longevity DNA Package (Lifecode Gx) Purasomes (Dermoaroma) Opus (Alma)

Time to look forward to your next aesthetics event… Now that CCR 2023 has concluded, it’s time to begin preparations for your next aesthetics event. ACE 2024 will be taking place on March 15 & 16 at the Business Design Centre in London, with the glamorous Aesthetics Awards taking place on the evening of the second day. But there’s more – Aesthetics is now

launching an exclusive one-day expert injector event the day before ACE, at the Bulgari Hotel London. This masterclass will feature three international key opinion leaders, including Dr Steven Liew all the way from Australia. Delegates will be able to learn global insights in an intimate venue, gaining crucial advanced injection advice and the chance to watch live demonstrations from the best in the world.

Save the date

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proportionate to the physical problem that they see.” Facial plastic surgeon Professor Alwyn D’Souza agrees the media coverage has a lot to do with growing popularity, noting that it makes the treatment seem like a harmless ‘lunchtime’ procedure. He says, “I notice that most websites and articles don’t mention the risks, only the incredible outcomes that the procedure can bring. So, I think a lot of patients present to clinic with the idea that it’s an easy procedure and a quick fix.”

Assessing suitability Dental surgeon Dr Yusra Al-Mukhtar explains that the desired outcome of the patient is the basis for her treatment decisions, noting, “I assess both the intention and the goal, as well as the current aesthetic appearance of the nose. If there is a minor dorsal hump deformity, a drooping tip, or midline deviation, these are ideal candidates for an NSR. However, if the dorsal hump is very high, with limited space at the radix where filling may obliterate the nasofrontal angle, then the patient may have a better result with surgery. So, it’s important to consider whether or not the treatment can provide them with their desired outcome. And, as always, provide alternative options.” Three practitioners discuss best practice when According to Mr Harb, 90% of the patients treating the nose with fillers and provide advice who present to his clinic with concerns for optimal results about the nose can be treated using NSR techniques. He says, “I won’t inject patients Non-surgical rhinoplasties (NSR) are becoming an increasingly with complicated large noses who need a reduction, although these popular procedure, with patients recognising it as a less invasive may benefit from non-surgical refinement following surgery. I also alternative to the surgical nose job.1 The global non-surgical won’t inject those who are getting treatment for certain medical rhinoplasty market size was valued at $696.6 million in 2022 and is issues such as ongoing infections or cancer treatment, chronic expected to grow at a compound annual growth rate of 8.1% from inflammatory conditions, pregnancy or breastfeeding, and those who 2023 to 2030.2 Although the procedure can achieve great results come in with unrealistic expectations such as expecting a nose that similar to that of its surgical counterpart, it is also known to cause is beyond what NSRs can achieve. Aside from that, I think everyone serious adverse events such as vascular occlusion and blindness.3 can benefit from an NSR if done correctly.” With a rise in interest, it is important for practitioners to be aware of how to perform the treatments safely. We spoke to three practitioners Product selection to get their advice on how to achieve the best results when performing an NSR, whilst also reducing the risk of complications. When it comes to which dermal filler to use for NSRs, Professor D’Souza explains that he currently likes to treat using the Restylane Growing popularity range, depending on the patients skin and soft tissues. “I like these products because they don’t cause as much swelling as some of According to plastic and reconstructive surgeon Mr Ayad Harb, the other hyaluronic acid products I have tried,” he says. He adds requests for NSR has increased by 20% in his practice since 2020. that he tends to combine fillers with botulinum toxin, particularly for He believes this is to do with social media trends. “Non-surgical nose those who have excessively active nasalis and procerus muscles. procedures have increased in popularity in the last 10 years. I think this He explains, “This is because the product is likely to migrate and is because people were unaware of the availability of such a treatment possibly disintegrate quicker, because of mobility related to muscle for a long time, and then the explosion on social media showed them action. Weakening the muscles with botulinum toxins will help to that they no longer have to live with this huge insecurity,” he says, “I mitigate these effects and patients are likely to get longer and more would say that, more than any other area of the face, nose insecurity optimal results.” can cause serious psychological distress to patients as it’s so central In terms of product amounts, Professor D’Souza says that less is more and visible on the face. Most of the time the mental effect is not when it comes to the nose. “I find that anything more than 1ml is too

Perfecting NonSurgical Rhinoplasties

Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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much – it will be overfilled. It’s important to treat cautiously – you can always add more product, but you can’t take it away without consequence and additional treatments once it’s in resulting in unnecessary costs!” he explains. Although he has tried many products, Mr Harb says that Belotero Intense or Volume are currently his favourite to use in the nasal area. “When selecting a product for NSRs, look at quality and property. You want a solid stiff high G prime, which has a low tendency to absorb water and expand, and something that is inert and stable so there is less risk of swelling or drooping,” he notes. Mr Harb adds that currently there is no filler in aesthetics specifically indicated for the nose, so all products are used off-label. “However, I know that it is something that is on the radars of many of the big dermal filler companies, so watch this space,” he says. Dr Al-Mukhtar explains that her product choice will depend on the desired outcome of the patient and the underlying structure of the nose. She notes, “For example, if a patient has a deviation and I want to align it, I may choose Restylane Lyft as it has a high G prime and is perfect to provide structure, precision and lift without volumisation – it’s also malleable. However, if a patient has a structured nose but wants an elevated tip with high definition, I may choose something like Teosyal Ultra Deep which is a firmer gel. I also like Belotero Intense for this indication because it has a high G prime, is long lasting and integrates with the tissues with minimal inflammatory response. I recommend choosing a product with a high lifting capacity that is not hydrophilic and won’t spread laterally or over-volumise the nose.”

When it comes to treatment methods, Dr Al-Mukhtar has developed her ALR technique: the Align Lift Refine protocol which can be utilised for each indication regardless of gender and ethnicity. She says, “For a patient who has a dorsal hump and needs a tip elevation, I first align the radix using one injection point. This corrects 90% of patient concerns and immediately aligns the dorsum of the nose. I then lift the tip which helps to define and improve the light reflex and shorten the nasal bridge. If necessary I augment the nasal spine to support the soft tissues and improve the nasolabial angle. Then, I refine the dorsum if needed.” However, she adds that if a patient has had surgery in the past, she would treat them differently. “For these patients, I always use ultrasound to vascular map the area, as following surgery, the blood

vessels will change position and may be tethered to the underlying hard tissues. There is also scar tissue to navigate. Using ultrasound helps me reduce the risk of vascular occlusion by first visualising the location of the vessels and navigating around them where possible, or if appropriate, declining treatment where the risk to the patient is too high,” she states. Dr Al-Mukhtar tends to use a 22 gauge cannula when doing NSR treatments. She notes, “If I want to improve deviation and give better alignment I will use a cannula, as this will mean there is less risk of hitting a blood vessel.4 In addition, for a patient who is Afro-Caribbean or Asian and has a flattened bridge and wants to define the dorsal bridge to create better frontal definition, I will use a 25 gauge cannula to place product in microdroplets along the midline dorsum of the nose and recreate the bridge in a safe manner.” Professor D’Souza prefers to use a needle because in his view you can get greater precision, but only injects small amounts of product as he has found this reduces the risk of complications. He says, “In the nose, you want to layer the filler really deep just on top of the bone, and just on top of the cartilage if you’re doing the base of the nose. Needles give me the control that I need and allow me to use a smaller amount of filler for better outcomes.” He explains that as cannulas are larger in size, they insert a larger amount of filler. So, although they can help you prevent going into a blood vessel, it may cause compression of the blood vessel by injecting too much product.5 “This will cause pressure around the vessel. Therefore, I wouldn’t necessarily consider cannulas safer,” he explains. He advises that repeat treatments are typically not required in less than 12 months. “In some patients I have found that the filler can last for up to two years, but it depends on a variety of patient factors including muscle activity and skin biology. Generally, I would say the patient needs to return once a year. In rarer cases, it may be every six months,” he notes. Mr Harb explains that he keeps his technique consistent for all patients regardless of gender or ethnicity. He states, “Noses cannot just be categorised as Black or Caucasian now – we live in an interracial society. This means there are a lot of variables to be considered during each treatment, so to try and simplify each procedure I follow a very standard system to reduce the amount of modifications. I keep where I inject, how I inject and how much pressure I apply the same for each patient. I inject at three main areas – the radix, bridge and tip. The injections are placed at the deep plane on periosteum or perichondrium.”

Before

Techniques for NSRs

After

Figure 1: 30-year-old patient before and after NSR treatment using 0.9ml of Juvéderm Voluma. Images courtesy of Dr Al-Mukhtar.

After

Figure 2: Patient before and after NSR treatment using 1ml of hyaluronic acid filler. Images courtesy of Professor D’Souza.

Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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Before

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After

Figure 3: Patient before and after NSR treatment using 0.7ml of Belotero Volume. Images courtesy of Mr Harb.

Complications of NSRs When it comes to potential complications, Dr Al-Mukhtar explains that these are the same as any other filler treatment including bruising, swelling, nodules and infection, although there is greater risk of these in the nose due to the blood supply and the anastomosis between the internal and external blood supply. One study of 436 reported complications showed that 230 of these had occurred in the nasal area, as opposed to 53 in the eyebrows and 26 in the glabellar region.6 However, the more serious risks include vascular incidents, which can cause necrosis.3 She says, “This means a risk of skin death and long-term scarring. There is also a risk of permanent visual loss if the filler has gone into a blood vessel that has occluded the central retinal artery or caused a vascular spasm, resulting in a loss of blood flow to the eye.7 This is an ophthalmic emergency and vision loss can be permanent or partial, and may include necrosis, ophthalmoplegia and there is also a risk of stroke.” Due to the seriousness of the complications, Dr Al-Mukhtar emphasises the importance of ensuring that the patient is well informed of all potential risks prior to the procedure, and has consented to continuing. Professor D’Souza adds that if a patient is considering having a surgical rhinoplasty in the future, practitioners should recommend that they do not have an NSR in the meantime to avoid potential complications during the surgery. “It can make the surgical procedure more difficult, as fillers can block the lymphatics and cause the nose to swell more, therefore compromising the surgical result to a degree,” he explains.

Other considerations for a successful NSR Professor D’Souza adds that it’s important to always address skin quality before performing an injectable treatment. “You should always address poor quality skin, as it will help to improve the overall final result. I like to recommend that my patients use Tretinoin of prescription strength and certain other products, particularly in oily

skin.” He also adds that a lot of patients think that getting an NSR is more cost-efficient than surgery, but this isn’t actually the case. “An injectable treatment is a fraction of the cost of a surgical rhinoplasty, so I think patients will push for this when weighing up treatment options. However, they forget that surgery is a one-off cost, whereas it is likely they will need to get top-up treatments of filler once a year. So in the long run, it may end up being more expensive for them. It’s important to remind them of this in the consultation so they can make a fully informed decision,” he explains. Mr Harb emphasises the importance of receiving specialised training before performing NSRs. He says, “The biggest thing practitioners get wrong is that they don’t respect the anatomy of the nose, causing both clinical and cosmetic complications. So, clinicians need to get adequate training in this area. It’s completely different from anywhere else on the face – even the way you hold the needle is different. So, just because you’ve done a foundation fillers course for treating the lips doesn’t mean you’re qualified,” he says. Mr Harb adds that you also need specialist training in complications management, so you can spot any kind of adverse event straight away and know how to treat it. Mr Harb adds that he is also part of a Whatsapp chat with 300 other global aesthetic medical professionals, which serves as a way for all nose injectors to discuss treatments, share results and techniques, and provide help/advice if needed. “Having a mentor or a network of nose specialists around you means that you have a wide support system you can refer to if you have any questions, need advice or want to share something new. Because our group is international, it also means that someone, somewhere will be awake at any time to help and guide you!” He explains that you can become part of this group by joining the NSR-PRO community through the Aesthetic Intelligence website. According to Dr Harb this gives you access to the full library of online training videos, as well as an invitation to join the global community. “It will save you a lot of stress and anxiety just knowing you have that support system, as well as save the patient from a serious problem,” he says.

Become specialised in NSR Mr Harb advises that despite the risk of complications, practitioners shouldn’t be put off from treating the nose, as long as they are experienced in performing dermal filler treatments in other areas and are interested in developing skills to treat noses. “Don’t be discouraged by the fear-mongering that’s out there! The most important thing is not to dabble in noses – don’t bother just doing one a month, it will cause you too much stress. Do them, but do them properly and regularly. Get involved with other like-minded professionals and become specialised in this very delicate area if it’s what you’re passionate about,” he concludes. REFERENCES 1. Singh P, Vijayan R, Nikkhah D, ‘Filler Rhinoplasty: Evidence, Outcomes, and Complications’, Aesthet Surg J. (2018). 2. Grand View Research, Non-surgical rhinoplasty market size, 2022, < https://www.grandviewresearch. com/industry-analysis/non-surgical-rhinoplasty-market-report#:~:text=The%20global%20nonsurgical%20rhinoplasty%20market%20size%20was%20valued,rate%20%28CAGR%29%20of%208.1%25%20from%202023%20to%202030.> 3. Nguyen et al., Specific Complications Associated with Non-surgical rhinoplasty, 2020, <https:// pubmed.ncbi.nlm.nih.gov/33709866/> 4. Alam M et al., Rates of vascular occlusion associated with using needles v cannulas for filler injection, 2021, <https://pubmed.ncbi.nlm.nih.gov/33377939/> 5. Frank Rosengaus, Cannula versus needle in medical rhinoplasty, 2020, <https://pubmed.ncbi.nlm.nih. gov/32991042/> 6. Oranges C et al., Complications of Non permanent Facial Fillers, <https://pubmed.ncbi.nlm.nih. gov/34703713/> 7. Eric Sorensen, Update in soft tissue filler associated blindness, 2020, <https://pubmed.ncbi.nlm.nih. gov/31490297/>

Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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Exploring CBD in Medical Aesthetics Dr Shirin Lakhani investigates the potential use of CBD in aesthetics as well as its various benefits and potential considerations Cannabidiol, commonly known as CBD, has gained immense popularity in recent years as a natural remedy for various health issues like sleep, anxiety and pain.1 UK CBD sales were valued at £690 million in 2021 compared with £314 million in 2019 with sales expected to reach £1 billion by 2025. Around 30% of UK adults have used CBD in 2023 compared with 9% in 2019.1 This compound, derived from the cannabis plant, is distinct from its psychoactive counterpart tetrahydrocannabinol (THC), and does not produce the ‘high’ associated with marijuana use.2 In this article, I will explore the potential of CBD in medical aesthetics, its origins and interaction with the endocannabinoid system, the various benefits it offers and potential risks. I will also investigate its diverse uses in the world of aesthetics and wellness, and the future of CBD.

What is CBD? Cannabinoids are chemical compounds which occur naturally in the plant Cannabis sativa L.2 The plant contains more than 100 cannabinoids, the two most abundant being THC and cannabidiol (CBD).2 CBD, unlike THC, does not possess psychoactive properties, meaning it does not alter mood, perception and behaviour in the ways often associated with recreational use of cannabis.2 CBD is typically extracted from hemp, a variety of cannabis that contains very low levels of THC (usually less than 0.3%). It can also be found in marijuana plants, but in this case, the THC content is much higher, leading to psychoactive effects.3 CBD has a wide range of potential therapeutic applications. It interacts with the body’s endocannabinoid system (ECS), a complex network of receptors found throughout the body.3 This system plays a crucial role in regulating various physiological processes, including pain perception, mood and sleep, as well as immune function.3 This interaction forms the basis for many of the potential health benefits of CBD.3

Receptors The ECS consists of two primary types of receptors:5 • CB1 Receptors: These receptors are primarily found in the central nervous system, including the brain and spinal cord. CB1 receptors are abundant in regions of the brain responsible for mood, cognition and motor control. When activated, they can influence processes like pain perception, memory and appetite (Figure 1). • CB2 Receptors: CB2 receptors are mainly found in immune cells and peripheral tissues, such as the spleen and tonsils, and are less prevalent in the central nervous system. CB2 receptors play a significant role in regulating the immune response and inflammatory processes.5 Enzymes They are responsible for the breakdown of endocannabinoids once they have fulfilled their purpose. The two main enzymes involved are fatty acid amide hydrolase (FAAH), which breaks down anandamide, and monoacylglycerol lipase (MAGL), which breaks down 2-AG.5 The ECS is involved in the regulation of a wide range of physiological processes, including but not limited to:6

The ECS is a complex and intricate regulatory system within the human body that plays a fundamental role in maintaining homeostasis in various physiological processes. The ECS was first discovered in the 1990s by researchers Professor Allyn Howlett, William Devane and Raphael Mechoulam who were exploring THC.4 The ECS consists of three main components: endocannabinoids, receptors and enzymes.5

• Pain perception: The ECS can modulate pain signalling pathways, making it a potential target for pain management and relief. • Mood and stress regulation: The ECS has a role in regulating mood and reducing stress and anxiety. Endocannabinoids like anandamide are often referred to as ‘bliss molecules’ because of their role in promoting feelings of wellbeing and relaxation. • Immune function: CB2 receptors in the immune system help regulate immune response and inflammation, suggesting a potential role in autoimmune diseases and inflammatory conditions. • Appetite and metabolism: The ECS plays a role in regulating appetite and energy balance, making it a target for conditions like obesity and eating disorders. • Sleep regulation: The ECS is involved in the regulation of sleep patterns, and some studies suggest that it may influence sleep-wake cycles.7-9 • Neuroprotection: There is ongoing research into the ECS’s role in protecting and supporting the health of neurons and brain cells, which may have implications for neurodegenerative diseases.10-12 • Reproductive health: The ECS plays a role in reproductive processes, including fertility and embryonic development.6

Endocannabinoids These are naturally occurring compounds produced by the human body. The two primary endocannabinoids identified currently are anandamide (AEA) and 2-arachidonoylglycerol (2-AG). These endocannabinoids are produced on-demand in response to specific physiological needs.5

The ECS can also interact with exogenous cannabinoids, such as those found in the cannabis plant (e.g. THC and CBD, also known as phytocannabinoids), and synthetic cannabinoids (e.g. dronabinol, nabilone) used for therapeutic purposes. These external cannabinoids can bind to the same receptors in the ECS, leading to various physiological effects.13

The endocannabinoid system

Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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Brain

• Learning, memory, cognition • Motor control • Anxiety and depression • Appetite and food intake • Reward and addiction • Neuroprotection • Neural development • Sleep

Liver

• Ascites formation • Lipogenesis • Fibrosis • Insulin resistance

Reproductive system

• Fertility regulation • Embryo implantation • Embryonic development

Cardiovascular system • Negative inotropy • Vasodilation • Cardiac function

Skeletal muscles

• Energy metabolism • Muscle fibre formation

GI tract

• GI motility • Enteroendocrine function • Intestinal barrier function • Energy balance

Other

• Nociception • Immune modulation • Nausea and emesis • Intraocular pressure • Bone remodelling • Bronchodilation • Cancer

Figure 1: Major localisation sites and associated functions of the CB1 receptors in the human body.6

Understanding the ECS is a relatively new area of research, and scientists are continually uncovering its complexities and potential therapeutic applications. It is a fascinating and rapidly evolving field that has the potential to offer new insights into a wide range of health and medical conditions.

Benefits of CBD While research is ongoing and further clinical trials are needed, there are some therapeutic uses of CBD that have shown promise:14 • Skin conditions: CBD’s anti-inflammatory and sebum-regulating properties make it a potential treatment for acne, helping to reduce inflammation and prevent excess oil production. CBD-infused topicals, such as creams and balms, are also used to alleviate symptoms of skin conditions like eczema and psoriasis due to their anti-inflammatory properties.15 • Inflammatory conditions: CBD may help manage inflammatory conditions such as Crohn’s disease, rheumatoid arthritis and inflammatory bowel disease by reducing inflammation and modulating the immune response.16 • Sleep disorders: CBD may promote better sleep by addressing underlying causes of insomnia, such as anxiety or chronic pain. Some users report improved sleep quality and reduced sleep disturbances after using CBD.17 • Pain management: CBD may help alleviate chronic pain conditions such as arthritis, multiple sclerosis and fibromyalgia due to its interaction with the ECS and its anti-inflammatory properties.18 • Anxiety and depression: CBD has shown promise in reducing symptoms of various anxiety disorders, including generalised anxiety disorder, social anxiety disorder and post-traumatic stress disorder. It may help promote relaxation and reduce anxiety levels.16 Some studies suggest that CBD may have antidepressant effects by influencing serotonin receptors in the brain.12,19,20 • Epilepsy and seizure disorders: Epidiolex, a medication containing CBD, has been approved by the US Food and Drug Administration for the treatment of two rare forms of epilepsy, Lennox-Gastaut syndrome and Dravet syndrome.21 It has shown significant effectiveness in reducing seizure frequency.21 • Neurological disorders: CBD’s neuroprotective properties have prompted interest in its potential for managing neurodegenerative diseases such as Alzheimer’s and 34

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Parkinson’s disease. While more research is needed, it may help slow the progression of these conditions.11,22 Some individuals with multiple sclerosis have reported improvements in spasticity and muscle stiffness after using CBD products.22 • Addiction and substance abuse: Some studies suggest that CBD may help individuals struggling with addiction by reducing cravings and anxiety associated with substance withdrawal. It may be a supportive component of addiction recovery programmes.23,24 • Cancer-related symptoms: CBD, often in combination with THC, has been used to alleviate nausea and vomiting in cancer patients undergoing chemotherapy.25 It has also helped manage cancer-related pain and stimulate appetite in cancer patients.25 • Cardiovascular health: CBD may help reduce blood pressure and could have a cardioprotective role in ischaemia and strokes.26 It is essential to note that while CBD shows promise in these areas, individual responses can vary, and its effectiveness may depend on factors such as dosage, product quality and the specific condition being treated. Therefore, further clinical studies are needed.

CBD use in aesthetics CBD is recognised for its anti-inflammatory properties, making it a powerful ingredient in addressing skin conditions and reducing redness and irritation. When applied topically, published literature has shown that it can help reduce swelling and inflammation associated with various skin conditions, including acne, eczema and psoriasis.15 Furthermore, a small open label study involving five patients with psoriasis and five patients with atopic dermatitis who applied a topical CBD product twice a day. Results showed an improvement at three months with no reported adverse events.27 Although current research is limited, an in-vitro study by Jin et al., showed that a hemp seed hexane extract (HSHE) exhibited anti-microbial activity on Cutibacterium acnes while inducing inflammation, and lipogenesis in sebocytes at the molecular and cellular level.28 With 20% HSHE treatment, complete inactivation of C. acnes was observed. Therefore, the content of CBD in HSHE was not reported; hence it is difficult to attribute the contribution of CBD alone towards the inactivation of C. acnes.28 In another small clinical study of 11 healthy males suffering from buccal facial acne, a 3% cannabis seed extract containing cream led to decreased sebum content and erythema.29 However, as cannabis seed extract contains minimal CBD content, it limits our understanding of the application of CBD for acne and seborrhoea therapy.29 It can also reduce the pruritus associated with inflammatory skin conditions.15 One study has also shown that CBD can reduce sebum production, and this combined with its anti-inflammatory properties, may make it an effective addition to acne treatment regimens.15 As a potent antioxidant, CBD has also been shown in the literature to help combat oxidative stress and free radicals that contribute to premature ageing.15 Incorporating CBD into skincare can help to protect the skin from environmental damage, with some studies showing reversal of UV-induced photodamage with topical application of CBD.15,30,31 Many of the studies to date are in-vitro and more large scale human clinical studies need to be performed. Furthermore, CBD-infused skincare products often contain essential fatty acids that promote skin hydration and maintain the skin’s natural moisture barrier, leading to a healthier and more radiant complexion. CBD can be combined with other skincare ingredients,

Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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such as hyaluronic acid, vitamins and botanical extracts, to create well-rounded skincare products that target specific skin concerns.32 In addition, recent studies have shown the benefits of CBD for hair regrowth.32-34 CBD has also been demonstrated in hair shaft elongation, increase the differentiation of dermal progenitor cells into new hair follicles, and maintain the anagen phase of hair growth. The effects appear to be dose dependant with higher doses leading to hair loss.32-34

Benefits in women’s health As well as aesthetic treatments, some clinics provide treatments to help improve women’s health, specifically during the menopause. Whilst research on the use of CBD on this topic is ongoing, there are several potential implications of CBD helping women’s health. CBD’s anti-inflammatory and analgesic properties may help alleviate menstrual pain and reduce the severity of cramps when applied topically or ingested.35,36 It may also be beneficial in reducing the pain of endometriosis.35 However, this study was conducted on rats, so further human studies are required. The ECS, with which CBD interacts, is involved in regulating hormonal balance. Some women use CBD to help manage the symptoms of hormonal fluctuations associated with premenstrual syndrome or menopause. However, more research is needed to fully understand the extent of CBD’s influence on hormonal balance. Additionally, as mentioned above, CBD can help with anxiety, mood disorders and insomnia, all conditions associated with the menopause.35 Aside from the documented anxiolytic effects of CBD, there is growing evidence that CBD may influence sexual function in women. The ECS is involved in regulating various physiological processes, including those related to sexual health. CBD interacts with the ECS, potentially influencing sexual responses and satisfaction. Some women report heightened sensations and increased tactile awareness when using CBD-infused sexual products, which can contribute to sexual pleasure.36,37 CBD-infused lubricants or creams may help with vaginal dryness by promoting moisture and reducing friction.36,37

Considerations of CBD While CBD is generally considered safe, with limited side effects (somnolence, diarrhoea, fatigue, vomiting, pyrexia and lethargy), there are some potential risks and considerations to keep in mind.38 CBD can interact with certain medications, including anticoagulants and drugs affecting cytochrome p450. Prolonged use has been associated with elevated liver enzymes.38 There is an increased risk in patients who are also taking sodium valproate.38 Furthermore, the quality and potency of CBD products can vary significantly, so it is important to use a reputable brand which engages in independent testing and quality control. The CBD industry is relatively unregulated, which can lead to inconsistencies in product quality and labelling with respect to cannabinoid concentrations or may include constituents (e.g. THC, synthetic cannabinoids) that are not listed on the label.39,40 It is important to note that the quality and potency of CBD skincare products can vary significantly between brands. When considering CBD skincare, it’s advisable to choose products from reputable manufacturers that provide third-party testing to ensure purity and potency. Although rare, some individuals may be allergic to CBD or other components in CBD-infused products, so a full medical history is essential to rule out potential allergic reactions. While there is a growing body of pre-clinical and observational research on CBD, high-quality

clinical trials are still relatively limited. Many studies are small in scale, and larger, well-controlled trials are needed to establish CBD’s safety and efficacy for specific medical conditions.

The future of CBD in medical aesthetics and wellness CBD’s journey into the world of medical aesthetics and wellness is marked by promise and potential. However, more research and clinical studies are needed in this area to highlight its benefits for the aesthetics market. With its array of benefits, CBD could be a new approach to skincare and wellbeing in the future. However, it is crucial to inform patients of the potential risks, and to select high-quality products from reputable sources. As research into CBD’s applications continues to expand, practitioners can look forward to more innovative solutions and a deeper understanding of its role in enhancing both patients’ appearance and their overall quality of life. Disclosure: Dr Shirin Lakhani works with CBD company Pharmstrong as an advisor. Dr Shirin Lakhani is a cosmetic practitioner specialising in advanced aesthetic treatments, intimate health and HRT for men and women. Dr Lakhani appears regularly on television and in the press, as well as contributing to articles and speaking at conferences both in the UK and internationally. She is currently involved with the APPG for menopause. Qual: MBBS, MRCA, MRCGP, DRCOG

Test your knowledge!

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

Possible answers

a. b.

Which of the following statements regarding cannabinoids is incorrect:

c. d. 2.

Regarding the endocannabinoid system, which of the following statements is false:

a. b. c. d.

CBD is an endocannabinoid There are more than 100 naturally occurring cannabinoids CBD is primarily derived from hemp, whereas THC is primarily derived from marijuana CBD does not possess psychoactive properties The primary receptors are CB1 and CB2 CB1 receptors are primarily found in the central nervous system CB2 receptors are responsible for the effect of cannabinoids on appetite CB2 receptors are responsible for the anti-inflammatory effects of cannabinoids

CBD is not useful in the management of:

a. b. c. d.

Glaucoma Substance addiction Rheumatoid arthritis Epilepsy

Which of the following statements is incorrect:

CBD has an inhibitory effect on sebum production CBD is not absorbed topically CBD may reduce UV-induced photodamage CBD has antioxidant and anti-inflammatory properties

Regarding regulation, which of the following is true:

b. c. d.

There is strong regulation around CBD products All CBD products that are legally sold in the UK are free of THC All products available for sale in the UK have been independently tested Ingestible CBD products must be registered in the UK as novel foods Answers: A,C,A,B,D

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Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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Treating Facial Palsy Aesthetic nurse prescriber Michelle McLean provides insight into facial palsy and treatment options within aesthetic medicine Facial paralysis, or facial palsy, is a common neuropathy with an annual incidence of 70 cases per 100,000 members of the population in the UK.1 It may be more following COVID-19 infection and its reported possible side effects, although more research is needed into this area to confirm any hypothesis.2,3 Patients with concerns about facial paralysis frequently present to aesthetic clinics hoping to achieve better facial balancing through aesthetic treatments. Increased patient knowledge and awareness of non-surgical procedures and the advancement of injection techniques have led to a significant shift from surgical to non-surgical and combined approaches. As a clinician, a sound understanding of facial paralysis is essential when treating patients presenting with facial palsy, and considerations should be made to ensure that treatment positively impacts both the physical and psychosocial care of patients.

Causes of facial palsy Facial paralysis, or facial palsy, generally refers to weakness or total loss of movement of the facial muscles resulting from temporary or permanent damage to the facial nerve.4 Facial palsy can be a congenital disorder, meaning it presents at the time of birth due to delivery traumas and genetic or malformative diseases.5 It can alternatively be acquired, possibly Site

Aetiology

Intracranial

• • •

Acoustic neuroma Stroke (forehead spared) Brain stem tumour

Intratemporal

• • •

Bell’s palsy (diagnosis of exclusion Herpes zoster oticus, Ramsay-Hunt syndrome) Middle ear infection Trauma: • Surgical • Temporal bone fracture • Lacerations anterior/inferior to the tragus

Extratemporal

•

Parotid tumours

Miscellaneous

•

Sarcoidosis, polyneuritis

Table 1: Causes of facial nerve palsy10

appearing at any time during life due to infective, inflammatory, neoplastic, traumatic or iatrogenic causes, and affecting people of any age.5 The most common known cause of facial paralysis is generally idiopathic with no apparent reason: Bell’s palsy.6 Other facial nerve palsies can be related to several conditions: Ramsay-Hunt syndrome (caused by herpes zoster outbreak), cholesteatoma, parotid gland tumours, Lyme disease, otitis media, HIV, leprosy, amyloidosis, Guillain-Barré syndrome and sarcoidosis (autoimmune diseases), diabetes and strokes (Table 1).6-8 Infection reports account for 7% of presenting cases, trauma 10-23% and tumours 2-2.5%.9 When facial paralysis presents, there is damage or injury to a particular branch of the facial nerve and the correlated muscles.1 Facial nerve damage can result from various causes frequency of these is as yet unknown.1 Facial paralysis can be identified as unilateral (affects one side of the face), which is most commonly seen, or bilateral (affects both sides) – a rarer presentation.1 The symptoms of facial palsy can vary between patients depending on the underlying cause and severity of the condition.1 In some cases, the weakness or paralysis may be mild and only affect certain areas of the face, such as the mouth or eyelid. In more severe cases, the entire face may be affected, including the ability to close the eye on the affected side.11 Medical treatment for facial palsy depends on the underlying cause of the condition. In some cases, the condition may improve on its own over time. In the UK, patients experience a considerable variation in care pathways, including medication, physical therapy and surgery.12 A face-to-face consultation should establish if the patient has a confirmed diagnosis of facial palsy, and the severity of their condition. In the absence of a confirmed diagnosis, the clinician must refrain from treatment and refer the patient back to their GP for further investigation. In an upper motor neurone palsy, the frontalis is spared, and the patient can still wrinkle the forehead on the affected side. There is no effect on the eyelid or closure of the eye itself. Various causes of upper motor neurone facial palsy include multiple sclerosis, stroke, intracranial tumours, HIV and infections such as syphilis.13 Lower motor neurone lesions are associated mostly with Bell’s palsy, and around 10 to 40 people per 100,000 are

Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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affected annually.14 A lower motor neuron palsy presents with a total unilateral palsy presentation.14 Other lower motor neuron lesions are associated with Ramsay-Hunt Syndrome.14 It is important for clinicians to refrain from attempting to diagnose patients with facial palsy. Diagnosis should be established through the patient’s GP/NHS secondary care pathway to determine the condition’s underlying cause. These individuals possess extensive training and experience in this field, so patients should be referred on to them. Successful treatment of patients relies on assessing the individual’s presentation in-clinic, rather than focusing solely on the cause of paralysis. An all-encompassing understanding of the patient is essential for effective treatment since symptoms are unique to each patient and a generalised approach will not suffice. Analysing the patient’s psychosocial wellbeing and the impact of paralysis on their daily life is crucial in identifying their specific concerns and objectives. Damage to the facial nerve CN VII, whether inflammation or compression, can trigger substantial variable symptoms depending on the lesion site and the branch affected, which can be permanent or reversible.15,16 Symptoms can include a visible mouth droop, flattening of the nasolabial fold, inability to close the eye and smoothing of the brow on the damaged side.15,16 The main causation of Bell’s palsy suggests it relates to the herpes simplex virus.15 Therefore, understanding the facial nerve complexity and its variability is pivotal for clinicians in the non-surgical medical aesthetics arena to treat nerve-related injuries/conditions, and prevent damage whilst providing satisfactory results to patients.

Aesthetics as a potential cause of facial paralysis From an aesthetic perspective, nerve injury secondary to dermal fillers, although rare, can occur, whether it be through blunt or sharp force. The facial nerve can undergo trauma through direct injection into a nerve by needle or cannula, or through compressing and excessive massaging of dermal fillers, which can result in sensory or motor deficit.17 Threads and dental block procedures can also result in nerve injury.18,19 Whilst sound anatomical knowledge is pivotal and will help to reduce the risk and potential of nerve-induced trauma, practitioners should acknowledge that anatomical variations do exist. If a patient presents with paralysis or weakness following an aesthetic procedure, it is vital that a full face-to-face consultation, medical history Before

After

Figure 1: 56-year-old female patient at baseline in 2019, and at 2022 following botulinum toxin treatment

Aesthetics

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analysis and examination of ocular and perioral musculature is sought, as this will greatly assist in the effective and appropriate management of onward secondary care referral. Facial paralysis caused by dermal fillers is extremely rare, and in my 12 years of aesthetic practice, I have never encountered this complication. Studies in this area are limited, and it would be beneficial for it to be recorded in the future. To ensure the safety of the patient, it is important to have a reliable referral system in place. The use of ultrasound scanning can provide valuable information about the placement of dermal fillers, which can be shared with emergency services if immediate treatment is needed.20 If the clinician lacks relevant experience or cannot provide treatment, it is necessary to refer the patient for emergency treatment via the NHS Emergency Department or with a complications management specialist. The facial nerve is a vital structure for emotion and communication, and impairment can cause a substantial decline in a patient’s quality of life.14 The impact of the inability to smile and express emotion is the main distressing aspect of facial palsy, and such individuals fear being negatively evaluated by others, which has a detrimental impact on their social interactions.21

Aesthetics as a treatment for facial paralysis The administration of botulinum toxin can play a crucial role in improving quality of life in facial palsy patients. A recent study showed that a single dose of botulinum toxin administered on the unaffected side of 18 patients with acute facial paralysis generated momentous improvement in facial symmetry four weeks post-treatment.21 Individualised botulinum toxin injection patterns are critical for optimal unilateral synkinesis and contralateral hyperkinesis success. It is important to note that synkinesis treatment aims to target accurate, viable synkinesis muscles and not stimulate flaccid muscles.21 When it comes to individualising treatment for patients with facial paralysis, it is crucial that the clinician is well-trained and highly experienced. They should have received ample training and gained experience by shadowing other specialist practitioners who regularly treat facial palsy. In addition to having a thorough understanding of facial anatomy, clinicians should also take a holistic approach to treatment and be familiar with various options such as surgery, therapy, rehabilitation and more. If a clinician is not experienced in treating facial paralysis, referring the patient to a specialist practitioner or back through their NHS pathway is recommended. Those seeking to expand their knowledge can refer to courses like ‘A Multidisciplinary Approach to the Management of Facial Palsy’ developed by Catriona Neville (ESP Physiotherapist at Queen Victoria Hospital NHS Foundation Trust) and Sally Glover (Clinical Specialist Physiotherapist, University Hospitals Birmingham NHSFT).22 Botulinum toxin can be administered into the non-paralysed facial muscles for successful hyperkinesis treatment to help relax the activity and improve symmetry. Clinicians must carefully consider the precise injection location, depth and angle of treatment, as unnecessary side effects can harm such patients and further exacerbate facial asymmetry. To help minimise such risks, under-correction is essential in the initial treatment plan, as additional injections can be made during the review appointment.23

Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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Baseline

Aesthetics

After toxin

Aesthetics

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After EMFACE

Case study two This case looks at a 35-year-old female patient. She suffered facial palsy due to nerve damage from surgical operations on the jaw. Her wellbeing was deeply affected by the physical effects of facial paralysis, meaning she was sometimes withdrawn from society.

Treatment Initially, toxin was chosen as the management plan to relax unwanted muscle activity on the unaffected side. Azzalure was injected into the corrugator supercilia (20 units s.U), frontalis (15 units s.U) and orbicularis oculi (15 units s.U) Figure 2: 35-year-old female patient at baseline, after botulinum toxin treatment in 2023 and after EMFACE treatment in 2023 on the unaffected side to achieve symmetry and facial harmony by reducing unwanted Case study one tension and hyperactivity due to synkinesis. Four months following toxin treatment, we utilised this patient as part of a small study using EMFACE This case looks at a 56-year-old female patient. The patient has technology. The patient underwent four sessions of EMFACE, each attended my clinic for regular treatment over the past four years. She session one week apart. In EMFACE, three facial applicator pads has Ramsay Hunt syndrome, and had previously accessed toxins simultaneously emit both synchronised radiofrequency and high for palsy from the NHS. Free NHS treatment is limited, so additional intensity facial electromagnetic stimulation (HIFES) energies, causing treatment at my clinic has been used to maintain results in between. stimulation on the elevators of the facial muscles – the frontalis, Following a recent appointment with her NHS consultant, she was the zygomaticus major and minor and the risorius muscles.25 The highly dissatisfied with the results, noting that the results seemed treatment resulted in significant improvements in facial symmetry to emphasise asymmetry. The patient’s wedding was imminent and even after one session. following successful treatment at my clinic in the past, she returned to discuss possible options before her big day. Results A consultation was conducted before treatment to assess suitability The patient results show facial balance and harmony have been and manage the patient’s expectations. It was explained that a restored (Figure 2), and she reported her wellbeing and mental health conservative approach with a view to subsequent top-ups would be had significantly improved. Aftercare advice was general for any the best approach, as in patients with facial palsy, higher doses of patient undergoing toxin or EMFACE treatment; no aftercare specific botulinum toxin can lead to difficulty talking, eating and drinking.24 to facial paralysis was necessary. Toxin results typically last around four months, so the patient will next attend the clinic in four months for a Treatment new assessment for toxin management. Botulinum toxin type A (Azzalure from Galderma) was injected into the depressor anguli oris (5 Speywood units) and the upper horizontal Improving patient wellbeing fibres of the platysma (20 s.U) on the contralateral side to the facial palsy to decrease the tone of the muscle and improve symmetry. When carrying out aesthetic treatments, sound anatomical knowledge This reduced the downward force of zygomaticus major, zygomaticus is required to minimise the risk of nerve injury/neurapraxia, which can minor, levator labii superioris and levator labii superioris alaeque nasi, be linked to dermal fillers and thread administration, resulting in facial and provided an elevation of the tissue. palsy. When it comes to facial palsy patients, whether the condition Azzalure was also injected into the mentalis (10 s.U) to enable oral is related to Bell’s palsy, Ramsay Hunt Syndrome etc., experienced commissure elevation, and the orbicularis oculi (20 s.U) and corrugator clinicians can play a pivotal role in improving patients’ quality of life supercilia (20 s.U) on the unaffected side to improve symmetry and through the successful administration of botulinum toxin and other balance. Vivacy Stylage dermal filler was combined with botulinum aesthetic treatments. toxin to improve zygomaticus function and balance as well as improve Michelle McLean is the founder and medical lead lip symmetry at rest. Stylage S (1.2ml) was used to augment the lip for Aesthetically You, a ‘good’ rated CQC clinic in the and soften perioral lines on the hyperactive side. Stylage M (1.3ml) Northwest of England. She has more than 12 years of experience in the industry and is a regional leader for the was used to soften and reduce static line activity in the nasolabial fold BACN. McLean is currently completing a second Master’s areas and to support oral commissure elevation. Results The patient results show facial balance and harmony have been restored (Figure 1), and she reported that her wellbeing had significantly improved. Aftercare advice was general for any patient undergoing toxin and dermal filler treatment; no aftercare specific to facial paralysis was necessary. The patient will next attend the clinic four months after treatment for a new assessment and potential continued treatment.

in Cosmetic Medicine. Qual: RGN, INP, MSc, BSc (Hons), DIP/HE

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Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

RESTYLANE LYFT ™ by

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*G’ is a measure of gel firmness (resistance to deformation), which can be used to understand how a gel’s physical properties relate to its in vivo performance8 REFERENCES: 1. Restylane® Lyft™ EU IFU; 2. Nikolis A et al. Aesthet Surg J Open Forum. 2020; 2(1): ojaa005; 3. Gregario G et al. Clin Cosmet Investig Dermatol 2022; 15: 681-690; 4. Huang S and Tsai T. J Drugs Dermatol 2020; 19(9): 836-842; 5. Galderma. Data on File. MA-43049; 6. Lundgren B et al. J Drugs Dermatol 2018; 17(9): 982-986; 7. Nikolis A et al. Poster presented at the 20th Aesthetic & Anti-aging Medicine World Congress. 31 March-2 April 2022. Monte Carlo, Monaco; 8. Öhrlund Å. J Cosmet Dermatol Sci Applic. 2018; 8(2): 47-54.

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Trauma and cosmetic-induced ptosis

Case Study: Correcting Eyelid Ptosis with Toxin Dr Alexander Parys and Dr Steven Land present two cases of eyelid ptosis and how they corrected the condition using toxin Lid ptosis, or blepharoptosis, is a medical condition characterised by the drooping or sagging of the upper eyelid.1 It occurs when the muscles responsible for lifting the eyelid, the levator palpebrae superioris and the superior tarsal (Müller’s muscle), weaken or become stretched. This results in the eyelid covering a portion of the eye or drooping lower than its normal position.2,3 Several factors can cause blepharoptosis. It can be present at birth, caused by a developmental abnormality in the muscles that lift the eyelid, or develop later in life because of ageing, trauma, certain medical conditions like myasthenia gravis or Horner syndrome, or as a complication of botulinum toxin (BoNT-A).3

Causes of ptosis Lid ptosis can be congenital or acquired later in life due to age-related weakening of the muscles, trauma or injury to the eyelid and the nerves controlling it.1 Ptosis can also be secondary to a range of underlying neurological or muscular conditions, including third cranial nerve palsy, chronic progressive external ophthalmoplegia (CPEO), oculopharyngeal muscular dystrophy, Horner’s syndrome, and myasthenia gravis.3 In aesthetics, ptosis is exclusively related to the inadvertent injection of BoNT-A into an unwanted area, leading to muscle weakness and a resultant droop.4,5 Compensated brow ptosis is also possible, which is corrected subconsciously by the patient, through contraction of the frontalis muscle in the forehead to raise the brow to a more desirable or functional position.6 In general, the unilateral or bilateral drooping of the upper eyelid that characterises ptosis can affect appearance and impair visual function, both of which can negatively impact a patient’s quality of life.3,4

In many cases of cosmetic toxin-induced ptosis, patients tend to continue with their usual lives as it usually settles within three to four weeks.4,7,8 To reduce the duration of ptosis, however, muscle stimulation can be employed through muscle exercises or mechanical or electrical stimulation, such as the back of an electric toothbrush.4 However, we don’t recommend this to our patients due to lack of evidence of efficacy. In addition, 0.5% apraclonidine (iopidine) eye drops (one to two drops three times daily) can be used off-license for the treatment of ptosis.4 Currently, there is no literature which specifies how long these should be used, however, one source notes common practice is to use them regularly until resolution. In many cases, this can happen within a matter of weeks, as the effects of the toxin and ptosis wears off.9 It may elevate the lid by 1-3mm, but needs to be repeated up to three times a day to maintain results.4,10 Potential side effects include redness, eye discomfort, impaired/blurred vision, dizziness and drowsiness.9 If the ptosis does not affect day-to-day tasks, such as driving, you may recommend only using the apraclonidine on a ‘when required’ basis, such as on special occasions, to minimise side effects.10 For long-term cases, surgery is an option.11-12 In both of the cases discussed in this article, we chose to use pre-tarsal injections of BoNT-A to treat ptosis, guided by the techniques described by ophthalmologists Dr Mustak, Dr Rafaelof, Dr Goldberg and Dr Rootman in their paper published in the Journal of Clinical Aesthetic Dermatology.10 One paper included the Complications in Medical Aesthetics Collaborative (CMAC) Study Group on the Management of Severe Botulinum-Induced Eyelid Ptosis with Pre-tarsal Botulinum Toxin and Oxymetazoline Hydrochloride 0.1.13 Another paper on the ‘Safety of Pre-tarsal Botulinum Toxin for Blepharospasm Associated Pseudo-apraxia: Is Ptosis a Real Concern?’ was also consulted.14 The product used was prabotulinumtoxinA-xvfs (known as Jeuveau in the US and Nuceiva in Europe and Canada), a BoNT-A approved by the US Food and Drug Administration (FDA) for temporary improvement in the appearance of moderate-to-severe glabellar lines.15-18

Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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In aesthetics, ptosis is exclusively related to the inadvertent injection of BoNT-A into an unwanted area, leading to muscle weakness and a droop

Other brands of toxin available in the UK include abobotulinumtoxinA (Dysport, Azzalure); incobotulinumtoxinA (Xeomin, Bocouture) and onabotulinumtoxinA (Botox). There have also been several new toxins launched, including relabotulinumtoxinA (Alluzience) and letibotulinumtoxinA (Letybo). While all brands of toxins perform in a similar way, there are some nuances with the products.19 The rationale for choosing prabotulinumtoxinA-xvfs for this indication was that, in our experience, it appears to be more precise and has a tighter diffusion radius (although it must be noted that this is our anecdotal opinion and no studies have yet evidenced this). In the past, we had been cautious about injecting the eyelid as you can potentially worsen ptosis.19 However, our experience with the tighter field of effect of this new toxin, which we had treated other areas of the face with, made us feel comfortable in trying the technique described by ophthalmologists Mustak, Rafaelof, Goldberg and Rootman.10

Trauma-induced ptosis case study by Dr Parys In April 2023, a 34-year-old female patient presented to my clinic asking me to dissolve dermal filler in her lips and under her eyes that she had received in another clinic. She had lost confidence in the previous practitioner and wanted more natural results. During the consultation, it was obvious that she had prominent eyelid ptosis. After seeing her a few times – the consultation, the appointment for dissolving the filler and then another for refilling – I felt we had built up enough rapport and trust for me to ask 44

Before

After

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about her ptosis. She explained it was caused by a traumatic injury to her eyelid when a pet hamster scratched her when she was 16. The patient had previously seen a surgeon but was advised that if they made an incision to remove the skin to try and lift the eyelid up, she would have to sleep with one eye open, so surgery wasn’t an option. Initially, we injected some filler above her eye on the affected side to level her lids. This improved slightly, but when one of the eyelids was half-covering her eye and the other was wide open, it was still obvious. When I was reviewing the filler, I explained to her that I had read about a pre-tarsal technique using toxin, and something we could try. It is important to inform your patients of all treatment information and the risks involved as well as getting full written consent. I told her that I had never done the procedure before and that we could potentially worsen the eyelid temporarily. I gave the patient a cooling-off period of two weeks to think about her decision but as she had ptosis for so long, she was happy to go ahead with treatment. On the day, I applied LMX 4 to make it comfortable for the patient and to stop her flinching as I was injecting close to the eye. PrabotulinumtoxinA-xvfs was injected transdermally 2mm above the lash line in the medial (lining up with the limbus of the pupil) and lateral third of the pre-tarsal orbicularis.10 I used two units per point (total of four units) and altered the dilution of my product. The normal dilution is 50 units in 1.25ml of saline, whereas I did 50 units in 0.5ml. I used a more concentrated dose as I wanted to inject more units due to the severity of the ptosis and wanted a tighter field of effect.19 Whilst injecting, I pinched the skin and injected in between my fingers, which was easier than stretching the skin. The patient reported that the treatment was comfortable. I prefer to mark up where I’m injecting to ensure landmarks are correct. I decided not to use LMX 4 on subsequent treatments, and it didn’t affect patient comfort – I found the pinch technique to be sufficient for reducing pain levels and less likely to cause LMX to get into the eyes, causing irritation. The patient reported seeing results three days post-treatment but missed her two-week follow-up due to contracting COVID-19. I reviewed her one month after her toxin treatment, where we took ‘after’ photos to assess the results. She will need the treatment repeated every three to six months as per normal toxin reschedules to maintain results. Before

After

Figure 1: 34-year-old patient before and one month after toxin treatment with results showing an improvement in eyelid ptosis.

Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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Aesthetics

Toxin induced ptosis case study by Dr Land A practitioner who works at my clinic has BoNT-A injections for her migraines on the NHS every three to four months. In November 2022, she came into work with visible left-sided lid ptosis after visiting a practitioner she hadn’t seen before. After two weeks of waiting for everything to settle she spoke to the NHS. However, as the treatment was successful in helping her migraines, she was told to deal with the undesirable cosmetic effect. She asked if I would prescribe some apraclonidine eye drops for her, and I told her I could but that I was aware of a technique for intertarsal toxin injections that I could try if she felt comfortable. I had been aware of the technique for two to three years but hadn’t seen ptosis since I’d read about the technique, as it is rare.10 I felt confident to try it at this stage as we had been using prabotulinumtoxinAxvfs in-clinic. The patient was aware that

aestheticsjournal.com

we could make it worse as we were weakening the closing mechanism to rebalance the lid position. Like Dr Parys, I informed my patient of the risks involved and treatment process. The patient had a cooling-off period to think about her decision. Being an aesthetic doctor herself, my colleague was open to trying the technique and was happy to go ahead with treatment. PrabotulinumtoxinA-xvfs was injected transdermally 2mm above the lash line in the medial and lateral limbal lines, into the pre-tarsal orbicularis.10 I used a small, cautious dose (0.5 units in each side), so if I did cause a problem, such as lagophthalmos, exposure keratitis, or making the ptosis worse it would subside in three to four weeks.10 The technique worked well, and the patient saw an improvement within two days. She had full resolution of lid ptosis and no further treatment was required due to the initial ptosis being the result of a complication from toxin.

Although there is no recorded cases of lagophthalmos (difficulty closing the eyelid fully), patients should be informed of this as a potential risk

Considerations for treating eyelid ptosis with toxin

A promising solution for eyelid ptosis

It is important to counsel the patient accordingly as in our experience, there is a chance of temporarily worsening the ptosis if the toxin diffuses to the levator muscle. Although there is no recorded cases of lagophthalmos (difficulty closing the eyelid fully) which could cause dry-eye symptoms, patients should be informed of this as a potential risk. We suggest going low and slow – if you are sticking to standard dilution, don’t jump in with a high number of units. The liquid causes a surprisingly and concerningly large bleb even at the concentrated dose of 0.02ml, so consider a lower dose first. We recommend practitioners consider splitting the treatment across two sessions (i.e. the second treatment two weeks later) if using low doses. This can be a useful review of your own experience to see the result for the given dose. In terms of experience, the eyelid is an advanced area to inject. Novice injectors should focus on understanding the correct placement of toxins, cause of the ptosis and not mistake eyebrow ptosis with eyelid ptosis.

Pre-tarsal injections of BoNT-A potentially offers a promising solution for the treatment of eyelid ptosis as demonstrated in these toxin-induced and trauma-induced cases. Both patients saw an improvement in eyelid ptosis, resulting in an improvement in vision and cosmetic appearance within a few days. More research and clinical trials, including peer-reviewed, larger sample size, placebo etc is needed to substantiate the results, but this offers a promising approach.

Potential side effects include redness, eye discomfort, impaired/ blurred vision, dizziness and drowsiness

Dr Alexander Parys is an aesthetic doctor and founder of SONÜ Medical Aesthetics in Cheshire and Manchester. He worked within the NHS for nearly a decade as both an Emergency Medicine and Clinical Radiology specialist registrar. He was the author of an aesthetic textbook chapter, Decision Making in Aesthetic Practice, in 2021. Dr Parys was the Aesthetics Awards Winner 2021 for Rising Star of the Year. Qual: MBChB Dr Steven Land qualified in 2001 and has trained in medicine, surgery, plastic surgery, and emergency medicine on his journey to be an A&E doctor at the regional MTC and an aesthetics doctor. He is the clinical director of the award-winning clinic Novellus Aesthetics in Newcastle and has a special interest in dermal filler complications. Dr Land also runs his own training academy and is a key opinion leader for Neauvia, Nuceiva and Nuchido. Qual: MBBS, MRCEM

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Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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Treating Asian Patients Dr Souphi Samizadeh discusses facial aesthetic treatments in Asian patients and outlines treatment strategies Asia is a vast and diverse continent that encompasses a variety of cultures and ethnicities, and, as such, the facial features of different regions vary widely. It is not possible to generalise Asian facial characteristics or treat all Asian patients the same way. For example, the facial features of someone from Southeast Asia may differ significantly from those of someone from Northeast Asia, and even within regions, there may be significant variation. Furthermore, it is important to note that Asians age differently than their Western counterparts, and as a result, different management and treatment planning strategies are utilised. However, most of the published recommendations and clinical evidence for aesthetic treatments refer to Western populations, which may not be applicable to Asians due to differences in facial morphology and anatomy, ageing rates and standards of beauty. It’s important to highlight that while there may be some overarching agreement on beauty standards globally, these ideals often diverge significantly among different ethnic groups.1-3 Therefore, understanding the unique features and differences of Asians is crucial for providing safe and effective facial aesthetic treatments that are tailored to their individual needs and preferences. This article predominantly concentrates on East Asians.2-9

Facial physiognomy Facial physiognomy, or the belief that a person’s facial features can reveal their character or destiny, has a long history in many cultures, including Asian cultures. This belief is rooted in ancient Asian philosophy and traditional medicine and is still prevalent in many Asian societies 46

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today.4,10,12 Furthermore, different areas of the face are believed to correspond to specific organs or meridians in the body. By examining a person’s facial features, practitioners of traditional medicine in Asia diagnose and treat various health conditions.13-15 For example, facial complexion is used for diagnosis.16 Beyond health, facial physiognomy is also believed to reveal a person’s characteristics and future. For example, certain features are associated with good luck or success, while others may be seen as less favourable. A square face, characterised by a broader lower face, is often perceived as harsh and unfeminine. Hence surgical and non-surgical jaw reduction is popular in Asia as a ‘wide’ bigonial width is considered less desirable.4,8,17,19 In some Asian cultures, facial features such as a high nose bridge or a well-defined and delicate jawline (not angular) are seen as desirable, while others, such as a round face, may be considered less attractive.2,3,20 Facial physiognomy continues to play a role in contemporary Asian cultures, particularly in areas such as matchmaking and career counselling. However, it is also a controversial practice, with some critics arguing that it reinforces harmful stereotypes and is not supported by scientific evidence. Nonetheless, the belief in facial physiognomy remains an important part of Asian culture and continues to shape how some individuals perceive themselves and others.4 A study I conducted of 1,816 respondents found that the belief in facial physiognomy is deeply ingrained in Chinese society and can influence the types of requested and provided treatments.4 By taking these factors into consideration, practitioners can provide more effective and personalised treatments that meet the needs and preferences of their patients.

Differences in facial ageing Ageing is a multifaceted phenomenon, determined by a constellation of both intrinsic and extrinsic factors. The dermatological manifestations of ageing encompass rhytides (wrinkles), solar lentigines (sunspots), skin colour heterogeneity, and skin laxity. These phenotypes can demonstrate ethnic-dependent variations attributable to underlying structural and functional disparities. Ethnic skin, representing a significant fraction of the global population, possesses unique characteristics that modulate its ageing trajectory. For instance, Asian, Hispanic, and African American populations exhibit distinct facial morphologies, and the distribution of epidermal melanin and dermal collagen fluctuates across ethnic lines. An in-depth understanding of these differences is critical for the efficacious management and treatment of age-related dermatological changes in ethnically diverse patient cohorts.6,20,21-24 According to the ‘baby model’ described by aesthetic practitioner Dr Yukio Shirakabe, the Asian face shares many attributes with an infant’s face, such as a wider and rounder shape, higher eyebrows, fuller upper eyelids, lower nasal bridge, flatter mid-face, apparently more prominent lips, and a more recessed chin.24 These similarities are thought to contribute to the perception that Asians have a more youthful appearance. However, the Asian face also has some unique structural characteristics that can impact its appearance with ageing. For instance, their skeletal support, heavier soft tissue, a larger amount of malar fat, thicker skin, and a retruded chin can lead

Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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Facial anatomy in Asians The physical features of the Asian face are unique and are related to specific skeletal and morphological features that distinguish them from those of Caucasians (Figure 1). Despite the diversity that exists among Asian populations, certain facial characteristics can still be identified:2,3,20,22 • Wide and short face • Flat or concave profile • Greater intercanthal width than Caucasians • Epicanthal folds • Smaller eye fissure length than Caucasians • Hooding of the upper eyelid/ lateral brow

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• Smaller oral width than Caucasians • Greater mandibular width than Caucasians and a square lower face • Retruded chin • Flat dorsum of the nose • Wider base of the nose than Caucasians • Less tip projection of the nose than in Caucasians • Fuller lips, with the upper lip often being more prominent than Caucasians These physical differences have important implications for cosmetic treatments, as practitioners must take into account the unique facial anatomy of their Asian patients to achieve optimal results.

to a greater amount of gravitational force on the face, causing it to sag and appear older over time.6,20,24 The melanin concentration within Asian skin provides inherent photoprotection, thereby decelerating the onset of photoageing and contributing to the prevalent notion of superior ageing among Asians. While it holds true that Asian populations typically exhibit ageing signs later than their Caucasian counterparts, it’s vital to acknowledge that even within Asian demographics, age-associated transformations can transpire, necessitating potential treatment. In particular, elder Asians presenting for the first time may necessitate interventions targeting underlying anatomical features that can unfavourably affect their aesthetic appearance, in addition to addressing cumulative age-related alterations. Such scenarios often mandate a multifaceted treatment approach that encompasses the intricacies of the interplay between the underlying anatomical structure and skin ageing.20,21,23,24

Aesthetic treatments and Asian patients Popular non-invasive and minimally invasive treatments for Asians, similar to other ethnicities, include injection of botulinum toxins and dermal fillers, chemical peels, laser resurfacing, mesotherapy and microneedling.25 However, these treatments are often used to address concerns such as structural changes at a younger age and at later years to treat fine lines and wrinkles, volume loss, uneven skin tone and textural irregularities. Additionally, there is growing interest in treatments such as thread lifting and platelet-rich plasma therapy for facial rejuvenation.25-29 Upper eyelid surgery and facial contouring surgery to correct the ‘square face’ is a popular cosmetic procedure in Asian countries.18,30-36 This type of surgery typically involves zygoma and mandibular angle reduction and contouring. Individuals with a ‘square’ facial shape often desire a more oval or ‘V-shaped’ face, which are considered more aesthetically pleasing in Asian cultures.30,34,37 In addition to facial contouring surgical and non-surgical interventions, the administration of botulinum toxin for body

Figure 1: Comparison of Asian (a, c) and Caucasian (b, d) skulls. A, b Anterior view. C, d Lateral view.20

contouring is also prevalent in Asia.38 This procedure entails the injection of botulinum toxin into the musculature of the target area, temporarily inducing muscular weakness, which in turn results in atrophy, thereby cultivating a perceived ‘slender and feminine appearance’. This modality is particularly favoured among Asian women aspiring to achieve a more petite body frame.39-41

Understanding Asian patients Overall, understanding the unique aesthetic concerns of Asian patients and their standards of beauty is essential for effective treatment planning, particularly for younger patients seeking to enhance their facial features and older patients looking to restore volume and address signs of ageing. The unique aesthetic differences between individuals of different ethnic backgrounds are an important consideration when it comes to cosmetic treatments. By recognising these differences, practitioners can develop customised treatment plans that enhance a patient’s natural features while maintaining their ethnic identity. It is essential to approach cosmetic treatments with sensitivity and cultural awareness, particularly when working with patients from diverse ethnic backgrounds. By doing so, practitioners can ensure that patients feel respected and understood and that they receive the best possible care. Dr Souphi Samizadeh is a visiting associate professor, founder of the Great British Academy of Aesthetic Medicine, and clinical director of Revivify London Clinic. She is an honorary clinical teacher at King’s College London and an honorary clinical teacher at University College London. She practices and teaches in the UK and in China. Qual: BDS, BSc, MJDF RCS (Eng.), PGCert (Clin Edu), MSc (Aesth. Med), FHEA

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Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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Introducing the new SmartXide Handpieces Unleash the potential of the SmartXide Punto CO2 laser with its new handpieces For many years, fully ablative CO2 laser treatments were considered the ‘Gold Standard’ for laser skin rejuvenation. There’s no doubt that the results from full resurfacing were remarkable due to the pronounced collagen remodelling effects, but the unpredictable healing response and high risk of infection, scarring and pigmentary disturbance meant that the risks of treatment often didn’t outweigh the benefits. In 2004 Deka bought the first fractional CO2 laser to the market with the aim of overcoming these problems. Fractional resurfacing treatments deliver precise microbeams of laser light to the skin, resulting in narrow columns of ablation, surrounded by a microscopic zone of thermal damage. Since

SCAR3

Dermascan

these zones are surrounded by healthy epidermis, keratinocyte migration means we see rapid epithelialisation - within days rather than weeks - reducing recovery times and drastically reducing the risk of unwanted reactions.1 It was soon discovered that the collagen stimulation effects from delivering light fractionally were on a par with full ablation and the SmartXide went on to become the best-selling fractional CO2 laser in the world, delivering exceptional results for lines and wrinkles, skin laxity, dyschromia and scarring. Alongside offering fractional treatments for rejuvenation and collagenesis, CO2 lasers are an outstanding surgical tool for the cutting and vaporisation of soft tissue and minor skin lesions, such as seborrheic keratosis, dermal naevi and xanthelasma. The advantages of CO2 laser over other surgical techniques such as diathermy and traditional surgery include reduced healing times, less requirement for anaesthesia, reduced thermal damage, less bleeding due to haemostasis, less inflammation and a reduced incidence of undesirable side effects such as scarring and pigmentary disturbance. The CO2 laser is also particularly useful for treating tissue in anatomically difficult areas, such as the corners of the eyes, ears, nasal alae and genital regions.

Advertorial Lynton SCAR3 The SCAR3 handpiece can offer the deepest CO2 ablation on the market for the treatment of deeper, thicker scars. Greater ablation depths are required for the treatment of scarring, and the SCAR3 scanner can deliver fractionated laser emission in columns that are exceptionally thin and can penetrate up to 6mm into the skin.2 The reduced diameter of the ablative zones means that the laser can penetrate deeper at lower comparative energies, reducing the risk of prolonged healing and post-inflammatory hyperpigmentation.2 The deep ablation encourages new collagen pattern in thickened scars, which reduces fibrosis and improves both the appearance and pliability of scar tissue. Dermascan The new Dermascan microscanner connects directly to either a four-inch or seven-inch focal handpiece. It was developed for surgical dermatology treatments to enhance the vaporisation capability, depth control and speed of standard freehand handpieces. Generally, lesions are treated with freehand handpieces in which the laser beam is fixed and delivered in a diameter of less than a millimetre, and the practitioner must move the handpiece over the lesion to remove it completely. Using the new Dermascan, vaporisation can be administered in a variety of scan patterns, ensuring rapid, effective treatment of a variety of skin lesions. Both handpieces bring additional versatility and a broader range of treatments to the SmartXide Punto CO2 laser, enabling users to treat the most complex skin concerns safely and effectively. As with all systems by Lynton, ongoing training and support are provided to clinics making use of the SmartXide Punto to assure the very best standard of care and effectiveness for all its patients. REFERENCES 1. BM Hantash, M Bilal Mahmood, ‘Fractional Photothermolysis: A Novel Aesthetic Laser Surgery Modality’, Dermatol Surg, 2007. 2. Bonan P, Pieri L, Fusco I, et al., ‘Ex Vivo Human Histology Fractional Treatment with a New CO2 Scanner: A Potential Application on Deep Scarring’, Medicina, 2023.

New handpieces for SmartXide Deka, in conjunction with Lynton Lasers, is pleased to announce the introduction of two new handpieces for the SmartXide laser, further expanding the treatment applications of the system and enhancing clinical results. Aesthetics | November 2023

This advertorial was written and supplied by Lynton.

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Case Study: Using Threads in the Nose Dr Mahsa Saleki shares a case study illustrating results achieved utilising PDO threads in the nose The boom in online content over the last few years has created challenges in the medical field, with aesthetic transformations portrayed as a quick and easy fix. Patients’ demands to narrow the gap between surgical and non-surgical results has given way to a growing number of treatments on the market. Increasingly, my patients are looking for an alternative to surgery, but with similar results. Since their introduction by Dr John Alcamo in 1964,1 threads have evolved from having a purely surgical use, to their first cosmetic indication from Dr Marlen Sulamanidze using Aptos sutures to create the ‘featherlift’ in 1999.2 The following two decades have led to the development of an array of thread lift types, designed to re-position soft tissue. The most prevalent design of the barbed polydiaxanone (PDO) threads was devised by Singaporean surgeon Dr Woffles Wu in 2002.3 The cog PDO threads create mechanical lift through engagement of the feathered surface with the subcutaneous layer of the skin.3,4 Through the process of collagen neogenesis, the threads form an exoskeleton to add support and structure roughly six months before they dissolve through hydrolysis.3-5 In 2019, regulation for thread lift treatments by medical practitioners was added to the list of activities requiring inspection and regulation by the Care Quality Commission (CQC) in England, making them in effect a minor surgical procedure.6 This is due to the complexity of the procedure and the liability for complications. The industry has seen an influx of complications in thread treatments over the past year, as reported by Save Face.7 The organisation shared that it received 118 complaints related to thread lifting procedures being performed by non-qualified practitioners in 2022 – a 30% increase from 2021.7 I hypothesise that this is predominantly due to poor quality technique resulting in misplaced threads and poor post-procedural protocol, often performed by under-trained or under-qualified practitioners. With this in mind, thread lifting remains an 50

advanced practice reserved for those with significant experience in delivering aesthetic treatments, and the treatment should only be delivered by those with extensive anatomical knowledge. Nasal threads With the growing demand for non-surgical alternatives to match surgical outcomes, treating the nose is no exception. Nose threads offer a good alternative for patients who want to treat lax skin and soft nasal tissue that may result in drooping of the nose tip.8 They can also be an appropriate choice for those who want to add structure and support to their nose without the risk of adding volume, which may in turn make the nose appear larger.9 Threads’ rigid form makes them a good material to build and lift the nose bridge in a way that mimics the bony and cartilaginous tissue. For patients concerned with augmenting the nose bridge, the solid form of threads, particularly PCLA threads – a copolymerised version of both polycaprolactone (PCL) and poly-L-lactic acid (PLLA) threads – are a fantastic non-surgical implant to reshape the area. In addition to treating the nose bridge, threads can be successfully used to contract and support the overlying nasal skin to shorten and lift the nasal tip. One of the main treatment specific contraindications remains a nasal implant and coagulopathy.10 I have found that swelling, bruising and pain are the most common side effects of nasal thread procedures.11 The risks of infection, scarring and neurovascular damage remain

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collectively as <1% in my practice, but are still a possibility.11 Other adverse events could include temporary difficulty opening the mouth, or extrusion of the thread.12 The 2023 British College of Aesthetic Medicine (BCAM) Annual Clinical Review found that of 3,523 complications addressed by 357 members in the past year, 12% were caused by threads.11 A study on complications following thread rhinoplasty conducted in 2022 by Chen et al. is of note here.13 A total of 30 patients were assessed following thread placement in the nose. The most common complication was infection (46.7%), followed by thread extrusion (30%), chronic inflammation (16.7%) and dimpling (6.7%).13 Notably, most patients who developed complications had been treated by non-medical practitioners (70%).13 The authors concluded that thread lifting is not recommended as a regular alternative to surgical rhinoplasty, unless performed by a very experienced practitioner.13

Case study A fit and well 22-year-old female of far eastern ethnicity presented to clinic with concerns of a flat nose bridge. Her main concern was to add height to the bridge of her nose to create a more defined and contoured appearance. During the consultation, it was confirmed that she had no previous surgical or non-surgical history. Prior to her presentation in-clinic, she had explored the options for a surgical rhinoplasty, but due to the clinical risks associated as well as the financial burden, she had opted for a less invasive and more affordable alternative. In recent years, patients have been more likely to present at clinic with some prior knowledge of treatment options, and this patient was no exception. Through her own research, she concluded that nose threads may be a more suitable non-surgical technique for her. Following our consultation it was clear that the patient wanted a precise contour to her nose bridge without the risk of volumisation.

The industry has seen an influx of complications in thread treatments over the past year

Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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Before

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After

Figure 1: 22-year-old patient before and immediately after four threads placed in the nose. Results show augmentation and elevation of the nasal bridge with tightening of the overlying skin, creating a more defined contour with improved nasal tip support.

Dermal fillers, although a great tool for camouflaging nose bridge humps, have their limitations when it comes to achieving nose bridge elevation that holds and maintains its shape. The main reason is due to the filler’s consistency – its shape can change and mould over time subject to facial expression and movement. On the other hand, nose threads’ solid form make this complication less likely as it means they cannot be inserted into a vessel in the same way that filler can. Once the patient’s options were explored and I presented her with a balanced view of what treatment would work best for her, the patient was able to confirm her treatment request for a nose thread lift due to the aforementioned factors. I made sure the patient was aware of all potential adverse events, and gave her a two week cooling-off period before proceeding with the treatment. Treatment I advise patients to avoid alcohol or smoking for 24 hours prior to treatment, and also steer clear of using vitamin A skin products for five full days beforehand.14 It is also advisable to avoid any blood thinning medications which could aggravate bruising, including ibuprofen, aspirin, omega-3 fatty acids, green tea or green tea extracts, multivitamins, vitamin E and D and fish oils.14 The treatment duration for this procedure is variable, but averages around 30 minutes. Once this patient was made aware of what to expect and photographs were taken, the midline was marked from the columella to the radix as a guide for the threads’ insertion. It’s worth noting that the use of good imaging devices is a great way of monitoring and demonstrating patient progress as the subtle changes will be more evident. The nose was then numbed with a local anaesthetic –

something I tend to do as standard for any procedures involving cannula insertion to minimise any pain or discomfort involved. A total of 1ml of 1% xylocaine is sufficient in most cases. An initial bolus was injected at the midpoint of the columella. Once an insertion point was marked, the remaining anaesthetic was injected from the tip to the uppermost border at the radix, covering the junction of the glabellar region. An initial two PDO 2o 80mm threads were prepared in an aseptic technique. The patient was positioned in a supine position with a head tilt of 20 degrees. The skin was cleansed with chlorhexidine and drapes were used to maintain an aseptic environment. The threads were placed in the midline in the subcutaneous layer. Once the threads were inserted, the patient was able to review the results. If at this point during a treatment I feel a more enhanced lift would be required to achieve optimal results, I can add further threads. However, it was not necessary for this particular patient. Post-treatment Practitioners should follow the manufacturer’s guidelines for whichever product they use when it comes to post-treatment care. Every company’s guidelines will differ, so make sure to check with each individual provider before treatment. Guidelines will often include avoidance of cigarette smoking and alcohol consumption for 24 hours to reduce the risk of post-procedural haematoma and infection. Exercise, as well as use of saunas and hot tubs, should be avoided for seven to 10 days to reduce the risk of swelling and infection. Treatment specific guidance includes the avoidance of spectacles and sunglasses for 10-14 days to avoid inflammation. The skin can remain swollen and bruised for

up to seven days. Makeup can be worn over the bridge of the nose, but must be avoided over the tip and columella to mitigate the risk of infection. In this case, the patient made a good recovery with minimal side effects of swelling and tenderness. At the four-week follow up, the patient was happy with her results. Patients are typically healed two weeks after treatment, with results lasting up to 12 months when PDO threads are used.

An emerging treatment option As the thread lift market grows, patients are becoming more aware that they are a legitimate and safe treatment option. Patients previously unable to access non-surgical results to match those achieved by surgery now have the option to shorten the nose, lift the tip and elevate nasal height, all while using materials that better reflect the natural anatomy of the nose. Having said this, thread lifts are an advanced technique. An in-depth understanding of anatomical and fascial planes allows for a safer approach in thread placement, minimising the risk of puckering, thread protrusion, wound dehiscence, infection and pain. Surgical training and/or extensive injectable proficiency are crucial to ensure patient safety and excellent results. Dr Mahsa Saleki is a former London surgical trainee in cardiothoracic surgery. She has been practising aesthetics for the past 10 years and is currently the medical director of CQC-registered SAS Aesthetics where she specialises in advanced thread lift treatments and training. Qual: MBBS, MReS

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Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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How chemical peels work Chemical peels are extremely useful in daily practice. The facial skin is the first part of the body that is visible to most people. Therefore, having healthy, glowing skin is what most patients desire, with some believing that good skin quality makes us more attractive.5 However, I find that in many instances, patients come into clinic worried about the size of their lips, yet neglect sun damage, melasma or acne scarring on their skin. Logic dictates that one would first pay attention to the overall health of the skin, but this is not always the case with patients. From a clinical perspective, chemical peels allow practitioners to treat different skin issues by removing skin layers, inducing new skin growth and activation of fibroblasts to stimulate collagen, elastin and hyaluronic acid in the skin.6 Chemical peels can also help reduce fine lines and wrinkles, improve skin dehydration, dry/oily skin, acne, acne scarring, post-inflammatory hyperpigmentation (PIH), rosacea, melasma, sun damage and lentigines, skin elastosis, sebaceous gland hyperplasia and many other conditions.6 Many peels available are superficial peels which essentially target the epidermis. Agents used for such peels include acids like glycolic, Dr Xavier Goodarzian provides an overview of the lactic, mandelic, phytic, kojic, salicylic, retinoic development of chemical peels over the years and trichloroacetic. Superficial peels can be used for most skin conditions and are suitable Chemical peels have been around for thousands of years. The for all skin types.7 Once a peel penetrates the papillary dermis, it earliest known use was in Egypt by the beautiful Egyptian queen, becomes a medium depth peel, with TCA being the most commonly Cleopatra. She allegedly had fair skin, and history notes that she used agent for such peels. Medium peels provide skin tightening and used to bathe herself in sour milk and use wine extract to treat her faster collagen production in the skin, so can be more effective for fine skin. We now know that the lactic acid in the milk and the tartaric lines, scars or deeper pigmentation.7 Despite this, skin types V and VI acid in the wine, both alpha hydroxy acids, would have helped her are not suited for this type of peel.7 1,2 to achieve great skin. If a peel penetrates the deeper reticular dermis, it is generally In 1882, German dermatologist Dr Paul Gerson Unna started using classified as a deep peel. For this level, combinations of phenol, various ingredients such as salicylic acid, trichloroacetic acid (TCA), croton oil and sometimes TCA are used in various concentrations to resorcinol and phenol to perform chemical peels for improving fine determine the depth of penetration (Figure 1).8 Deep peels help to 3 lines and wrinkles. In the 1920s, the phenol-croton oil peel became popular in the Superficial Medium Deep peel peel peel US and was performed on Hollywood stars, which later became 3 favoured by the public in the 1960s. In 1961, medical doctors Dr Thomas Baker and Dr Howard Gordon Epidermis created a new formula for the phenol peel which became the standard at the time and is still occasionally used today by some Papillary dermis clinicians. The peel consisted of a formula based on phenol, croton oil, septisol and water. However, as this peel generally caused loss of pigment in the skin, over the last decades, it has been replaced Reticular dermis by more acceptable phenol peel formulations that are safer and 3 cause fewer side effects. Nowadays, we have a multitude of peels available for patients, from superficial to deep. The newer deep phenol peels have Hypodermis various percentages of phenol and croton oil and are sometimes mixed with other substances like trichloroacetic acid (TCA). This allows different depths of acid penetration and therefore increases the safety, creating more choices for the practitioner.4 Figure 1: The depths of chemical peels on the skin

Past, Present and Future of Chemical Peels

Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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remove deeper wrinkles and are only suitable for skin types I, II and III, as they can cause visible depigmentation for darker skin tones.9 Practically, chemical peels are not too difficult or time-consuming to perform, unless we use medium depth or deep peels. Superficial peels are usually performed as a course of treatments. On average, a course may include four peels, but this can vary according to the brand.7 Peels can be spaced apart weekly, bi-weekly or every three to four weeks depending on the peel type. The exact number of peels in a course and how they should be spaced is specified for each peel in the treatment protocol.7 Furthermore, medium peels are generally performed once or twice a year, but they can be repeated if necessary after four to six weeks, whilst deep peels are generally a one-off procedure and are not repeated (for many years).7,8

Developments over time The initial chemical peels seemed to be very deep phenol and croton oil peels which have their limitations as they could only be performed by experienced clinicians on certain skin types.3 They also would leave the skin depigmented with a wax-like, almost unnatural surface. As time went by, more people started experimenting with peels and other ingredients were used. As a result, the old formulas became obsolete and new products became more popular.3 With phenol and croton oil specifically, we now have various formulations available on the market that allow differing depths of deep peeling with an increased level of safety and a reduced risk of causing the white, unnatural look to the skin.3 TCA is another ingredient that has gone through a journey of its own. Initially, high percentages such as 50% of water-based TCA were used with sometimes terrible scarring as a side effect.4,6 Nowadays, we have amazing TCA-based formulations available that use a mixture of TCA and a base product, which slows down the penetration. This has greatly increased the safety of TCA peels and has eliminated the need to use high percentages as the lower percentage formulations can be applied with multiple coats, creating a more controlled depth of penetration.4,6 Recently, multi-ingredient peels have become very popular, and can be used superficially or at medium depth. They have the advantage of having multiple beneficial effects on the skin simultaneously and as the percentages are lower, they tend to cause less side effects and are safe to use on the body, in areas where the skin is very thin and fragile.4,6 The Baker-Gordon phenol peel was ideal at the time when it was invented in the 1960s, however, it was a complicated procedure and very few practitioners were able to perform it. This was because it caused deep depigmentation in the skin. As time has passed, many more clinician-friendly peels have become available from brands such as SkinTech, NeoStrata, Obagi, PH Formula, Medica Forte, Medik8, mesoestetic, Promoitalia and skinbetter science to name just a few.

Current state of chemical peels Most clinicians want to uphold patient safety, and many patients want zero downtime from their treatments. Because of this, not everyone is suitable for a medium or deep chemical peel due to the potential complications and the necessary downtime. In terms of downtime, superficial peels have little to none. Sometimes, patients may experience mild dryness or flaking for a few days. Medium peels have a six-to-ten-day downtime with severe desquamation of the skin from day four onwards. Deep peels have a full seven days of a crust phase. After the removal of the crust, there will be another week or so of dryness and severe erythema which can

last to some degree for as long as three months.10 Complications with peels can include hyperpigmentation, hypopigmentation, infections, excessive erythema and even scarring.10 It is therefore important to make sure that we as practitioners have appropriate training in these procedures before performing them, and also have the necessary knowledge to deal with potential complications.

Combining treatments In recent years, more and more combination approaches have become available. For example, the Pixel Peel is a combination of microneedling and superficial TCA which, in my opinion, is ideal for acne scarring and stretch marks. This means combinations of various ingredients in different percentages, but also the use of peels during the same session or the use of differing peeling depths in different zones of the face during the same session. As a result, this has improved patient safety, allowing for a safer approach as there is no need to use a deep peel across the whole face, further reducing complications.11 Other combinations include using alpha hydroxy acids (AHA) and TCA peels together, performing laser alongside TCA combination peels as well as sand abrasion and TCA combination peels.

A popular treatment Chemical peels have been around for thousands of years. In modern times, peels in various forms have become very popular from the 1920s onwards. The deep peel during the 1960s has now been replaced by a variety of peels at differing depths of penetration. This allows us to treat a large variety of skin conditions with a good level of safety. The recent development of combination peels and the use of various peeling depths in different areas of the face has increased patient safety and reduced the risk of complications. Dr Xavier Goodarzian is the medical director and co-owner of Xavier G. Clinic in Southampton. He is a member of the Royal College of General Practitioners and has postgraduate degrees is clinical dermatology and cosmetic medicine. Dr Goodarzian is a past BCAM committee board director and currently part of their examination board. He is also the author of the book Chemical Peels in Clinical Practice. Qual: MD(Hons), MRCGP, DipClinDerm, PGCCosMed, MBCAM REFERENCES 1. Li AW, Yin ES, Antaya R, ‘Topical Corticosteroid Phobia in Atopic Dermatitis: A Systematic Review, JAMA Dermatol, 2017. 2. DermaNetwork, ‘History of the Chemical Peel, 2023, <www.dermanetwork.org/article/cosmeticenhancements/history-of-the-chemical-peel> 3. Wambier CG, Lee KC, et al., ‘Advanced Chemical Peels: Phenol-croton oil peel’, JAAD, 2019. 4. Deprez P, ‘Textbook of Chemical Peels: Superficial, Medium, and Deep Peels in Cosmetic Practice’, CRC Press, 2018. 5. Goldie K, Kerscher M, et al., ‘Skin Quality – A Holistic 360 View: Consensus Results’, Clin Cosmet Investig Dermatol, 2021. 6. Soleymani T, Lanoue J, Rahman Z, ‘A Practical Approach to Chemical Peels’, J Clin Aest Dermatol, 2018. 7. Lee KC, Wambier CG, et al., ‘Basical chemical peeling: Superficial and medium-depth peels’, J Am Acad Dermatol, 2019. 8. Rendon MI, Berson DS, et al., Evidence and considerations in the application of chemical peels in skin disorders and aesthetic resurfacing, J Clin Aesthet Dermatol, 2010. 9. Starkman SJ, Mangat DS, Chemical Peels: Deep, Medium and Light, Facial Plast Surg, 2019. 10. Goodarzian X, ‘Chemical Peels in Clinical Practice’, Routledge, 2023. 11. Khunger N, Chanana C, ‘A perspective on what’s new in chemical peels’, CosmoDerma, 2022.

Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

Advertorial Prollenium

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Contour and Shape Your Way to the Next Generation HA Revanesse® Contour and Shape help to restore facial volume and restructure the lower face and jawline Whether it be caused by weight loss, age or general lifestyle factors, loss of definition and laxity along the jawline and lower face is a very common concern for patients. Although there are several devices being launched across the industry to help combat this, injectables are still the most reliable and reputable treatment. Restoring lost volume and definition within this area helps to support the structural architecture of the jawline and creates a firmer and more defined appearance in the surrounding areas. This can be achieved by using high-viscosity hyaluronic acid (HA) dermal fillers, such as Revanesse®. Revanesse® contains greater HA content per

ml, and a higher viscosity than its comparative brands, helping to explain why it’s an excellent choice for shape retention. This multi-purpose dermal filler is made unique by a proprietary cross-linking technology called Thixofix. This technology allows for the creation of a smooth and consistent gel that is easy to inject and produces naturallooking results. Thixofix also helps the filler to integrate more seamlessly with the patient’s own tissues, minimising the risk of lumps or bumps, and aiding the longevity of the product within the body. When it comes to the lower facial area, Revanesse® Contour and Revanesse® Shape are two excellent options.

Case study Before After A 42-year-old female expressed concerns about her lower face. The patient illustrated a lack of definition across the jawline, along with the appearance of jowling and marionette lines. These concerns created a resting sad and shorter appearance on the face. Using a combination of both Shape Figure 1: 42-year-old patient before and after dermal and Contour, Dr Watson was filler treatment. able to restructure and define the patient’s concerns. To achieve this result, Dr Watson injected: Revanesse® Shape (0.3ml bolus injected onto bone gonial angle, 0.3ml s/c fanning gonial angle, 0.3ml bolus injected onto bone midline in chin and 0.2ml s/c pre-jowl fanning) Revanesse® Contour (0.3ml each side s/c fanning marionette support, 0.2ml each side s/c chin, 0.3ml each side s/c labiomental crease)

Aesthetics | November 2023

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Dr Amy Watson, cosmetic doctor, says, “When approached by patients who need high architectural support, I tend to reach for Revanesse®. Not only do I receive high satisfaction every time I use Revanesse®, but I feel its formulation enables me to create my patients’ desired results, easily and smoothly. It’s certainly one of my favourites in my toolkit.” Revanesse® Shape is the highest viscosity HA gel, which is advantageous to sculpting and volumising deep tissue areas, creating high impact yet touchable projection and lift. Revanesse® Contour is another highviscosity HA gel, used to treat deep folds and larger areas of volume loss. Again, this helps to sculpt, firm and lift. These two products combined in harmony create an impactful result, which you can see in this case study from Dr Watson.

About Revanesse® With more than 20 years in the industry, Prollenium is renowned for its forward-thinking approach, and sets itself out from the crowd of other dermal HA fillers with an extensive and rigorous quality testing process. The Revanesse® collection is recognised for its remarkably homogeneous filler created in small batches, which allows for product consistency and precision control over manufacturing temperatures and cross-linking. Using HA with an exclusively high molecular weight means the formula requires less BDDE to bind. The formula is pre-hydrated through dialysis for seven days where unsuccessful BDDE and toxins are removed, resulting in a gel product that is more comfortable in the skin with less swelling to the injected tissues.1 Integral to their exceptionally high standards of purity and quality assurance, each Revanesse® product is delivered in glass syringes and individually inspected before leaving Prollenium’s state-of-the-art manufacturing facility in Ontario, Canada. For more information about Prollenium and Revanesse® please contact: info@prollenium.co.uk REFERENCE 1. Revanesse® Ultra clinical Study Report SYM 2014-02

This advertorial was written and paid for by Prollenium.

PN99231 Rev 00 Revanesse® Contour and Shape- Prollenium Advertorial content - UK [EN]

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A summary of the latest clinical studies Title: Comparative Efficacy and Safety of Cell-Assisted and Conventional Lipotransfer in Facial Filling: A Systematic Review and Meta-Analysis Authors: Shen S, et al. Published: Aesthetic Plastic Surgery, October 2023 Keywords: Cell-Assisted, Facial Filling, Lipotransfer Abstract: The PubMed and Embase databases were searched for studies on cell-assisted (CAL) and conventional lipotransfer (CLT) in facial filling. We calculated pooled standardised mean difference (SMD) and 95% CIs for continuous outcomes and pooled risk ratio (RR) with 95% CIs for binary outcomes. A total of 15 studies with 737 patients were included in this analysis. The fat survival rate and patient satisfaction rate were significantly higher in the CAL group compared to the CLT group (SMD: 3.04, 95% CI 2.09-3.99; RR: 1.34, 95% CI 1.08-1.67). However, no significant difference in complication rates (RR: 0.95, 95% CI 0.50-1.81) and a lower secondary operation rate in the CAL group (RR: 0.52, 95% CI 0.030.82) were observed. No obvious publication bias was observed in the funnel plot (Egger’s P values = 0.084 and 0.403). Based on the pooled results, we tentatively conclude that CAL may have superior fat survival rate and satisfaction rate compared to CLT in facial filling, without compromising patient safety. However, many of the included studies were observational studies with small sample sizes. Future research should focus on investigating the long-term efficacy and safety of these techniques.

Title: The Strength of Correlation Between Female Genital SelfImage and Sexual Function: A Systematic Review and Meta-Analysis Authors: Alavi-Arjas F, et al. Published: The Journal of Sexual Medicine, October 2023 Keywords: Genital Image, Sexual Function, Women’s Health Abstract: This study is the first systematic review to reveal the strength of the correlation between genital self-image and sexual function. Electronic databases were comprehensively searched from January 2000 to December 2022. After duplicate removal, 146 articles were retrieved by searching keywords in titles and abstracts. A positive correlation is noted between genital selfimage and sexual function; the strength of this correlation was 0.375. By omitting irrelevant articles according to the eligibility criteria, 16 articles remained for a total of 13,505 participants. All but one of them indicated a statistically significant positive correlation between genital self-image and sexual function. For a more accurate result, a meta-analysis was conducted noting a considerable heterogeneity. The results of this study may be used in counselling women with sexual dysfunction who are dissatisfied with their genital appearance. This systematic review concludes a positive correlation between genital self-image and sexual function. The results are restricted by inconsistency and of the articles considered. Using different tools in different cultural contexts without considering confounding factors leads to a wide range of correlation sizes, and significant heterogeneity is evident.

Title: The Psychosocial Burden of Skin Disease and Dermatology Care Insights Among Skin of Colour Consumers Authors: Cartwright M, et al. Published: Journal of Drugs and Dermatology, October 2023 Keywords: Dermatology, Skin Disease, Skin of Colour Abstract: Skin conditions are associated with psychological symptoms and may be particularly distressing for skin of colour (SOC) individuals. SOC consumers’ decisions to pursue dermatology care may be negatively impacted by the scarcity of skin tone diversity in dermatology. This survey explored SOC consumers’ perspectives on dermatologic care to provide insight into the psychosocial burden of skin disease. An anonymous web-based survey was conducted among self-selected consumers. Demographics, bothersome skin condition effects on mental health, insights about skincare products, and dermatologists’ ability to address SOC were captured. 775 responded, 64.6% (n=501) with SOC. Among these, 94.2% were female, 76.6% Black/African American, and 48.9% 18-24 years. 79.6% reported a bothersome skin condition that was moderate to extremely bothersome. 57.4% reported skin condition(s) affected mental health. Discolouration/ acne-related post-inflammatory pigmentation changes and acne and ingrown hairs were most common. The face was most frequently affected. 40.9% believed available skin products do not address their specific skin needs; 44.8% have consulted a dermatologist; 46.4% felt like the dermatologist did not know how to treat their skin; and 92.5% did not believe most dermatologists or aestheticians are trained to treat darker skin tones. Dermatology products, services and education tailored to SOC consumers is evidently needed.

Title: Evaluation of Nerve Innervation Distribution of Orbicularis Oculi Muscle for Botulinum Neurotoxin Application Using Sihler’s Method Authors: Çiçek F, et al. Published: Annals of Anatomy, October 2023 Keywords: Blepharospasm, Botulinum Toxin, Nerve Innervation Abstract: Blepharospasm is the involuntary and forced closure of the eyelids due to spasm-like contraction of the orbicularis oculi muscle around the eye. The study aimed to reveal the nerve innervation of the orbicularis oculi muscle for botulinum neurotoxin (BoNT) treatment of blepharospasm by Sihler’s staining technique. This study used six cephalus (12 orbicularis oculi muscles) with an average age of 65 (6288) years. The orbicularis oculi muscles were removed by dissection, and Sihler’s staining technique was applied to the muscles. In the region above the palpebral fissure, the nerves entering the muscle were densely located in the superolateral quadrant between 9-12 o’clock in the right eye and between 12-3 o’clock in the left eye. In the region under the palpebral fissure, the nerves’ density in the orbicularis oculi muscle was higher between 4-7 o’clock in the right eye and between 5-8 o’clock in the left eye. This study pinpointed precise crossing points of these nerve branches, which can be targeted for applying BoNT in treating blepharospasm. By utilising minimal BoNT, it is anticipated that the quantity of toxin administered will decrease, leading to more efficient outcomes and reduced expenses.

Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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Creating Referral Pathways for Your Patients Dr Olha Vorodukhina delves into the importance of establishing a referral pathway in aesthetics and how it can contribute to the success of your clinic Delivering exceptional results to patients and running a thriving medical aesthetics practice isn’t solely dependent on being the best at what you do. Success in this field is more about the approach you apply to your practice. Over the last decade we have learnt that in order to achieve good results we often need to combine different therapies and treatments that target different layers of the face. But it is also understandable that not every clinic or practitioner is able to offer all these treatments under one roof. For example, some patients may benefit from surgery more than having non-surgical treatment. It is important to recognise this and be able to make appropriate referral to other medical professionals in order to achieve better results. It also will help to build an honest long-term relationship with your patients, as well as reputation among your peers.

Specialists to consider referring patients to In medical aesthetics, the referral pathway model resembles that of private medical or dental sectors. While it may be a concern that referring elsewhere will cost you a patient, it actually demonstrates you as an honest, ethical practitioner. In my experience, the patient will return to you after completing referral treatment. There are many professions you could create referrals for, such as nutritionists, dietitians, hormone specialists, performance or professional coaches, fitness coaches, among many others. However, the most common are the following. Dentists Dentistry plays a significant role in medical aesthetics practice, particularly in the field of facial aesthetics. Dentists are skilled in performing comprehensive facial analysis as part of their training. They assess the patient’s facial features, bone structure, and soft tissue characteristics to provide personalised treatment plans. Dentists with expertise in temporomandibular joint (TMJ) disorders can also address facial asymmetry, 60

jaw pain, and limited jaw movement, thereby improving facial balance and function. Referral to a dentist may be necessary for cases involving an enlarged masseter muscle, crooked teeth, gingival dysplasia, or gummy smile treatment.1,2 Surgeons Plastic surgery plays a significant role in enhancing and improving the appearance of the face. Surgical procedures such as blepharoplasty, rhinoplasty, lip implants, lip, face, and neck lift can provide long-lasting results. While non-surgical treatments have gained popularity, there are cases where plastic surgery remains a viable option. During consultations, surgical options should be presented to patients as a possible choice of treatment. Effective communication between the patient’s surgeon and the aesthetic practitioner is vital to maintain the desired results.3 Psychiatrists Collaboration with psychiatrists provides insights into the psychological aspects of patients’ treatment journeys, enabling a holistic approach to patient care. Referral to a psychiatrist or mental health specialist is necessary when diagnosing or suspecting body dysmorphic disorder. In cases where patients require assessment and treatment beyond the scope of a practitioners’ expertise, referral to an appropriate mental health specialist is essential.4 General practitioner In addition to the mentioned specialists, collaborating with general practitioners (GPs) is crucial in aesthetics. GPs play a vital role in overall patient care and can provide valuable insights and medical expertise in various scenarios. Here are some common scenarios where referral to a GP may be necessary: Pre-existing medical conditions: If a patient has underlying medical conditions such as cardiovascular problems, autoimmune disorders, or uncontrolled diabetes, it is important to consult their GP

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before performing any aesthetic treatments. The GP can assess the patient’s overall health and provide guidance on whether the procedure is safe for them. Medications: Some medications can interfere with aesthetic treatments or pose risks during the procedure. For example, blood thinning medications such as dabigatran, rivaroxaban and apixaban and patients on long courses of oral steroids and oral vitamin A. It’s crucial to consult their GP to find out if they are on any medications and what these are so that the treating practitioner can assess if there are contraindications or a higher risk of complications Allergic reactions or adverse events: In the event of an allergic reaction or other adverse event during or after a procedure, it is important to provide the patient with necessary treatment and care. It will be considered good practice to inform the patient’s GP about the event, and the GP may decide to provide appropriate medical care and further evaluation if necessary. Suspicion of an underlying medical condition: During the initial consultation or assessment, if you notice any signs or symptoms that raise concerns about an underlying medical condition, it is prudent to refer the patient to their GP for further investigation and diagnosis. Post-treatment complications: If a patient develops complications or experiences unexpected side effects after an aesthetic treatment, the GP may provide appropriate medical management or refer the patient to a specialist if needed. Emotional or psychological concerns: Aesthetic treatments can have a significant impact on a patient’s self-esteem and body image. If a patient expresses emotional or psychological concerns related to their appearance, referring them to their GP or a mental health professional can ensure that their overall wellbeing is addressed. By involving GPs in the referral pathway, aesthetic practitioners can ensure comprehensive care for their patients, considering both the aesthetic and medical aspects of their wellbeing. Dermatologists Dermatologists’ opinions and assessments are valuable in cases involving conditions such as acne, rosacea, melasma, or moles. Their expertise in diagnosing and managing these conditions can significantly contribute to the overall treatment plan and patient outcomes. Whether you refer them to a consultant dermatologist or another medical

Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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Your referral protocol:

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To implement effective referral protocols in your practice, I would recommend practitioners follow these five steps: 1) Evaluate your professional skills: Determine the treatments you are comfortable and competent in offering. Create a list of treatments that may require referral to specialists. Remember, just because you don’t perform a specific treatment doesn’t mean it should not be offered to the patient. 2) Approach clinics/professionals in your area: Find those that are willing to accept referrals for complex cases. Look for clinics equipped with ultrasound for diagnosing and managing complications. Training providers with whom you have completed your training can be a valuable point of contact for referring advanced and complex cases. professional who has dermatology training will depend on the severity of the skin problem and what their previous treatment history is. For example, usually, skin concerns such as acne, melasma and rosacea can be referred to a practitioner with a special interest in dermatology. In rare cases such as severe acne or suspicious moles, it would be wise to refer to a dermatologist on the specialist register.

Complications and complex cases It is advisable to build a good relationship with clinics/practitioners who offer more specialised treatments such as non-surgical rhinoplasty, PDO threads, or laser skin resurfacing if you lack the expertise to perform them safely. When it comes to complication management, it is good to plan ahead and have contacts who are willing to offer you support and have the right experience and equipment. For example, someone who has an ultrasound device or holds stock of hyaluronidase if you are unable to.

Finding your network One of the best ways to start establishing your network of colleagues is attending professional events and conferences such as CCR and ACE, and utlilise networking opportunities to find like-minded professionals. You also may ask your initial training providers about available support. I have found that social media can also be a great tool to do your own research and reach out to your colleagues in the area, or even speaking to other people within the industry to gain recommendations.

Seven steps of a referral pathway In my experience, these seven crucial steps can help when deciding on a referral plan: 1. Initial consultation: During the initial consultation, patients visit an aesthetic

3) Collaborate with earlier mentioned specialists: Establish collaborative relationships with dentists, plastic surgeons, psychiatrists, dermatologists, and other specialists mentioned earlier. Building a professional network ensures seamless referrals and effective patient care. 4) Update your team: Educate and inform your team about the referral system at the clinic. Clear communication within the team helps streamline the referral process and ensures everyone is on the same page. 5) Maintain effective communication: During the referral process, maintain effective communication with your colleagues, including specialists and referred practitioners. Follow-up with your patients to ensure their continuity of care.

practice to discuss their concerns and desired treatments with a primary healthcare provider who is a medical aesthetic practitioner.5 2. Assessment and treatment plan: Based on the patient’s needs, the practitioner assesses their condition and recommends appropriate treatment options. However, if specialised procedures or services beyond the expertise of the primary provider are required, a referral may be necessary. 3. Referral decision: The practitioner determines whether a referral is needed and identifies the appropriate specialist or healthcare professional to whom the patient should be referred. Factors considered include the complexity of the procedure, the patient’s unique circumstances, or the need for specific expertise. Of course, a patient may refuse a referral. If this occurs, remember you don’t need to provide treatments yourself just because you’re feeling under pressure. 4. Referral process: The practitioner initiates the referral process by communicating with the specialist or healthcare professional who will be receiving the patient. This may involve sending medical records, test results, and a detailed referral letter outlining the patient’s condition and treatment history. 5. Specialist evaluation: The referred specialist evaluates the patient’s condition and determines the most suitable course of action. They may conduct further assessments, order additional tests, or provide specialised treatments or procedures. 6. Continuity of care: Throughout the referral process, effective communication between the referred practitioner, the specialist, and the patient is essential to ensure continuity of care. Updates, treatment plans, and necessary adjustments are shared to ensure a comprehensive approach to the patient’s care.

7. Follow-up and feedback: Once the specialist has provided the necessary treatment or procedure, they communicate the outcomes and recommendations back to the practitioner. This information helps the primary provider maintain a complete medical record for the patient and coordinate any required follow-up care or future treatment.

Create a referral pathway to optimise your practice By establishing a well-defined referral pathway, aesthetic practices can ensure that patients receive the most appropriate and specialised care for their specific needs. Collaborating with specialists contributes to better patient outcomes and an enhanced overall healthcare experience. Remember, success in a medical aesthetic practice is not just about being the best, but also about implementing a collaborative approach for delivering exceptional results. Practitioners should follow General Medical Council (GMC) ethical guidance on the referral pathway that is available on the GMC website.7 Dr Olha Vorodyukhina is a dental surgeon and the clinical lead for training provider Cosmetic Courses, as well as a trainer for Sinclair Pharmacy, and KOL for Evolus. Dr Vorodyukhina is the owner and founder of Shine Medical (now Cosmetic Centre) and Angels Twelve clinics in the Midlands. She is also the author of the book Beyond the Mirror which looks at patient experience and motivation. Qual: Dip Stom Ukrainian Medical Stomatological Academy 2005

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Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

EXOSOMES THE FUTURE OF REGENERATIVE AESTHETICS

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Implementing Wellness Services In-Clinic Dr David Eccleston and business manager Laura Eccleston outline the benefits of integrating wellness services into your clinic and discuss why the sector is gaining popularity The demand for wellness services in aesthetics has boomed over the last few years. In the UK, the health and wellness market is estimated to hit £30.6 billion in 2023.1 As well as this, globally, the wellness market is growing at a rate of 10% and is expected to continue at this rate until 2025.1 With many clinics beginning to embrace this growing trend, it is time to look into what wellness is, how it fits into aesthetics and whether it is worth incorporating into your practice.

What is wellness? The Global Wellness Institute defines ‘wellness’ as the active pursuit of activities, choices and lifestyles that lead to a state of holistic health.2 In our clinic, we have noticed a rise in patients seeking a holistic approach to aesthetic treatments and realising that their internal health is reflected in their external appearance. Many of our colleagues have noticed this too, causing the industry to open its doors to various wellness services.3 As a result, the Medical Longevity Summit at CCR was created due to the aesthetics industry shifting its focus to this sector. This has enabled medical practitioners to not only support their patients’ health but also to improve aesthetic outcomes, leading to greater patient satisfaction. Today, wellness can be split into six dimensions: better health, fitness, nutrition, sleep, mindfulness and appearance (Figure 1).4 The appearance dimension primarily relates to beauty products and non-surgical aesthetic procedures. So, can we help patients seeking an enhanced appearance in their other wellness goals, too?

Medical vs. wellness Historically, healthcare in the UK has always focused on increasing lifespan, but our wellness services focus on improving patients’ healthspan. Healthspan can be defined as the number of years a person lives in good health.5 Therefore, if we investigate how we can ensure patients live their lives in good health and vitality using preventative and lifestyle measures, this will provide a massive opportunity for medical aesthetic clinics to expand their offering. If we look at wellness as a continuum from poor health to optimum wellbeing, it can be split into medical and wellness paradigms. When in a state of poor health, patients want to feel better and look for ways to treat and cure their illnesses, making the APPEARANCE medical paradigm a reactive approach to health.2 Whereas, in the wellness paradigm, it NUTRITION MINDFULNESS focuses on maintaining and improving health so patients can thrive in life, and is viewed as a preventative, proactive approach.2 A solid foundation FITNESS SLEEP for introducing wellness services is to focus on how you can BETTER HEALTH optimise your patients’ health, allowing them to achieve their ideal state of wellbeing. Figure 1: The dimensions of wellness.4

Types of wellness services for your clinic There are a range of wellness services on the market currently, many of which are not new but a great addition to the aesthetic field. Services such as weight management, nutritional advice and supplementation are an ideal complimentary offering to aesthetic clinics as we are aware that weight and diet have a direct correlation to the skin and ageing. However, some of these services require an additional staff member such as a nutritionist. Furthermore, clinics can implement referral pathways for these services or build a relationship with a professional to come into clinic every month to help patients. Other services such as menopause management and bioidentical hormone replacement therapy (BHRT) also bring with them a great opportunity to cross sell as the age of these patients means your aesthetic services will likely appeal to them too. Well person screening, intolerance testing and biological age testing are also available, and we have found most patients, regardless of age, sex or gender are interested in understanding their health status.

Fitting into your aesthetic practice Clinics are ideal for offering wellness services, as patients are often concerned about the ageing process externally, so want to resolve the internal effects too. Patients are specifically interested in understanding how we can slow the ageing process and prevent the diseases associated with it. For patients who don’t understand, educating them on the benefits of your wellness services is imperative. It is easy to be seen as a yoga retreat or spa, so communicating what you do to your patients is critical. Try and explain what medical wellness is, why it’s essential in aesthetics and how it can complement their other treatments. Initially, it was a challenge to get our messaging across, so we created complementary branding which runs alongside our aesthetic practice branding. We also have a dedicated clinic space and section on our website to try and make it as clear as possible. Statistics are a powerful tool as well as any case studies and results you have achieved combining wellness services with aesthetic treatments. During consultations, a medical history should be taken, including a variety of lifestyle questions such as alcohol consumption and smoking status. As we have known for years, patients who engage in unhealthy

Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

We’ve got you covered We are he leading provider of cosme ic insurance services and are proud o cover he mos comprehensive range of cosme ic rea men s.

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habits such as these, or sunbed usage, are wreaking havoc with the cellular processes involved in longevity. Nowadays, there are ways we can enhance patients’ results by understanding what is going on underneath the skin and treating the cause of the problem rather than masking it with aesthetic treatments. For example, collagen formation requires the presence of vitamin C, so patients deficient in this are unlikely to achieve optimum results. But where do you start when incorporating these services into your clinic? Remember your audience If you are a sole practitioner providing basic injectables, it is likely that introducing reiki energy healing and meditation isn’t going to be a big return on investment. Therefore, market research is paramount. Ask your patients during their consultation if wellness services are something they would be interested in – send an email round to patients or conduct an Instagram poll. These will give you a great idea as to whether your patients would be interested in the services you are considering introducing. Think about where these services will fit into your current offerings. Are they an easy cross sell off the back of your existing services, or will they take a little more work? You could start with introducing a simple service like NAD+ supplements as an addition to your existing treatments to reduce downtime and enhance results. Biological age testing also gives patients a gauge on their overall health and is a great starting point in their wellness journey. You won’t need to invest in additional equipment or employ anyone to conduct the service for you. They are simple cross sells which benefit your patients’ health and aid aesthetic outcomes. However, if you are an established clinic offering services such as BHRT and prescription-only weight loss injections, your reach might be a little further. At this stage, you might look to introduce nutritional advice, health screening or even work with local personal trainers as it’s likely you’ll have an opportunity to cross sell these services. For us, it took around three months and persistent marketing for our patients to start showing an interest. We had to be very clear with our strategies, as wellness can encompass many service lines and patients can be confused by the term. We also focused on education, so our patients could understand why wellness is such an important part of their aesthetic journey with us.

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Don’t expect it to happen overnight When it comes to introducing wellness services, many practitioners expect to have a huge waiting list and patients queueing at the door from the day they launch. The reality is that it will likely take a few months for some of your patients to start considering your services. Keep your marketing clear and engage with your audience on the benefits of these services, not just the features, and it will pay off eventually. It can take up to seven touch points for a patient to be aware and show an interest, so be persistent, but don’t harass! It is key to start marketing these services before you launch them, so you can hit the ground running. We used various tactics such as regular email marketing with waiting lists for the services. Social media Q&As also worked nicely as they get your audience involved. Train your staff and yourself! Before you jump straight into integrating wellness into your clinic, make sure you understand it. Read up on it, talk to the companies and ask them for the latest data and results, attend talks at conferences on the topic and talk to peers who are offering these services already. These are all non-negotiables for us when we considered introducing a new service line so we could ensure it was the right fit for us and our patients. Once you’ve decided on specific services, most companies offer complimentary training when you set up an account with them. Ensure to utilise this for yourself and your staff, as well as any additional support the company or supplier offers you for marketing support. If you work in a larger clinic, ensure all staff, whether they offer the services or not, understand the value of patients embarking on a wellness journey with you. We hold regular training days in-clinic throughout the year. Although closing your clinic for a day for training may feel like a financial loss, if your team is on board, this will not only improve the patient journey but also the conversion rates and cross selling of the services.

So, what do you need to consider? Incorporating wellness services is relatively low cost if you start with the basics. Most services can be done without the need for an expensive medical device or a large stock of products. It also means these patients are on a journey with you, as wellness isn’t a one-stop shop. However, new clinics should perhaps hold off implementing these services,

until they have established a solid patient base of returning patients. As wellness is a journey, you will need to spend additional time with your patient which may reduce your time onboarding new patients or lots of appointments in one day. For example, you conduct a well-person screen, which assesses a patient’s overall health. This comes back with some red flags such as disease markers or abnormal blood counts. If you decide to not do anything, your patients will be left feeling more vulnerable and dissatisfied. You must be aware that you may be opening a can of worms in some cases, especially if your patient has health anxiety, so patient selection and referring outside your specialty is paramount. Many wellness services, such as health screening, are limited to medical professionals only due to patients needing blood tests and analysis. You may have a phlebotomist on site who can take bloods, but a medic will still be required to review and discuss the findings of these, as well as prescribe or suggest treatments. This can help you stand out in an increasingly crowded market by offering holistic care to your patients.

A growing industry Wellness is a growing modality in the aesthetic field, with patients seeking to slow the ageing process both externally and internally and live a more fulfilled life. It offers practitioners the opportunity to enhance their aesthetic outcomes, improve patient satisfaction and retention, as well as adding another revenue stream with relatively little investment. Dr David Eccleston qualified in medicine from the University of Birmingham in 1987 and undertook postgraduate dermatology training at the Birmingham Skin Centre since 1994. He has worked in the field of cosmetic dermatology, having been trained by Professor Jean Carruthers more than 20 years ago. He is a global trainer and key opinion leader for Evolus, Dermafocus and Cutera as well as running his own private GP practice. Qual: MB, CHB, BCAM Laura Eccleston is the business director for MediZen Clinic. She gained a BSc in Biomedical Science in 2016 from the University of Sheffield and has since undertaken various roles in the pharmaceutical and life science industry before joining the family business to help development.

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Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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Employing Patient-Centric Marketing Strategies Marketing professional Reena Sandhu shares an introduction for practitioners seeking to excel in patient engagement and treatment promotion The past decade has witnessed an unprecedented surge in the popularity of aesthetic treatments in the UK.1 Worldwide, the projected worth of the medical aesthetic market is expected to be almost US $125 billion by 2028.1 In today’s competitive landscape, standing out and attracting patients to choose your treatments and services over your competitors is a vital aspect of success for practitioners. This article will provide an introductory overview of how practitioners and clinics can encourage patients to choose you as their treatment provider by employing a patient-centric marketing strategy. I will focus on digital and in-person marketing approaches, as you can action these methods effectively right now to begin the process of building trust and credibility with patients.

Digital marketing strategies The digital age has transformed how businesses connect with their audiences, and the aesthetics industry is no stranger to this revolution. Patients now search the internet to research aesthetic treatments, read reviews and seek recommendations. Therefore, having a robust digital presence has become indispensable for aesthetic practitioners and clinics when promoting treatment options. Your website serves as your virtual storefront. 66

Begin by investing in a well-designed, mobile-responsive website that highlights your treatment portfolio, credentials and patient testimonials. To optimise your online presence, it may be beneficial to collaborate with an external agency that can amplify your clinic’s brand identity, ensuring an engaging user experience that entices patients to explore further. To enhance your website’s visibility and attract potential patients, prioritise search engine optimisation (SEO).4 This entails optimising a website’s structure and content to secure higher rankings in relevant searches, ultimately driving organic growth and increasing your clinic’s online reach.2 Aesthetic practitioners and clinics can produce informative content, including blog posts, videos, infographics and eBooks, to educate patients about the latest treatments, their advantages and the science behind them. This valuable information can be spread across your website, social media channels and email marketing. This content showcases expertise and builds trust with patients as they feel they can be fully informed before making any decisions on their treatment plan, boosting the clinic’s reliability. Building a strong foundation of trust and rapport between a practitioner and their patients is of paramount importance.

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Maintaining a solid email marketing strategy is another effective way to stay connected with potential and existing patients.3 Aesthetic clinics should factor in sending monthly newsletters containing valuable information, treatment options and exclusive offers to existing and prospective patients who have signed up to receive news and updates.3 This keeps the clinic at the forefront of patients’ minds and nurtures ongoing engagement, as well as being a reliable way to emphasise targeted messages.3 Effective email marketing requires strategy, data analysis and ongoing optimisation. Understanding your audience, personalising content and testing different elements can increase the likelihood of a successful email marketing campaign. Experiment with varying variations of email or A/B testing to see which elements (subject lines, content, visuals, times of day etc.) resonate best with your audience.4 Try out different subject lines to be attentiongrabbing and relevant. For example, ‘Unlock Radiant Skin with XXX Treatment’, ‘Discover the Science Behind XXX Product’ or ‘Exclusive Offer: 20% Off Skincare’. Test these out to see which perform best; the key to successful email marketing is providing value, so think about what you can actually offer to patients this way. Including compelling before and after images in newsletters is beneficial because they visually demonstrate the transformative effects of your treatments, capturing the audience’s attention and inspiring confidence in your services. The aim is to make your emails stand out so patients don’t delete them as soon as they arrive in their inbox. When reviewing your social media, maintain active and appealing profiles. Platforms like Instagram and Facebook are valuable for sharing visual content, creating a portfolio of your work and engaging with your audience. As a visual platform, Instagram is also great for showcasing your before and after images of patient results when appropriate consent has been obtained. This can be done through short-form video as well as static images, in order to follow the growing trend of videos performing highly on social media platforms.5 Video also diversifies the ways in which you can promote treatments – you could film a team member having the treatment to show what it looks like, or perhaps post video testimonials from a consenting patient discussing their treatment journey. You can create simple videos within Instagram itself, or use apps like CapCut and Canva to add

Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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extra creativity.5 Creating eye-catching visuals or even engaging with trends can be a good way to increase wider awareness of the treatments you offer. Partnering with trusted influencers in the beauty, aesthetics and wellness niche can significantly expand the reach of your clinic by promoting it amongst their followers.6 Influencers can share their experiences with treatments, creating a relatable and authentic connection with their followers. This can lead to increased curiosity and interest among the influencer’s audience, driving them to explore the treatments offered. Remember that when treatments are gifted to influencers free of charge, this must be clearly stated in order to stay within Advertising Standards Authority (ASA) guidelines.7 When creating any promotional materials for patients, be mindful of ASA guidelines preventing the promotion of prescriptiononly medications (POMs) to the public, and remember your social responsibility to ensure content is not potentially damaging to vulnerable users.8 Following a public consultation in May 2022, new guidance from the Committee of Advertising Practice (CAP) and Broadcast Committee of Advertising Practice (BCAP) has implemented restrictions forbidding cosmetic intervention adverts directed at under-18s, so be mindful of what content you create so it’s not immediately appealing to children.8 Testimonials should also be on clinics’ radars, because my clients over the years have attested that reviews hold immense power in influencing purchasing decisions. Aesthetic practitioners and clinics should actively gather and display positive feedback from satisfied patients. Testimonials build credibility and address common concerns potential patients may have. They can be used within marketing materials such as social media posts or your website to showcase treatments’ positive effects. It’s essential to ensure that testimonials are accurate, verifiable and obtained with the patient’s informed consent, respecting their privacy and maintaining transparency in all promotional efforts. For further expert insights and guidance in the digital landscape, I recommend delving into the new book Black Belt Digital: Grow Your Aesthetics Brands by business consultant Rick O’Neill.9

In-person marketing It might be a good idea to offer long-standing patients first access to new treatment options; initially offering this in-person is a great way to develop your personal relationship. These

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loyal patients have already established trust and rapport with the clinic or practitioner, making them more open to experimenting with new treatments. Devoted patients often act as brand advocates, sharing their positive experiences within their social circles and significantly boosting the adoption of new treatments. By offering exclusive access to loyal patients, clinics can strengthen longer-lasting patient-provider relationships. Visual evidence is a powerful tool in the aesthetics industry. Showcasing before and after photos of real patients in the form of leaflets or flipbooks in your clinic can be incredibly persuasive, and makes sure they are aware of exactly what each treatment option entails. These images can be used during consultations to instil confidence and motivation for potential patients to try the treatments themselves, although they should be reminded that results cannot be replicated universally in order to manage expectations. Remember to gain consent from your patients before using any images on your website, social media or email campaigns. Additionally, offering printed educational materials for patients to take home on each treatment can further enhance their interest and confidence in trying it. Hosting in-clinic events on specific treatments or skincare routines can be engaging and educational. Focus on providing treatment demonstrations with a knowledgeable speaker who can talk it through and answer questions; this might be your lead practitioner or the clinic owner. Event promotion can be achieved through various channels, including email marketing, social media platforms and your website. Additionally, consider collaborating with a local social media influencer who can help boost event attendance by driving traffic to it. This in-person format allows practitioners to interact directly with potential patients, answering their questions in real time and alleviating concerns. These interactive sessions can help to foster community and trust, making participants more likely to book treatments there and then. As motivational speaker and author Bob Burg said in his 1993 book Endless Referrals, ‘People buy from people that they know, like and trust’.10 Events can be a great way to get to know patients even more, meaning they may be more likely to trust you when it comes to suggesting new treatments to try. When patients come into clinic, creating a sense of urgency through limited-time offers and exclusive deals can encourage patients to act, but this cannot be done for treatments

deemed to be ‘cosmetic interventions’.11 The ASA defines cosmetic interventions as ‘any intervention, procedure or treatment carried out with the primary objective of changing an aspect of a consumer’s physical appearance’.12 The ASA emphasises that the decision to engage with an aesthetic procedure should not be made to seem like a ‘flippant’ one.11 According to the ASA, clinics should ‘ensure that consumers are not put under undue pressure to purchase, and that all those notified of the offer are given a reasonable amount of time to consider it’.11 Countdown clocks and claims such as ‘Hurry, offer must end Friday’ should not be used for such treatments, including injectables.11 Clinics can promote offers on specific treatments or packages not regarded as ‘cosmetic interventions’ such as facials or skincare bundles, motivating potential patients to seize the opportunity before it’s gone. These promotions can be strategically timed, such as during holidays or special occasions. Summer holidays and Christmas tend to be great times to enhance and grow your return on investment as patients might be more likely to treat themselves so they can look their best. It’s crucial to remember that POMs, including botulinum toxin, cannot be advertised to the public at all.11,13 No time-limited offers can be made, and they cannot be promoted to your patients in any way.11,13

Building your business on trust Marketing treatments in aesthetic clinics revolve around building trust, educating patients and providing personalised experiences. Remember, a patient-centric approach focusing on providing value and addressing individual needs will set the foundation for a thriving aesthetic practice in an increasingly competitive landscape. Reena Sandhu has been a marketing professional for more than 26 years, with over 10 years’ experience focusing on skincare solutions. She previously ran her own marketing consultancy business, offering marketing strategies tailored to aesthetics. After selling the business, Sandhu is now a senior member of the Crown Aesthetics team as head of marketing & operations UK&I and international lead for digital.

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Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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In The Life Of Mr James Olding Oral and maxillofacial surgery registrar Mr James Olding shares his typical days in the NHS, aesthetic practice and running a training academy A typical working day…

Other work commitments…

I still work full-time as a specialist registrar in oral and maxillofacial surgery in the NHS, so five days a week, I wake up at 6am. I’m lucky to live nearby to St George’s Hospital where I’ve just started working, so after a big pot of coffee and a high-protein breakfast like eggs, bacon and avocado, I leave the house around 6:30am so I can start my shift at 7am. I’m training to be a maxillofacial surgeon, so I spend my NHS days assisting my consultant with surgeries and emergency patients. It’s usually intense, so I don’t have much time to think about anything else! I’m seeing patients all the way up until the end of my shift at 5pm-6pm. A non-negotiable for the end of my day is a gym session. It’s basically my therapy – it always makes me feel better both physically and mentally. At work, I’m on my feet all the time, as surgeries can sometimes last for eight hours or more. If I don’t go to the gym and do my weight training, I end up getting aches and pains. I preach about regular gym sessions to my colleagues a lot (not in an annoying way hopefully!) – it’s so helpful in mitigating stress. I think I would’ve been a personal trainer if I hadn’t gone into medicine! My other favourite way to wind down is listening to audiobooks before bed. I go through phases of what I’m interested in; currently it’s everything space – the history of the universe and physics is so fascinating! The best way to relax is of course spending time with my partner and friends on my rare days off. My days in my private aesthetic practice go at a lot more relaxed pace. It’s just me and a couple of colleagues coordinating my patients on Harley Street. As my time is so limited, I stick to a solid group of patients I’ve seen for years rather than continually growing my patient base. Because I know them so well, treating them is really fun. It’s always an enjoyable day when I get to catch up with them. I offer the typical treatments like upper-face toxin, skin boosters and other injectables,

I’m also the director and lead trainer at Interface Aesthetics training academy. My work as a trainer at Interface Aesthetics is mainly at the weekend, supported by the amazing clinical and coordination team. We offer training for doctors, dentists and nurses, including a lot of junior medical professional mentees. I’m normally involved in the more advanced side of the training, like one-to-one courses or masterclasses, plus creating new educational resources for our trainees. My favourite part of these days is hanging out with the trainees at lunchtime. I like finding out more about them, especially those just getting started in aesthetics who are the future of our specialty. I always advise them to be really enthusiastic about their work, but not to go beyond their area of competence. With regulation still unclear, it’s important to be well-trained and not jump into anything prematurely – that’s how you make sure patients always get good results. On top of that, I really value my role as a key opinion leader for Allergan Aesthetics. I train for them as well, both in the UK and internationally. Occasionally I film for the online learning environment, which we do with a whole camera crew set-up and gives me a chance to perform even more transformative procedures. I’ve had some great opportunities to present on stage, like at Allergan’s Infinity event in May alongside some incredible colleagues. I’ve also done some presenting internationally. The highlight of the last year was a three-day event launching HArmonyCa in Brazil as I speak both Spanish and Portuguese. It was one the best surprises of my career so far to be asked to attend, and I absolutely love it. I’ve recently been on a Scandinavian teaching trip as well which was an amazing experience.

but I also do lots of full-face rejuvenation. I do less of the beautification treatments, and more positive ageing transformations; I enjoy the more complex cases – maybe it’s the surgeon in me! Nearly half of my patients are male patients, which involves a lot of lower face and jawline procedures. I seem to have built up a bit of a niche in this area, which I love. I think it has built up through word of mouth. Men often worry about ‘looking done’ after receiving treatment, or even looking feminised – male patients are a few years behind women when it comes to the aesthetics taboo. It’s nice to be able to reassure male patients that good treatment is available to them.

Favourite holiday destination… I think Rio de Janeiro, Brazil is the most beautiful place – my partner’s from there, so it’s like a second home.

Your favourite cuisine for a dinner out… I love Japanese or Thai – I like to think that I can handle the spice!

Tunes that get you hyped up for a long day… My taste is pretty eclectic – house music is perfect for the gym, but indie rock like the Arctic Monkeys is another favourite.

Most memorable day in aesthetics… It would have to be The Aesthetics Awards 2023, where I’m proud to have won The AlumierMD Award for Rising Star of the Year, and Interface received Highly Commended for The CCR Award for Independent Training Provider of the Year! That was quite the night, and I’m still riding high.

Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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The Last Word Dr Elle Reid and Dr Chloe Aucott debate whether defibrillators should be a necessity in aesthetic clinics An AED is a medical device used to deliver an electric shock to the heart to restore its normal rhythm. It is primarily used in cardiac arrest (CA), where the heart suddenly stops beating effectively, leading to the cessation of blood circulation. CA is a time-sensitive medical emergency with the chances of survival decreasing by 10% with every minute that passes.1 Early defibrillation is recommended as it:2 • Increases the survival rate by 70% if performed in the first few minutes • Minimises the risk of brain damage through oxygen deprivation to the brain. • Enhances the effectiveness of CPR This article explores the necessity of defibrillators, also known as automated external defibrillators (AEDs) in aesthetic clinics across the UK.

Current landscape in aesthetics According to the Care Quality Commission (CQC) guidelines, clinical staff should receive training in medical emergencies, including use of AED equipment, on at least an annual basis.3 However, aesthetic practices are not always required to be registered with the CQC, with many practitioners working in non-CQC registered sites. In Scotland, Wales and Ireland, the frequency at which training for medical emergencies should be carried out can vary. The General Medical Council (GMC), General Dental Council (GDC) and Nursing and Midwifery Council (NMC) are all in agreement that their registrants should undergo regular training in medical emergencies and the use of medical equipment such as AEDs.3,4,5 The GDC states that their registrants must refresh AED training on an annual basis and have also released a joint statement with the CQC reiterating this.6 However, neither the GMC or NMC provide guidance on how regularly training should be conducted. This leaves a potentially grey area for aesthetic practitioners working in non-CQC registered premises.

Arguments in favour of having an AED A CA can happen to anyone with a reported 60,000 out-of-hospital CAs occurring in the 70

UK every year.2 Therefore, the presence of life-saving equipment can give peace of mind for practitioners and patients attending the clinic. Furthermore, it demonstrates a commitment to safety and can contribute to a positive reputation for the practitioner or clinic. Although the guidance from governing bodies is unclear, patient safety should always be a practitioner’s first priority. Practitioners should consider what medicolegal and ethical issues could potentially arise in the unfortunate event that a CA may occur whilst practising aesthetics and an AED were not available. For example, whether reasonable steps have been taken to ensure patient safety and duty of care to patients could be questioned. Upon purchasing an AED, you are encouraged to register the location of the equipment with The Circuit – the national defibrillator network.7 In some cases, practitioners may be located within areas that lack immediate action to healthcare facilities. By having an AED onsite, the practitioner or clinic can benefit the surrounding community to help anyone in need. Many aesthetic practitioners work solely alone within the UK. In other healthcare settings such as dental practices, it is essential to have multiple members of staff working within the clinical setting, and one of the GDC standards requires adequate support when treating patients with one of the key purposes being assistance if a medical emergency was to arise.8 It would be difficult for solo practitioners to locate the nearest defibrillator to the clinic, call 999 and perform the continuous CPR needed when working alone.

Counterarguments against having an AED AEDs are undeniably a reasonable expense to purchase and maintain and can be a considerable financial burden for a small aesthetic clinic. Prices typically range from £890 to £2,500.9,10 They also require regular maintenance including checking battery levels, ensuring the electrode pads are in date and conducting routine self-tests to ensure the equipment is functioning correctly, which can be time-consuming.11 As medical settings go, aesthetic practice is not typically a high-risk environment for cardiac emergencies. As a result, the AED

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may have limited usage, raising questions about cost-effectiveness. In addition, effective use of an AED requires appropriate training by the practitioner or clinic staff. Conducting such regular training can be time-consuming and costly. Whereas having an AED onsite demonstrates a commitment to safety, it comes with a potential liability and legal considerations. In the UK there are laws that protect individuals who assist in emergency situations, including the use of an AED, as long as they act reasonably and in good faith.14 Thought should be given to the obligations for its working order and correct use in the occurrence of an incident happening.

Why we decided to invest As medical professionals carrying out such procedures, we pride ourselves on the extent of our training, medical knowledge and professional registration. This begs the question, should our commitment to patient safety be dependent on the premises we are working in when our governing bodies stipulate the importance of maintaining training in the use of AEDs? Though not a CA, following experiencing a particularly challenging medical emergency in-clinic together we used this opportunity to revise our own protocols with regards to patient safety. As such, we decided to add a defibrillator into our clinic. It’s important for clinics to weigh up the arguments and counterarguments, just as with any prudent business or medical deliberation, and the responsibility lies in arriving at an independent conclusion. Dr Elle Reid is an aesthetic practitioner and dental surgeon graduating from Newcastle University. Dr Reid has a background in maxillofacial surgery, hospital and practice-based dentistry. She holds the positions of clinical lead for Acquisition Aesthetics in Newcastle and director of Paragon Aesthetics medical aesthetics clinic. Qual: BDS, MFDS Dr Chloe Aucott is an aesthetic practitioner and dental surgeon graduating from The University of Leeds. Dr Aucott is a general dental practitioner within primary care and is a trainer for Acquisition Aesthetics and a Senior Associate at Paragon Aesthetics. Qual: MChD, BChD, BSc

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Reproduced from Aesthetics | Volume 10/Issue 12 - November 2023

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