Aesthetics: October Issue

The

Light Therapy

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The latest product and industry news 17 Advertorial: £1 is All We Need! Donating just a small amount can make a huge difference to Facing the World

News Special: Regulating Mobile Practitioners

Aesthetics looks into mobile aesthetic practice in England

Special Feature: Treating the Glabella Practitioners detail the benefits and risks of treating the glabella

Miss Rachna Murthy and Professor Jonathan Roos explore the health and diseased states of eyelashes and provide considerations

Dr Jasmin Taher describes her treatment approach for patients with ‘M-shaped’ lips

Advertorial: SkinCeuticals Tripeptide-R Neck Repair The latest innovation to target the neck and décolletage

Dr Usman Qureshi demonstrates using permanent silicone threads 45 Managing Acne During Pregnancy

Dr Ravi Brar explores the best ways to treat pregnant women with acne 51 Case Study: Delayed Onset Nodules

Caroline Hall presents a case study of managing a dermal filler complication 54

Advertorial: Introducing Neofound

A new way to be profound through bio-remodelling 55 Abstracts

A round-up and summary of useful clinical papers IN PRACTICE 56 Incorporating Instagram Reels

Aesthetics explores Instagram’s newest video feature 58

Advertorial: Treating the Hands with Radiofrequency

Dr Rita Rakus presents her top tips for hand rejuvenation 59 Using Pay-Per-Click Marketing

Digital marketer Bradley Hall explains how aesthetic businesses can best use pay-per-click marketing 63 Planning Your Future Marketing

Brand marketing strategist Adam Haroun explores using the current period of uncertainty to your advantage 66

Utilising Smartphones for Photography

Photographer Clint Singh discusses smartphone imagery 69 In Profile: Mr Naveen Cavale

Miss Rachna Murthy is a Cambridge and Londonbased consultant oculoplastic and aesthetic surgeon and co-owns FaceRestoration. She is regarded as an authority on thyroid eye disease, eyelids, skin cancer and is on Allergan’s Faculty for filler complications.

Professor Jonathan C P Roos is a Harvard, Cambridge and Moorfields-trained consultant oculoplastic surgeon and academic based in London at FaceRestoration. His work has been published in the world’s leading medical journals.

Dr Jasmin Taher is a Level 7-trained aesthetic practitioner who runs a clinic in Fulham, London. She is a brand ambassador for VIVACY, and a Derma Medical Trainer. Dr Taher is well known for treating difficult lip cases, such as the ‘M-shaped’ lip.

Dr Usman Qureshi is an aesthetic practitioner at Luxe Skin Clinic in Glasgow. He started cosmetic practice in 2012 and now carries out advanced toxin, dermal filler and threadlifting procedures. He focuses on full face rejuvenation by combining the above.

Mr Naveen Cavale shares his journey to becoming a plastic surgeon 70

The Last Word: Master’s in Aesthetics

Dr MJ Rowland-Warmann asks, is a master’s in Aesthetic Medicine worth it?

Dr Ravi Brar is the co-director of sk:INSPIRE Medical Aesthetics and is a member of the Royal College of General Practitioners. He also accomplished a Postgraduate Diploma in Clinical Dermatology from Queen Mary University London. NEXT MONTH In Focus: Devices • Muscle Stimulation

Addressing Redness Caused by Rosacea

Caroline Hall is an independent nurse prescriber and the owner of R&R Aesthetics in Leeds. She worked as a nurse and midwife within the NHS for 14 years before becoming a full time aesthetic practitioner in 2016.

Reviewing Photobiomodulation

Chloé Gronow Editor & Content Manager @chloe_aestheticseditor

How do you practice? Do you own a clinic, rent a room or are you a mobile practitioner? While it’s not illegal to travel to patients’ homes to deliver aesthetic treatment, it is not recommended by numerous bodies, including the Joint Council for Cosmetic Practitioners and Save Face. Their opinions on the matter have been reiterated this month following the publication of two reports by the Chartered Institute of Environmental Health. The reports state that some of the most serious complaints received by local authorities were concerned with practitioners operating on a mobile basis or from domestic settings. As such, they recommend that legislation is introduced to enable authorities to take action on mobile practitioners performing treatments that penetrate the skin, such as dermal filler or botulinum toxin.

The JCCP and Save Face both agree that they also see complaints relating to mobile practice, highlighting concerns with an unhygienic

Clinical Advisory Board

environment and lack of oversight. Hamilton Fraser Cosmetic Insurance, on the other hand, says there is lack of data to indicate greater safety risks, meaning good mobile practitioners can be tarnished with a bad reputation as a result of others’ actions. What do you think? Read our article on the topic on p.18 and let us know your thoughts on social media or by emailing editorial@aestheticsjournal.com.

On a lighter note, how good are you at utilising your Instagram as a marketing tool? On p.56 two marketers emphasise how valuable the social media platform can be, encouraging clinic owners to start incorporating the new Instagram Reels feature into their strategy!

They say that the short video clips can be a fun way to promote your clinic, while ensuring you reach a relevant audience. We would love to see what you produce, so read the article now for some ideas of content you can create!

The team and I are planning to try it out for ourselves over the coming months, so follow @aestheticsjournaluk on Instagram and tag us in your Reels!

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

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

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

Miss Elizabeth Hawkes is a consultant ophthalmologist and oculoplastic surgeon at the Cadogan Clinic in Chelsea, London. She specialises in cosmetic eyelid surgery and facial aesthetics. Miss Hawkes also leads the emergency eye care service for the Royal Berkshire NHS Foundation Trust.

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

Alison Willis Director T: 07747 761198 | alison.willis@easyfairs.com

EDITORIAL

WE WANT TO HEAR FROM YOU!

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

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

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

ADVERTISING & SPONSORSHIP

MARKETING

Aleiya Lonsdale Head of Marketing T: 0203 196 4375 | aleiya.lonsdale@easyfairs.com Katie Gray • Marketing Manager T: 0203 1964 366 | katie.gray@easyfairs.com

DESIGN

Peter Johnson • Senior Designer T: 0203 196 4359 | peter@aestheticsjournal.com

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

Email editorial@aestheticsjournal.com

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

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

ARTICLE PDFs AND REPRO

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

Aesthetics Media

© Copyright 2020 Aesthetics. All rights reserved. Aesthetics is published by Aesthetics Media Ltd, which is registered as a limited company in England; No 9887184

Mr Dalvi Humzah, Clinical Lead

#Aesthetics

#Meeting

Ash Labib @ashlabib

Another VIP visit @gulgokyokus Allergan marketing manager was such a delight welcoming you at our Solihull clinic. PS they felt like Charlie’s angels!!!

#alaesthetics

#almedicalacademy #solihullclinic #AllerganMedicalInstitute #Allergan

#Digital

Terina Denny @terina.vivacy

Vivacy UK Medical Partners 2020 first meeting! Such a privilege to be working with such a fantastic team of KOLs, Brand Ambassadors and Mentors with special guests from Vivacy Head Office France in Paris @briannavivacy @julianvivacy

Education Harley Academy qualification receives diploma status

Training provider Harley Academy has received an elevated diploma status for its Level 7 Qualification in Injectables, a new status from awarding organisation VTCT that is supported by the Joint Council of Cosmetic Practitioners (JCCP). Harley Academy explains that it has worked closely with the VTCT and the JCCP over the last 18 months to develop an exclusive pilot and evolve the course into a Level 7 Diploma, as a way to recognise the expertise of its students.

Marcus Bull, chief commercial officer of VTCT, commented, “VTCT are very proud to be introducing this Level 7 Diploma qualification which we hope will help maintain high standards in aesthetic medicine, an area of increasing importance to the public. Harley Academy has been instrumental in helping us to ensure that all components of this qualification can be successfully delivered.”

Dr Tristan Mehta, CEO and founder of Harley Academy, said, “We are proud to introduce the Diploma as the recognition of higher standards of education and training represents another step toward better regulation in the field, which is part of our mission at Harley Academy.”

Radiofrequency

Cynosure launches RF microneedling device

#Community

Dr Tristan Mehta @dr.tristan.m Company picnic and farewell to Parveen, we wouldn’t be here without you!!

#Training

Sinclair Pharma @sinclair_uk

Our first @ellanse_global training today since March. It was great to be back with @skinexcellenceclinicssouthwest teaching delegates at our new Covid secure London training venue @cosmeticcentre_london #training #Ellanse #collagenstimulation #fillers

#Education

Dr Lee Walker @leewalker_academy

Incredible educational session with our VIP delegates today... big thanks to @billlewis3540 for hard work and support #TeoxaneUK #RHA #Multilayer

Laser manufacturer Cynosure has introduced Potenza, a radiofrequency microneedling device to its skin revitalisation portfolio.

The four-mode system consists of monopolar or bipolar, delivered at either 1 MHz or 2 MHz frequency. Cynosure explains that Potenza treatments use ultrafine needles and radiofrequency energy to penetrate the top layer of the skin and trigger the body’s natural healing process to regenerate new collagen and elastin. According to the company, Potenza treatments can be performed on all skin types, anywhere on the body and can also treat acne vulgaris.

Todd Tillemans, chief executive officer of Cynosure, said, “Our goal at Cynosure is to provide our customers with revolutionary technologies so they can consistently deliver outstanding results. Potenza takes the microneedling category to a new level by offering unprecedented flexibility for doctors, which translates to personalised treatments and satisfied patients with exceptional outcomes.”

To allow practitioners to learn more about the device, Cynosure will be hosting a webinar in November.

Celebration Industry companies to support the Aesthetics Awards

Companies across the aesthetic field are showing their support for the upcoming Aesthetics Awards on March 13 by securing category sponsorship. Skincare brand AlumierMD is sponsoring Best NonSurgical Result, pharmaceutical company Croma Pharma UK is supporting Clinic Reception Team of the Year, skincare platform Get Harley is celebrating medical practitioners through Medical Practitioner of the Year, medical aesthetic company Intraline is sponsoring Best Clinic South England, skincare brand SkinCeuticals is supporting Energy Device of the Year, device manufacturer Aesthetic Technology is championing Best Clinic London and product manufacturer ReLife is supporting Best New Clinic.

Nina McMurray of Croma Pharma UK, commented, “We know that teamwork and customer service are the most essential key drivers to the success of any aesthetic business. Every person in a clinic has an important role to play in delivering an excellent customer experience!”

Lizzy Hossain of AlumierMD, said, “We believe that everyone should feel truly powerful in their own skin, and thanks to innovative non-surgical treatments in the medical aesthetics industry this is more affordable, accessible and achievable than ever before – especially when combined with medical-grade skincare!” Charmaine Chow of Get Harley, said, “It is the medical aesthetic practitioners who we support with our service, and we truly believe they should be celebrated for their excellence. Since working closely with many well-known names, we have come to truly understand their businesses, and how we can best support them, and have been astounded by the level of expertise, talent and professionalism in this country.” Louise Taylor of Aesthetic Technology, emphasised, “We recognise the dedication it takes to be an outstanding clinic in such a competitive industry both from a clinical and patient experience perspective. We wish all the finalists the very best of luck.” Aesthetics Awards finalists will be announced in December. To show your support for the Aesthetics Awards, email contact@aestheticsjournal.com to enquire about sponsorship or to secure your tickets.

Diversity Allergan and SkinBetter Science launch diversity initiative

Global pharmaceutical company Allergan Aesthetics and skincare company SkinBetter Science have collaborated to launch a new initiative to improve diversity. Allergan explains that Driving Racial Equity in Aesthetic Medicine (DREAM) is committed to furthering the principles of racial and ethnic diversity, inclusion, respect and understanding. Carrie Strom, senior vice president, AbbVie and president, Global Allergan Aesthetics, commented, “As leaders in aesthetics, Allergan Aesthetics and SkinBetter Science are likeminded in our pursuit of advancing equality and diversity in the aesthetics market. We are inaugurating the DREAM Initiative with three important projects, which will immediately expand available resources to enhance the care of all patients, as well as to better diagnose and treat dermatologic conditions across the full spectrum of skin types and patients of colour.”

Vital Statistics

43% of 1,000 female respondents wanted more clinical research for skincare products for women of colour and wider-ranging products for all skin tones (LeCerre, 2020)

Botulinum toxin is the most searched for procedure in the UK, US, Canada, Spain, Germany, France, Poland and Brazil (Flawless.org, 2020)

73% of 2,000 respondents wouldn’t feel comfortable speaking to friends, or asking them for advice about aesthetics treatments and 77% wouldn’t speak to family (Glowday, 2020)

59% of healthcare workers seen in occupational skin disease clinics set up during COVID-19 were found to be affected by irritant contact dermatitis (BAD, 2020)

69% of Millennial women and 34% of Millennial men buy some type of skincare product every six months (Roy Morgan, 2020)

11% of men in Britain feel that they look at least five years older as a result of the stress and anxiety brought about by lockdown and the pandemic (Uvence, 2020)

Membership Hamilton Fraser partners with JCCP to offer free memberships

Insurance provider Hamilton Fraser has partnered with the Joint Council for Cosmetic Practitioners (JCCP) to offer new policy holders a free year of membership with the JCCP. The company explains that this is to help practitioners and clinics comply with patient safety and public protection standards following COVID-19. Eddie Hooker, CEO of Hamilton Fraser and JCCP trustee, commented, “I am really excited about the partnership between Hamilton Fraser and the JCCP. Joining the JCCP Practitioner Register through this new partnership is an important way in which practitioners can play their part and show their commitment to high professional standards.”

Professor David Sines, JCCP executive chair, said, “The partnership with Hamilton Fraser to substantially increase JCCP Practitioner Register numbers is not about generating profits or income, but about increasing exponentially patient safety and awareness of the need to be only treated by an appropriately qualified and experienced practitioner.”

Conference CCR postponed until 2021

CCR 2020, as part of events company Easyfairs, has been postponed until October 14 and 15 next year.

Easyfairs explains that the company has been closely following and monitoring all advice and recommendations about COVID-19 from the World Health Organization and from local governments, and that the safety of delegates is its top priority.

Alison Willis, divisional director of Easyfairs’ Aesthetics portfolio, commented, “We were very much expecting that the world would be open for business in order for the Autumn 2020 edition of CCR to be able to go ahead, especially after the green light had been given by the UK Government to run events back in July. However, as the situation continues to evolve, we have been in close consultation with the aesthetics community and all stakeholders in the event regarding their concerns around bringing the entire community together face to face at this time. Taking into account the global situation, the social distancing restrictions currently being imposed on live events and the requirements of our exhibitors, we have made the extremely difficult decision to have to postpone this year’s edition to 2021.” She continued, “During this difficult and unprecedented time, I have been overwhelmed by the support that we have from the community for the event and its critical role in bringing the industry together. We know that CCR and its sister event ACE – that takes place in March 2021 – will both play a vital part in the economic recovery and we look forward to continuing to work closely with the aesthetics community to steer the industry out of the crisis and to a strong future. I would like to wholeheartedly thank everyone for their unwavering support and understanding and express our ongoing commitment to the incredible businesses in this sector.” To register your interest for ACE 2021 or book a stand, head to www.aestheticsconference.com

Medik8 releases new toner

UK skincare manufacturer Medik8 has launched a new exfoliating toner called Press and Glow. The company explains that the product contains gluconolactone, a polyhydroxy acid (PHA) designed to exfoliate the skin to leave a clearer complexion. Other ingredients in the toner include prickly pear extract that aims to boost the activity of natural exfoliation enzymes, and aloe vera to reduce skin irritation and enhance the skin’s moisture retention properties. Daniel Isaacs, Medik8’s director of research, said, “We don’t deny that glycolic and other AHA/BHAs are fantastic exfoliators, but practitioners report that they see a lot of overuse and the result is dry sensitised skin. This is where PHAs come in.”

He continued, “When applied to the skin, the gluconolactone in Press and Glow converts to gluconic acid; an active acid within the skin. This conversion acts as a form of time-release, slowly releasing the acid into the skin meaning irritation is unlikely. An additional benefit of gluconolactone is its hydrating properties. It’s incredibly hydrating thanks to its chemical structure – the multiple hydroxy groups attached to the molecule essentially act as water magnets. The result? Skin that’s more resilient and better able to optimise vitamin C and A – both core ingredients in Medik8’s skin philosophy.” Medik8 states that the toner is not suitable for women who are pregnant or breastfeeding.

Skincare

International Croma Pharma expands

Medical aesthetic product manufacturer Croma-Pharma GmbH has partnered with China National Biotec Group Company (CNBG) to enter the Chinese market to supply the country with its hyaluronic acid filler Princess VOLUME, as well as other products in the company’s portfolio.

On the partnership, Andreas Prinz, CCO and co-owner of Croma, said, “Croma incorporates more than 40 years of experience in viscoelastic products. Our fully automated production lines deliver eight million prefilled injectables per year. With CNBG, we have found the perfect partner to merge our strengths and assets to successfully enter the fast-growing Chinese market. CNBG’s track-record and experience will heavily support Croma to sustainably prosper in Asia.”

Xiangrong Li, vice-president of CNBG, said, “CNBG, via its affiliate Lanzhou, has been very successful for years with its botulinum toxin in China. Our search for suitable HA filler products has finally come to an end – Croma indeed is the perfect partner and best possible fit for us. Together we are committed to shape and conquer the Chinese market with all its immense growth potential.”

SkinCeuticals opens second advanced clinic centre

Education

Merz launches new webinar series

Global pharmaceutical company Merz Aesthetics is launching an autumn/winter webinar series, which will share insights on the company’s BELOTERO filler range. Merz explains that the sessions will discuss why and how BELOTERO Volume allows practitioners to treat holistically and how natural lips can be achieved by tailoring each treatment using BELOTERO Lips Shape and Contour, as well as showing videos demonstrating different injection techniques and featuring live Q&A sessions.

According to the company, you can earn CPD points by attending each of the 20 sessions. Merz will also be partnering with marketing strategist Adam Haroun for five business webinars, discussing topics such as how clinics can get back on track after lockdown and how to gain patient loyalty. The webinars are available now and will run until December, accessible via the Merz webinars website. For a taste of the kind of education Haroun will bring, read his article on p.63.

Ageing

Neostrata releases athome peel treatment

Cosmeceutical

nurse practitioner Sarah White to launch its second advanced clinic centre, located at the Sarah White Clinic in Wirral.

The company explains that the centre is designed to provide patients with advanced knowledge and experience alongside the SkinCeuticals product offering. SkinCeuticals states that the clinic centre will have a dedicated treatment room where patients will be able to select from the company’s full treatment menu including facials and peels, skin scope appointments, the full product range and custom D.O.S.E personalised corrective serums, which will all be made in-clinic. White commented, “My clinic’s main ethos is holistic skin health. I am passionate about skincare and have built a thriving practice around ensuring patients are educated about skin health. SkinCeuticals is a key component of my business because it is what patients need, desire and expect as part of their aesthetic treatment journey.” SkinCeuticals launched its first advanced clinic centre in 2019, in partnership with the Cavendish Clinic.

Skincare company NeoStrata has launched a weekly athome peel treatment, designed to target skin ageing. The company explains that the formula includes a 20% blend of glycolic acid and antioxidant citric acid, as well as alpha hydroxy acid.

Vikki Baker, marketing manager at UK distributor AestheticSource, said, “With skincare purchase rising throughout lockdown and this set to continue, we are pleased to offer a new home peeling option for our practitioners and their patients. Industry feedback indicates that not all consumers have returned to their usual routines and with the added potential of local lockdowns to take place, the New Neostrata Citriate Solution Home Peel Pads are an effective solution to prolong clinic results as well as enhance a patient’s skincare routine by helping renew cell turnover and brighten the complexion.” NeoStrata is distributed in the UK exclusively through AestheticSource and will be available from mid October.

Skincare

company SkinCeuticals has partnered with aesthetic

BACN UPDATES

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

BACN REGIONAL DIGITAL CONFERENCES

September was extremely busy, with a number of digital conferences operating which offered interesting webinars from BACN partners along with Q&As from Hamilton Fraser Cosmetic Insurance. Members were then invited to attend a virtual peer-to-peer review with others in their region to discuss their own issues and offer case studies. There are a number of BACN events throughout October. Unlike in-person events, virtual events aren’t restricted to a single location. Members can register for any of the digital conferences regardless of their region. Members can attend all sessions or only the ones which interest them, joining the meeting as and when they wish. All digital events are CPD accredited but members must register to receive login details and post-event certificates. More information can be found by contacting Tara Glover, BACN Events Manager, at tglover@bacn.org.uk

BACN FORUMS

With it being ever more important that members can access their support network, members are reminded that the BACN has an active Facebook group of around 900 nurses who work and operate in the UK. This forum is managed by some of the BACN Board and is set up primarily to offer support and to ignite conversation around hot topics. Members can access the site by searching ‘BACN Members Only’ in Facebook. This is a forum only for BACN members, and everyone is a medical practitioner.

BACN WEBSITE

Members are reminded to check their details and update any existing clinic addresses in their members’ area of the BACN website.

The BACN Practitioner Finder is an opt-in service, and accurate information is essential for the public to use the service well. There are also specific questions that will allow the BACN to tailor specific services towards certain members.

This column is written and supported by the BACN

Education Dr Tapan Patel launches PHI College

Aesthetic practitioner Dr Tapan Patel has launched a new aesthetic training academy, PHI College.

Dr Patel explains that the college is an extension of PHI Clinic, designed to offer a range of CPD-approved training courses for aesthetic professionals. This will include accredited Level 3, 4, 5, 6, and 7 courses in laser and IPL treatments, as well as foundation and advanced Level 7 courses in botulinum toxin and dermal filler.

Training dates begin online on October 24, with five webinars being held over the course of the month. Topics include: an introduction to aesthetics, facial anatomy, complications, injection techniques, treatment plan training and an overview of running an aesthetic business. Practical dates will also continue in 2021.

Lasers

Cutera introduces Level 5 training course

Aesthetic laser manufacturer Cutera is collaborating with dermatologist and laser surgeon Dr Asif Hussein and Wynyard Aesthetics Academy to launch the UK’s first Level 5 Vascular Laser Course. Cutera explains that the new course is designed to educate delegates on the key fundamentals of treating vascular concerns, identifying the safest treatment protocols available. The course is CPD approved by the CPD Accreditation Group and externally moderated by the City of London Dental School.

According to Cutera, the training agenda will cover: theoretical understanding of vascular laser treatments, identifying different types of vascular concerns, evaluation of all technologies and treatment options available for vascular concerns, evaluation of the laser wavelengths most commonly used to treat varying vascular concerns, live demonstrations with Dr Hussein on models, case studies and practical training using varying technologies, risk assessments and health and safety. The course will be held at sk:n in London Victoria on October 18.

Digital

Lynton establishes monthly support meeting

Equipment manufacturer Lynton has launched a virtual monthly ‘Business Support Coffee Morning’ for its customers, taking place on the third Friday of every month. The company explains that the meetings will offer Lynton customers bespoke marketing support and guidance as aesthetic clinics adjust to reopening, and the topics covered in the meetings will include social media skills and strategy planning.

Hayley Jones, sales and marketing director, commented, “We are delighted to launch the Lynton Business Support Coffee Morning for our customers. This monthly event focuses on sharing key recommendations to help Lynton customers innovate and improve their businesses from both a marketing and strategic perspective. We will also be making the coffee mornings available on demand from our Lynton Customer Portal.”

When you reveal beauty, we’re by your side.

Croma offers a wide range of state-of-the-art products in minimally invasive aesthetic medicine. This allows you to combine techniques for personally tailored treatment and ideal results. Learn more about Croma’s products and services at croma.at

HA Filler | Threads | PRP | ACA & SVF | Skincare

Clinic opening

Harley Academy launches two clinics

Training provider Harley Academy is launching two clinics this month in Marylebone, London and Southwell, Nottinghamshire, under the brand name STORY. The company explains the clinics will offer treatments such as facials, skin scans, dermal filler, botulinum toxin and Profhilo. The Marylebone clinic will be run by STORY founders Dr Emily MacGregor and Dr Tristan Mehta, while Dr Marcus Mehta will head up STORY Nottingham.

Joining them are aesthetic practitioners and clinical trainers from Harley Academy, Dr Jo Hackney and dermatologist Dr Maja Swierczynska. Dr MacGregor commented, “The lack of regulation within the aesthetic industry is a great issue that we’re tackling one needle at a time. STORY is the continuation of the story of the many top tier practitioners that have graduated from Harley Academy. Every injectable, botulinum toxin and filler treatment available at STORY will be performed by a professionally regulated medical practitioner who has a Level 7 qualification in aesthetic medicine.”

On the Scene

BCAM Conference 2020

Allergies BAD releases warning against private allergy tests

The British Association of Dermatologists (BAD) has issued a warning against the use of unvalidated food allergy testing for different skin conditions, following the results of two studies presented at the virtual BAD annual meeting.

The studies suggested that many companies are not using laboratories with the relevant international accreditation for testing and that the type of tests being used often lack scientific evidence, which could lead to inaccurate representations of allergy and intolerance status. The BAD explains that this can affect patients with skin conditions, such as eczema and psoriasis, who are getting allergy tests to understand the triggers of their conditions.

Dr Alice Plant, dermatology specialist registrar and researcher of one of the studies, said, “Poorly informed patients are vulnerable to being misled about their allergy and intolerance status. There is a lack of evidence to suggest that certain foods trigger eczema, and we would encourage people to continue with their topical treatments as prescribed by their doctor rather than eliminating foods from their diet without first discussing this with a medical professional.”

Holly Barber, spokesperson for BAD, said, “It’s concerning to learn that several of the allergy tests available to purchase online may be unreliable. We would encourage anybody who suspects they have an allergy to visit their GP rather than seeking out tests online as allergy testing is available on the NHS.”

The British College of Aesthetic Medicine (BCAM) held its first virtual conference from September 14 to 21. The event featured leading speakers and explored the latest innovations, techniques and best practice in aesthetics. BCAM highlighted that patient demand for medical aesthetic treatments continue to climb, regardless of the COVID-19 pandemic, yet patient safety fears remain through the lack of sector regulation. Delegates heard of rising complications, as well as sessions on preventing and managing those that do occur. Other topics include body and weight treatments, women’s health, skin-ofcolour considerations and managing a clinic through the pandemic.

BCAM president Dr Uliana Gout said, “BCAM is going into its 20th anniversary year next year in great shape, even though 2020 has been the most challenging year in the history of aesthetic medicine. BCAM has shown fact-based leadership throughout, not just opinion, through our work at the highest legal levels, plus sharing our unique sectorial oversight data with the Department of Health and Social Care. We strive to fulfil our role in providing clear evidence and information to our members and colleagues based on facts. Our conference has underlined BCAM’s pivotal role in our specialty.”

Dr Catherine Fairris, conference director, added, “Real thanks is due to BCAM’s sponsors – Church Pharmacy, Healthxchange, HA-Derma, AestheticSource, Novo Nordisk, Enhance Insurance, Hamilton Fraser. It is only with their backing that BCAM could attempt this ambitious project. Also a huge thank you to our speakers who joined us from all over the world to deliver educational, evidence-based and inspirational talks.”

Learning Acquisition Aesthetics introduces Level 7 diploma

Training provider Acquisition Aesthetics is now offering a Level 7 Diploma in Aesthetic Medicine, having been approved by awarding organisation OTHM Qualifications.

Acquisition Aesthetics explains that the course will provide delegates with extensive hands-on injecting practice on live models within small groups, and all practical training will be undertaken with close supervision. Core units of learning on the diploma will include anatomy, pathophysiology and dermatology, alongside medical assessment and consultation, complication management, safety and welfare, and ethics and professionalism in aesthetic practice.

Dr Lara Watson, Acquisition Aesthetics director, commented, “We’re delighted to be endorsed to provide our learners with this prestigious qualification, and incredibly excited about the positive impact this will have on the learner experience and the regulation of the aesthetics industry as a whole.”

The British College of Aesthetic Medicine represents 400+ UK and international Aesthetic Doctors and Dentists whose mission is to help make Aesthetic Medicine safer, more ethical and more accessible to the general public.

Healthcare workers experience spike in skin conditions

The British Association of Dermatologists (BAD) has released statistics indicating that during COVID-19, 59% of healthcare workers seen in occupational skin disease clinics have been affected by irritant contact dermatitis, due to increased PPE use and frequent hand washing. The research was presented at the Virtual Annual Meeting of the British Association of Dermatologists, based on an audit of 200 hospital-based healthcare workers by the British Society of Cutaneous Allergy.

According to the study, acne was the second most common condition, seen in 15% of healthcare workers due to the occlusive effects of prolonged mask wear. The research also indicated that 18% of the healthcare workers had required time off work because of their occupational skin problems. Dr Harriet O’Neill, lead researcher of the study, said, “For the face, protecting the skin with medical-grade silicon tape before donning tight-fitting masks, then rechecking the fit of the mask, may be helpful. Facial skin should be regularly moisturised when not at work. Moisturisers are an essential part of treating dermatitis and should be applied generously after handwashing and whenever the skin feels dry. In severe cases, or if an infection is suspected, further treatment from a GP or an occupational health doctor may be required.”

Intraline announces new brand ambassador

Medical aesthetic company Intraline has appointed aesthetic practitioner Dr Amrit Thiara as its new brand ambassador. Dr Thiara is the founder of Tiara Aesthetics Clinic and is a trainer for Derma Medical. Terry Fraser, Intraline president, said, “Dr Thiara is a brilliant and passionate doctor, who truly cares about his patients and delegates. He will be a great addition as an Intraline partner and will help to continue to build educational resources to serve our customers and authorised resellers.”

Dr Thiara said, “Having used a variety of Intraline’s products over the years, I have always achieved industry-leading, patient-focused results. Their products are very premium and of exceptional quality. The team behind Intraline are also very approachable, friendly and receptive of feedback. To be able to partner and work alongside Intraline is a valuable opportunity I am proud to be a part of.”

Cosmetic Courses launches Level 7 diploma

Aesthetic training provider Cosmetic Courses is introducing a new Level 7 Diploma in Clinical Aesthetic Injectable Treatments. The company explains that the Vocational Training Charitable Trust (VTCT) approved course has been designed to cover a variety of dermal filler and botulinum toxin treatments, as well as providing a thorough understanding of the core knowledge surrounding aesthetic injectables. Cosmetic Courses states that on successful completion, delegates will be able to demonstrate competency in each modality making them eligible to join the Joint Council for Cosmetic Practitioners (JCCP) practitioner register. Consultant plastic surgeon and clinical director of Cosmetic Courses, Mr Adrian Richards, commented, “We are so pleased to have gained JCCP and VTCT approval to deliver the brand new Level 7 Diploma in Clinical Aesthetic Injectable Treatment. Over the last 18 years we have developed a passionate team driven to deliver the highest standard in aesthetic training whilst continuing to raise the bar. We are committed to the learning and safety of practitioners within the aesthetic industry.”

News in Brief

Mr Dalvi Humzah elected as BMA representative

Aesthetics Media’s Clinical Advisory Board Lead and consultant plastic, reconstructive and aesthetic surgeon, Mr Dalvi Humzah, has been elected as one of two ‘private consultant or specialist clinical practice’ representatives for the British Medical Association’s (BMA) Private Practice Committee. The committee engages with key stakeholders in private healthcare to represent the views of the medical profession. Mr Humzah commented, “Thank you to all those who voted in the recent BMA elections. I look forward to representing the members when the committee meets in October.”

BAS webinar speakers announced

The British Association of Sclerotherapists (BAS) has announced the speakers for its upcoming webinars, which will take place over the next four months. The first webinar titled ‘Varicose Vein Treatments in 2020: Reconciling Patient and Practitioner Priorities’ will be held on October 8, hosted by vascular surgeon Professor Bruce Campbell and consultant vascular surgeons Mr Manjit Gohel and Mr Philip Coleridge Smith. The BAS explains that the webinar will debate the merits and downsides of the many treatment modalities currently available for varicose veins and saphenous reflux. More talks will take place on November 12, December 3 and January 14.

Clinic marketing YouTube launches

Business coach and author Alan Adams has started a YouTube channel focusing on sales and marketing advice for aesthetic clinics. Adams explains that he will be creating and sharing sharing short videos about what clinics can do to improve their marketing strategies, as well as the psychology behind it and why it works. He said, “The aim is to give clinics a really thorough understanding of how to enable their business to thrive. I’m also always open to receiving questions and will focus on topics that clinic owners would like to know more about.”

LABthetics releases online training

Skincare manufacturer LABthetics has launched an online training academy to support its chemical peel kits, allowing practitioners and clinic owners to study the theory-based protocols at home. The company states that the training is CPD approved, and it will also be offering the training free for up to five practitioners per clinic. Emma Caine, founder of LABthetics, commented, “Being at the beginning at the chain we have a responsibility to help kick start the market. The online training is easy to follow and focuses on anatomy and physiology, skin conditions and extensive treatment protocols including our signature chemical LABpeels.”

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£11,100 – the average cost of one fellowship to train a medic to treat children suffering from facial differences. If every subscriber to Aesthetics was to donate just £1 to Facing the World, then we’d easily be able to fund a fellowship! Will you help?

In last month’s issue we told you about the amazing training missions that Facing the World hosts to upskill medical professionals to be able to offer the support these children so desperately need. The charity plans to fund 200 more fellowships across the next five years, but needs your support.1

Each fellowship will last two to six weeks, with all associated costs covered by Facing the World. The charity says, “Practising the ‘teach a man to fish’ approach creates a viable and sustainable solution… To date, over 100 Vietnamese medics have been offered fellowships to the UK, Canada and the USA, giving them the opportunity to observe and learn new techniques and approaches.”

Facing the World also highlights that one of the many positive

outcomes of its fundraising efforts has been that the Difficult Airway Society, which aims to improve education and understanding of managing patients with breathing difficulties, has introduced its guidelines into Vietnam.1

Donate

Regulating Mobile Practitioners

legislation to enable local authorities to take action on mobile practitioners performing cosmetic treatments that penetrate the skin, such as dermal filler or botulinum toxin. The report states that some of the most serious complaints received by local authorities were concerned with practitioners operating on a mobile basis or from domestic premises, and 71% of the survey participants believe that the inclusion of mobile practitioners within the regulatory regime could improve the regulatory system.6,7

At the moment in England, practitioners who do not operate from a permanent work premise can be registered under the Local Government (Miscellaneous Provisions) Act 1982. However, The Health and Safety Executive (HSE) is the current enforcing authority for home and mobile practitioners. This means that local authorities have limited powers to investigate and take action on practitioners operating from their home or on a mobile basis.7 The CIEH states in its report that it is currently not aware of HSE taking any enforcement action against any recorded complaints regarding cosmetic treatments performed in the home.7 With mobile practitioners causing a high percentage of problems throughout the UK according to Save Face,5,7 Aesthetics asks the question: is it enough to enable local authorities to intervene or should there be a greater push to have mobile practice banned altogether?

Over lockdown, independent accreditation body Save Face received almost 100 complaints about practitioners flouting Government rules by performing private procedures in homes, as an alternative to clinic settings.1,2 Not only was this a cause of concern due to the ongoing pandemic, but it also necessitated associations to highlight the risks involved with performing procedures in a non-clinical environment.2

These concerns are not new, with medical professionals having previously warned about the various dangers of mobile appointments. In 2014, the Royal College of Surgeons published Professional Standards for Cosmetic Practice, stating that practitioners should not undertake any procedures in unlicensed premises such as, but not limited to, domestic settings and that they should only practice if the premises meet the standards of the licensing body.3 The NHS also advises potential patients to avoid mobile services where procedures take place in homes or hotels.4

Last year, 41% of 1,617 complaints received by Save Face were a result of issues caused by mobile practitioners, while 33% of treatments resulting in complications were recorded to have happened in domestic settings. Although the majority were associated with beauticians, hairdressers and laypeople, medical professionals were also guilty of moving from home-tohome in order to perform treatments.5

Last month, the Chartered Institute of Environmental Health (CIEH) released two reports on the regulation of cosmetic treatments in the UK, alongside the Institute of Licensing, providing recommendations for the Department of Health and Social Care (DHSC) based on a survey of 258 professionals in England involved in an environmental health or licensing capacity. Those in Wales, Scotland and Northern Ireland were not surveyed. The report suggested that the DHSC should introduce legislation that requires mandatory licensing of all cosmetic treatments, introduce legal age limits for all invasive cosmetic treatments and that they should carry out an integrated public awareness campaign.6,7

One other suggestion put forward by the CIEH was that the DHSC should introduce new

The potential problems with mobile working

Emma Davies, clinical director of Save Face, says the association is constantly being made aware of the dangers surrounding mobile practitioners.

She says, “Almost half of the complaints Save Face received last year were because mobile practitioners could not follow the correct safety protocols – how can they when there are so many factors out of their control?

How can infection control be managed?

The patient might have kids or pets running around the house which can not only distract the practitioner from performing a safe treatment, but poses a hygiene risk. There might also be bad or inconsistent lighting so it’s harder to see injection points or there might not be appropriate facilities available to aid a complication should it occur.”

She continues, “The reality is that we see a lot of doctors, dentists and nurses who go from home to home doing their treatments, and there is a misconception that their medic status makes it safe. A lot of patients who complain to us state that they assumed it

Aesthetics explores the potential issues surrounding mobile aesthetic practice in England and outlines newly proposed recommendations

would be okay to have the procedure carried out in their home because it was being administered by a healthcare professional. However, this isn’t the case.”

Like Davies, Professor David Sines, chair of the Joint Council for Cosmetic Practitioners (JCCP), believes that the reason mobile workers pose a significant safety risk is because of the potential for low hygiene in the premises, as well as the lack of general oversight and support. He says, “It shouldn’t be overlooked that going from home to home may put the healthcare professional in danger too, as they never know for sure what they’re walking into. There is a lot that can go wrong, and this is on top of all the usual risks involved with aesthetics. The industry needs greater regulation overall to ensure the safety of both patients and practitioners.”

However, Mark Copsey, associate director of insurance company Hamilton Fraser Cosmetic Insurance, says there is a lack of data to show the greater safety risks of mobile practitioners who are medically trained. He comments, “Because a high number of mobile practitioners aren’t medically trained, the ones who are tend to be tarnished with the same bad reputation. As a company, we work with a lot of mobile practitioners who are qualified and who perform their treatments successfully. From a personal insurer point of view, there is no data or information to suggest they’re a greater insurance risk than someone operating in a clinic.”

He continues, “What we view as important is that all practitioners are following the same codes of conduct that they would in a clinic. Mobile working has never been something raised to Hamilton Fraser from associations

in the industry, so it’s not a problem that gets brought to our attention. I think the bigger issue that needs to be tackled is separating medics from non-medics, making it stricter on who can and cannot perform aesthetic treatments in a mobile setting.”

Professor Sines believes that the lack of conversation on the topic may be due to mobile practitioners being overlooked in industry conversations. He comments, “The problems surrounding the dangers of mobile practitioners are continually on the JCCP’s agenda as an area of concern. However, I think in general it’s something that can be swept under the carpet as there is no real way of tracking it. Like the rest of the aesthetics field, it isn’t an area that is regulated, meaning there is an absence of data that reminds people of the real extent of the problem.”

What help would the recommendations be?

With the recommendations set for local authorities to take action on mobile practitioners performing cosmetic treatments, it’s down to the DHSC to decide whether to put them into action, but will they make any difference?

Professor Sines expresses a positive opinion on the report, stating, “The JCCP’s explicit policy is that mobile practitioners should not exist. However, in the absence of a government aiming to prohibit mobile practice the CIEH should be supported, because environmental health enforcement officers are currently unable to extend their powers of inspection to mobile practitioners or home workers. This anomaly represents a major risk to public safety and so the

JCCP believes that the powers of inspection for these mobile practitioners should be extended as the CIEH have recommended.” While Davies sees the CIEH recommendations as a positive attempt to shed light on and regulate home injecting, she doesn’t believe enabling local authorities to intervene has the ability to create change and calls for a greater action.

She comments, “One problem with saying that local authorities can intervene is that, a lot of the time, these mobile practitioners don’t even give their full names, real names or proper contact details. A patient might get a number, but if there’s an issue I have heard many stories of them getting blocked or the number will be changed. It makes it very difficult to track someone down. The bigger issue is that although local authorities could do inspections under the new recommendation, they would be unable to check every single home that the practitioner will go to, or has gone to, so something more needs to be done.”

Davies proposes a blanket ban, making it illegal for mobile practitioners to perform treatments such as injectables in their patients’ homes. “Of course, making it illegal doesn’t mean that it will never happen. It’s impossible to say it would be gone forever, but what it would do is make the public much more aware that this isn’t something they should be investing in. Once they know it’s illegal, it should deter them,” Davies adds. Copsey believes the recommendations set out by the CIEH will aid in the distancing of the beauty sector and the medical aesthetics sector. He says, “As a company, we support anything that makes the industry safer. If local authorities are able to get involved, nonmedics who are performing on a mobile basis are more likely to be investigated.”

REFERENCES

1. Holly Carver, Practitioners breach lockdown rules, 2020. <https://aestheticsjournal.com/news/practitioners-breachlockdown>

2. Save Face, Cosmetic practitioners breaching lockdown rules to visit clients homes, 2020. <https://www.saveface.co.uk/ cosmetic-practitioners-breaching-lockdown-rules-to-visit-clientshomes/>

3. Cherie Scanlon, Where should aesthetic nurses practise?, 2014, <https://www.enhancinghealthandbeauty.com/wp-content/ uploads/2015/04/Premesis-article.pdf >

4. NHS, 2020, <https://www.nhs.uk/conditions/cosmeticprocedures/choosing-who-will-do-your-procedure/>

5. Save Face, 2020, Data on file

6. The Chartered Institute of Environmental Health, The Ugly Side of Beauty - Improving the safety of cosmetic treatments in England, 2020, <https://www.bacn.org.uk/news-andpress-releases/chartered-institute-of-environmental-healthissues-reports-on-current-state-and-issues-with-the-cosmetictreatment-sector-in-england-with-recommendations-for-dhsc/>

7. The Chartered Institute of Environmental Health, A fragmented picture – regulation of cosmetic treatments in the UK, 2020 <https://www.bacn.org.uk/content/large/news/a_fragmented_ picture_-_regulation_of_cosmetic_treatments_in_the_uk.pdf>

“I think mobile working is something that can be swept under the carpet as there is no real way of tracking it. Like the rest of the aesthetics field, it isn’t an area that is regulated, meaning there is an absence of data”

Professor David Sines

Treating the Glabella with Dermal Filler

The pair note that they would usually consider HA treatment in patients with deep static lines. “You’ll realise that sometimes botulinum toxin is not enough to create the significant effect sought by patients, so adding filler afterwards is of real benefit,” says Dr Molina, explaining, “It can help if there is significant brow ptosis and volume loss in the area.”

The glabella: one of the main facial features to display signs of ageing. When rhytids form in this area, they will generally range from fine lines to deep furrows. For many, their presentation does not simply present an aged appearance, but can make individuals look angry, sad, anxious, fatigued or fearful.1 Anecdotally, practitioners explain that this can cause undue distress in patients who feel that their emotional connection with friends, family and colleagues is being negatively affected by their appearance.

Thankfully, we all know treatment options are available. Botulinum toxin A has become a mainstay; inducing temporary paralysis when injected into the striated muscles and, thus, reducing the appearance of rhytids in the glabella.1 The well-established treatment is usually successful and low risk, so why use anything else you may ask?

Well, as aesthetic practitioners Dr Beatriz Molina and Dr Raul Cetto explain, administering hyaluronic acid (HA) dermal filler in the glabella can offer enhanced results for those with significant furrows, while also being longer lasting.2 That said, injecting HA in this area is off-label with some products and comes with higher risk than toxin or the use of HA in other facial locations. This article will explore the research, potential complications and precautions to take if it is a treatment option you’re considering offering your patients.

Practitioner concerns

According to Dr Molina and Dr Cetto, many practitioners became fearful of treating the glabella with filler after the publication of Avoiding and Treating Blindness from Fillers: A Review of the World Literature in 2015.3 In the paper, 98 cases of vision changes from filler were identified, with the glabella region being the highest risk area, with 38.8% of complications occurring there. Autologous fat was the most common filler type to cause the complication in all cases (47.9%), followed by HA at 23.5%.3 An update to the research was published in 2019, which identified 48 new reported cases of partial or complete vision loss after filler injection between January 2015 and September 2018. This time, the glabella was the second highest risk area (27.1%), following the nasal region where 56.3% of the complications occurred. HA filler was the cause of complications in 81.3% of the cases.4 Dr Molina and Dr Cetto suggest that complications involving the glabella may have gone down because, anecdotally, less practitioners have been injecting the area with HA since the 2015 report. Dr Cetto says, “Five years ago it became almost like a taboo to treat the glabella with filler, yet many practitioners had been treating the area routinely before then and achieving successful results.” Dr Molina explains, “When I started 15 years ago, you were taught to treat the glabella from the beginning of your training. Since we’ve become more aware of the anatomy and potential complications, however, there’s been a big shift to practitioners refusing to treat the area.” While they both acknowledge the serious risks associated with treating the glabella with HA, Dr Molina and Dr Cetto emphasise that it can be safely and successfully treated by experienced practitioners – not beginners – who have an excellent understanding of the anatomy and are appropriately trained. Doing so, they believe, will offer an overall enhanced result of the whole area.

Assessment and consultation

Dr Molina and Dr Cetto agree that using HA in the glabella should always be the secondline treatment, following the administration of toxin. “I don’t think there’s a shortcut,” says Dr Cetto, explaining, “If you just administered filler, you won’t take away the core component causing the concern, which is the muscle contraction deepening the groove or line.” Ultimately, he says, the patient won’t be satisfied with the result.

Dr Cetto adds, “As we know, muscles become hypertrophic from frowning a lot and skin loses its elasticity. When a patient has a static line with a dip or a groove it is very often not that easy to treat with toxin alone.” He continues, “Changing a patient’s expression through treatment can really help. Of course you’ve got to evaluate whether filler is appropriate on a case-bycase basis for every person you see.”

Dr Molina will follow-up with potential patients approximately two weeks after their toxin treatments to assess the result and decide whether HA will benefit. “As the toxin will have taken effect, you’ll have a good understanding of the result and can outline the next steps to the patient. Some people will prefer to wait a few months; it just depends on the severity and the amount of perfection the patient is looking for.”

Dr Cetto, on the other hand, prefers to wait to review after two cycles of toxin to decide whether filler would benefit the patient. The only time the practitioners would use HA alone in the glabella is if the patient specifically does not want toxin treatment or if they have a contraindication. Dr Cetto exemplifies a case of a patient who is a teacher who did not want toxin injections; while she wanted to soften the deep line in her glabella, he explains she did not want to relax the muscles in the area as being able to frown was an important part of her role when engaging with her pupils.

Both practitioners emphasise the importance of detailing the risks of the treatment to the patient, both verbally and in their written consent form prior to treatment. “It’s not about scaring the patient, but we should make them aware that there’s higher risk when injecting the glabella with HA compared to, for example, injecting the lip,” says Dr Cetto, adding, “We should make sure they’re fully aware of what could go wrong, how we will manage it if the worst happens and, like with any treatment, ensure they are given an appropriate cooling-off period of at least two weeks to consider whether they definitely want to go ahead.”

Practitioners detail the benefits and challenges of using hyaluronic acid in this high-risk area

Dr Beatriz Molina Dr Raul Cetto

Anatomy

The practitioners interviewed emphasise that the first thing to remember when injecting the glabella is that not everyone’s anatomy is the same. Dr Cetto notes that both the location and the depth of blood vessels can vary between patient so there’s no guarantee of safe areas to inject.

Dr Molina and Dr Cetto explain that the key arteries to be aware of are the supratrochlear

branch is not present in more than 80% of cases. This has been used as a basis of dividing the arterial patterns of the forehead into two types: type I – with superficial branches of the supratrochlear and supraorbital artery, with the deep branch of the supraorbital artery – and type II – with both superficial and deep branches of the supratrochlear and supraorbital artery. Baker and Mr Humzah explain that the types

expressions.” Teosyal RHA 2 is Dr Cetto’s product of choice, unless he is injecting a patient with particularly thin skin – he would then use RHA 1. “RHA 1 is less strong and more stretchable,” he explains. He usually injects the glabella into the mid-dermis with a 27 gauge needle, at a 10 degree angle. “I go perpendicular to the line, rather than going along the line in a retrograde fashion,” Dr Cetto explains, highlighting, “We know the arteries are more likely to be along the line, so you could be more likely to injure them by injecting this way.” Dr Molina uses a cannula in this area, explaining that there are two possibilities to make an entry point, which she usually does with a 23 gauge needle. “You can identify the middle point in-between the supratrochlear and supraorbital nerves or, if you’re a bit nervous of that small space, you can enter more laterally on the brow. Look at where the middle point of the middle and lateral brow meet and you can enter from there,” she explains.

and the supraorbital arteries (Figure 1), which are both branches of the ophthalmic artery. As detailed in the peer-reviewed article Anatomy, Head and Neck, Glabella, these arteries supply the forehead and medial canthal area. The supraorbital artery passes through the supraorbital notch, where it divides into two branches: a superficial branch and a deep branch. Superficial branches include the vertical and brow branches, while the medial, oblique, and lateral rim branches are deep.5

The article explains that the supraorbital and supratrochlear arteries anastomose with the angular artery at the medial angle of the eye to form an arterial arcade. The supratrochlear artery also branches from the ophthalmic artery and exits the superomedial orbit.

The authors claim that the artery becomes subcutaneous 15 to 25mm above the supraorbital rim; it can be relatively superficial, being about 2mm deep in the muscle layer. A branch of the dorsal nasal artery supplies the glabella and the inferior and middle transverse regions of the forehead; laterally it anastomosis with supratrochlear arteries.

In a 2019 article called Forehead Anatomy for Injectables, nurse prescriber Anna Baker and consultant plastic and aesthetic surgeon Mr Dalvi Humzah highlight a study that has suggested that the deep vertical lines observed in individuals may serve as a marker for the underlying supratrochlear arteries in 50% of cases.6 The artery is, however, variable in its arrangement. According to the authors, the superficial branch is always present, but the deep

are further divided depending on whether a central dorsal artery is present medial to the superficial branch of the supratrochlear artery. They note that this variability should be considered when dermal filler injections are being performed in the forehead, and deep placement with a cannula is recommended. The authors continue that the supraorbital and supratrochlear arteries travel with corresponding nerves and the supraorbital branch exits the medial aspect of the orbital rim along its superior course to the frontalis. An accessory foramen may be located just superior to the supraorbital foramen, which is a possible and significant anatomical variation to note when assessing an individual’s glabellar complex.

Whilst it is acknowledged that the glabella is considered a higher risk area owing to the medial and variable anastomosis of the supratrochlear vessels, Baker and Mr Humzah remind practitioners that they are advised to remain mindful of the extensive and varied anastomosis of the entire facial vasculature.

Product selection and technique

Dr Molina and Dr Cetto highlight that a HA filler with a moderate G-prime is best for treating this area. Dr Cetto says, “You want a product that’s cohesive but not stiff,” while Dr Molina adds, “It needs to be soft enough to integrate well and look natural, as most people don’t have much fat in their glabella so a thicker product can make it look lumpy. You also want it to support dynamic movement, so the patient can still have brow

Dr Molina then switches to a short 25mm 25 gauge cannula which, she notes, offers good control. “If you’ve gone in laterally through the brow there will be a slight bending, so you should guide the cannula with care. Know your layers to ensure you’re above the blood vessels when you place the cannula. Be slow and gentle; don’t push hard as you could move vessels,” she emphasises.

For Dr Molina, using a product without lidocaine is important. “As pain is one of the most common identifying factors of a vascular event, when injecting the glabella I want patients to be able to tell me if they are experiencing pain,” she explains, highlighting, “The problem with lidocaine is the area goes numb after the first injection, so it can be very nerve-wracking as, without the patient reacting, you may not be not aware that you’re applying pressure on the blood vessels.” As such, Dr Molina uses Aliaxin FL, which she explains is a soft filler that integrates well in the glabella and gives a very natural result.7

Risk management

Dr Molina explains that bruising is the most common side effect to occur when treating the glabella with HA. “You may hit a blood vessel superficially, so a bit of tenderness is expected,” she explains.

But of course, the most serious risk of injecting the glabella with HA is vascular occlusion, potentially leading to skin necrosis or blindness. Prevention is always better than cure, so having a thorough understanding of the anatomy, injecting slowly and with

Supratrochlear artery

Supraorbital artery

Figure 1: Diagram showing the approximate locations of the supratrochlear and supraorbital arteries

Choosing not to treat

While this article details the experiences of two practitioners who do treat the glabella with HA, Aesthetics wanted to hear from someone who chooses not to. We spoke to Clinical Advisory Board member and nurse prescriber Jackie Partridge for her perspective…

1. Have you treated the glabella with HA previously?

Yes, this is something I did when I first started in aesthetics, but certainly not something I would consider doing now. The process of lifting/supporting a deep static line will be effective; but, in my opinion it’s just not worth the risk. I will always say to my own patients that prevention is better than cure, and I think the glabella is a classic example of this. I appreciate mainly more mature patients will come into clinic with deep grooves to their glabella and I will still advocate relaxing this with botulinum toxin A if medically appropriate to try to prevent the groove from deepening further, but I won’t use dermal fillers here.

2. Why have you chosen not to treat the glabella with filler?

Anatomy! The supratrochlear artery lies precisely where the grooves are sitting. I appreciate that the artery starts off deep and becomes more superficial, so some practitioners might be happy to perform a superficial dermal filler injection, in what they believe to be a safe position; but, as we know, anatomy can vary from person to person, and even if you are able to avoid penetrating the artery itself, there is always the risk of compression on the artery leading to problems from dermal filler treatment. So personally, it’s not a treatment I perform.

3. What would you say to practitioners who are considering treating the glabella with filler?

Be very careful. Consider the speed of injection, and keep it slow. Aspiration is essential and the volume of product being injected should be limited. Understanding your product of choice is key. Never use a product that can’t be dissolved in this area.

care, and using small amounts of product is essential to avoid such complications, note the practitioners, as well as the authors of the 2015 literature review.3

Dr Molina recommends aspirating on each injection if using a needle and stopping immediately if the patient experiences pain or a change of colour or blanching is noted. If this occurs, then practitioners are advised to implement their vascular occlusion management strategy straightaway. The International Association for Prevention of Complications in Aesthetic Medicine (IAPCAM)8 and the Aesthetic Complications Expert (ACE) Group9 provide valuable guidance on this, highlighting the importance of having an emergency kit in reaching distance. Dr Cetto comments that aspiration is not always a reliable method of assessing if you are intravascular, noting that one recent consensus paper on preventing blindness does not recommend it.10

For Dr Molina, her approach involves always having a vial of hyaluronidase and 1ml of sodium chlorate next to her, so she is ready to mix and inject the solution immediately.

The volume can be increased once you have assessed and noted what is needed for the particular scenario, she advises. Speaking from experience of managing a vascular occlusion immediately after injection in the nose, Dr Molina highlights that in such an emergency situation there will be multiple things to do, all while needing to remain calm and reassuring the patient at the same time. “Having everything prepared in advance will make the process more manageable and ease any anxiety experienced by the patient or yourself,” she says, noting it can also reduce the possibility of long-term damage.

To treat or not to treat?

You may currently treat the glabella with HA confidently, but are you fully aware of the risks? Or maybe it’s something you’ve thought of doing after hearing success stories, but not known how best to approach?

This article has aimed to inform you of the risks and considerations to bear in mind and help you make an informed decision. It is not an exhaustive list and practitioners are always advised to speak to their peers and complete

appropriate training, both in injecting the area and in managing complications, before attempting any new treatment on patients. As highlighted, treating the glabella with HA is considered high risk so if you decide to go ahead, Dr Molina and Dr Cetto advise to be thoroughly confident in facial anatomy, undergo extensive training and ensure you have the qualifications and knowledge of exactly what to do if a complication does occur. They also recommend checking with your insurer that you will be covered to perform the treatment off-label if the products you use don’t have instructions for use. If treating the glabella is not for you, the practitioners highlight the value of having a network of colleagues who you can refer to. Dr Cetto concludes, “In my experience, patients appreciate your honesty and, if you do refer, their trust in you will increase, meaning they will always return to you for their usual treatments.”

REFERENCES

1. Macdonald MR, Spiegel JH, Raven RB, Kabaker SS, Maas CS. An Anatomical Approach to Glabellar Rhytids. Arch Otolaryngol Head Neck Surg. 1998;124(12):1315–1320.

2. Dubina M, Tung R, Bolotin D, et al. Treatment of forehead/ glabellar rhytide complex with combination botulinum toxin a and hyaluronic acid versus botulinum toxin A injection alone: a split-face, rater-blinded, randomized control trial. J Cosmet Dermatol. 2013;12(4):261-266.

3. Beleznay K, Carruthers JD, Humphrey S, Jones D. Avoiding and Treating Blindness From Fillers: A Review of the World Literature. Dermatol Surg. 2015;41(10):1097-1117.

4. Beleznay K, Carruthers JDA, Humphrey S, Carruthers A, Jones D. Update on Avoiding and Treating Blindness From Fillers: A Recent Review of the World Literature. Aesthet Surg J 2019;39(6):662-674.

5. Walker HM, Chauhan PR. Anatomy, Head and Neck, Glabella. [Updated 2020 Jul 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020.

6. Humzah D and Baker A, Forehead Anatomy for Injectables, (UK: Aesthetics, 2019) < https://aestheticsjournal.com/cpd/module/ forehead-anatomy-for-injectables>

7. HA-Derma, Aliaxin (UK: HA-Derma, 2020) <https://ha-derma. co.uk/products/aliaxin/>

8. IAPCAM, Working together for the management and prevention of complications (UK: IAPCAM, 2020) <http://iapcam.co.uk>

9. ACE Group, Guidelines for the Management of Complications in Aesthetic Practice (UK: ACE Group, 2020) <https://acegroup. online>

10. Goodman et al., A Consensus on Minimizing the Risk of Hyaluronic Acid Embolic Visual Loss and Suggestions for Immediate Bedside Management, Aesthetic Surgery Journal, Volume 40, Issue 9, September 2020, P1009–1021.

FURTHER READING

· Chatrath V, Banerjee PS, Goodman GJ, Rahman E. Soft-tissue Filler-associated Blindness: A Systematic Review of Case Reports and Case Series. Plast Reconstr Surg Glob Open 2019;7(4):e2173.

· Khan TT, Colon-Acevedo B, Mettu P, DeLorenzi C, Woodward JA. An Anatomical Analysis of the Supratrochlear Artery: Considerations in Facial Filler Injections and Preventing Vision Loss. Aesthet Surg J. 2017;37(2):203-208.

· Walker, Lee, and Martyn King. “This month’s guideline: Visual Loss Secondary to Cosmetic Filler Injection.” The Journal of clinical and aesthetic dermatologyvol. 11,5 (2018): E53-E55.

Beauty true to every side of you.

Help your patients stay true to themselves with BELOTERO ® Volume. Its 3D-Volume-Effect volumises at different angles to create the round and natural facial shapes that respect your patients‘ features and expressions.1

• Combines volumising effect with optimal modelling capacity 2

• Ensures a smooth transition between treated and untreated areas 2

• May last up to 18 months 2, 3 Enabling your patients to look their best from every angle.

1 Prager W et al. J Drugs Dermatol. 2017; 16(4): 351-357

2 Micheels P et al. J Clin Aesth Derm. 2015; 8(3): 28-34

3 Kerscher M et al. Clin Cosm Inv Dermatol. 2017;10:239-247

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

Eyelashes appeal

Understanding Eyelashes

Miss Rachna Murthy and Professor Jonathan Roos explore the health and diseased states of eyelashes and provide considerations for aesthetic practitioners

We sport between 90-150 lashes per eye, or as the Greeks termed them ‘blepharon,’ and these 300 also achieve a lot. They protect the eye by acting like whiskers to sense objects or wind and allow us humans to signal health, fertility and interest in another (flirting). Recently they have even been shown to alter airflow around the eye, thereby protecting the corneal surface.1

Gaze-tracking studies from the 1960s have shown that we are most preoccupied with the area around the eyes when meeting another person.2 But this has been intuitive knowledge since antiquity. The Egyptians, for example, were avid users of mascara and possibly the earliest hieroglyphs discovered have been found on a cosmetic palette.3 There persists then, even some 5,000 years later, a huge interest and industry around lash enhancement. In fact, there is even a patient-reported eyelash satisfaction questionnaire.4 However, it is important for medical aesthetic practitioners to know not just about lash appearance, but also their health and diseased states. Here we review the key concepts to keep you and your patients safe.

Normal lashes

Eyelashes are the first hairs we grow – they are already developed at week seven to eight in utero.5 They are made of the protein keratin, produced by a hair follicle, and are coated with sebum from the sebaceous gland (Figure 1). In the eyelid these glands are named after German ophthalmologist Dr Eduard Zeis. A blood supply to the follicle allows the hair to grow. Like all hair, they go through a cycle of growth and transition through an anagen, catagen and telogen phase, culminating in the loss of the blood supply and of the hair, encouraged by a new hair pushing through from below. However, for eyelashes,

the anagen growth phase is short and the resting telogen phase long (Figure 2). This means that they grow only to about 10mm and then shed naturally; we lose about one to four per day so all our eyelashes are replaced every six months. They grow in straight rows along the front edge of the eyelid and are surrounded by a number of glands.5 A study of 179 ethnically-diverse women showed that ageing results in shorter, thinner and lighter coloured eyelashes.6

Abnormal lashes

Wrong lash length

Because of the natural shedding cycle, lashes usually only grow to about 10mm, but the world record is 12.4cm.7 Longer lengths usually correlate with health issues. Children with allergic eye disease (vernal keratoconjunctivitis) for example, are found to have longer lashes.8 It has also been reported that excessive length can also be caused by AIDS9 as well as medical therapies; treatment for hypereosinophilic syndrome with the Janus kinase inhibitor ruxolitinib enhances lash growth,10 as does cetuximab treatment (an epidermal growth factor receptor inhibitor) for colorectal cancer.11

Crusts

Crusts on lashes are usually a hallmark of blepharitis – lid margin inflammation. This interferes with the normal supply of oil secretions to the ocular surface and results in an unstable tear film. To compensate, the eye waters. Sometimes the lashes develop small crusty cylinders around their base, so-called collarettes.12 This can also suggest the presence of eyelash mites – the Demodex species D folliculorum and D brevis.13 Their prevalence increases with age, and though they can be found in around 25% of asymptomatic controls; they are present in more than 63% of blepharitis patients and particularly in those who complain of itching.14 Previously, detecting Demodex required microscopy but a smartphone with a 90-diopter lens is adequate for the imaging and diagnosis on a lash root.15

More commonly however, it is developing a hypersensitivity to staphylococcal commensals that causes eyelid margin inflammation and affects meibomian gland function. For this, common blepharitis, maintaining lid hygiene and massage is paramount but can be difficult to achieve.16

Eyelid and eye specific antimicrobial cleansing products may be used to help, such as Purifeyes, which is antimicrobial and safe

Figure 1: The anatomy of a lash follicle in cross section is shown (A) with the shaft emerging through skin and coated with sebum from the sebaceous gland (gland of Zeis). In the eyelid (B) a number of glands maintain and support the ocular tear film, ensure a protected and moist margin with modified sweat glands (glands of Moll).5

Anagen (Growth Phase) 1-2 months

Nourishment of hair follicle via blood supply enables hair growth

Telogen (Resting Phase) 4-9 months Without nourishment the hair dies and falls out

Sebaceous gland

Catagen (Transition Phase) 15 days

Hair follicle detaches from nourishing blood supply

for the eye and eyelid.17,18 Other solutions that aid eyelid hygiene are Blephaclean or OcuSoft Lid Scrub.18

Blepharitis is invariably a bilateral condition with the exception that the preservatives in some glaucoma medications can cause unilateral blepharitis when only one eye is treated (Figure 3). In any other scenario of apparent unilateral blepharitis, sebaceous carcinoma must be excluded (see below).16

Misdirected lashes

Misdirected lashes are a leading cause of blindness around the world. Chlamydia trachomatis causes scarring on the conjunctival surface (Figure 1B) which draws the lashes in towards the eyeball and causes rubbing against the clear corneal surface and eventual scarring.21 This condition is best addressed with antibiotic eradication and surgical correction; it remains a major problem in Africa. In the UK, misdirected lashes result from lash blepharitis and local or systemic scarring disorders. As such, any aesthetic practitioner must be mindful to refer for investigations if necessary. Lash ptosis and epiblepharon (where an extra roll of skin causes the lashes to be pushed inwards) are other causes of misdirected lashes. The latter usually occurs in children and particularly in those of Chinese or Japanese ancestry. It can be addressed surgically if affecting comfort or vision, but most will outgrow the condition.21

Distichiasis is a condition where lashes also rub against the eye, but unlike trichiasis, the lashes originate from the wrong place. This can

Bimatoprost treatment case studies

Two patients (Figures 3A, & 3C) were treated with bimatoprost for glaucoma to their right eyes only. The superior sulcus is seen to be hollowed and the lid margin more pigmented and darker. The extra lid show gives a tired aesthetic look. The lashes are also more prominent compared to the untreated left eyes. Even three years after cessation of treatment (Figures 3B & 3D) the fat atrophy persists. This gave Dr Murthy the idea to trial bimatoprost 0.03% for conditions where there is excess adipose tissue such as in thyroid eye disease.16

be from the conjunctival surface or from meibomian glands being transformed from chronic inflammation. Such patients may have a double row of lashes rather than the usual rows at the lid margin (Figure 1B). Distichiasis can also be related to systemic disorders and congenital conditions affecting the FOXC2 gene and may need investigating. Misdirected lashes are difficult to treat and frequently recur.21

Discoloured lashes

Poliosis – the loss of colour of lashes – can be incidental but more usually is a marker of staphylococcal infestation or viral disease on the lids. It results from any process that causes destruction of the local melanocytes.22 A rare but serious cause is Vogt-Koyanagi-Harada syndrome, which is associated with eye inflammation and can result in blindness after the retina detaches.23

Cysts, skin tags and lash follicle tumours

Cystic lesions can appear near the lashes and include styes (infected hair follicles), Chalazia (infected or blocked meibomian glands), cysts of Moll (blocked sweat glands or hidrocystomas), cysts of Zeis (blocked sebaceous glands). These do not cause lash loss as they are not destructive, and so some practitioners are happy to lance them at the slit lamp. However, caution is warranted. A number of malignant lesions can masquerade as such cysts, including cystic basal cell carcinoma. Therefore histological confirmation is warranted for almost all lesions.24

Fleshy pedunculated lesions are usually viral warts and may recur after removal unless the base is excised or cauterised. Histology can be helpful to exclude solar keratosis, squamous cell carcinoma and keratoacanthoma. Unfortunately, the NHS places limits on what can be removed in the public healthcare system and so it’s advisable for patients to seek a private opinion.24

Pyoderma gangrenosum can occur on the lid margin and grow rapidly, which may worry patients. We excise them for cure and diagnosis if they fail to respond to a short course of topical steroids to which they are exquisitely sensitive.24

A number of eyelash follicle abnormalities can also form lumps or protrusions. The four that are neoplastic are uncommon and almost always benign.24 Nevertheless, we as well as our medical colleagues feel all should be excised and biopsied.25

The least worrying swelling is cilium incarnatum externum – an ingrown hair that forms a lump without visible features on the skin as it never protrudes through.26 Importantly, some lymphomas and

Bimatoprost 0.03%

of common treatments for hypotrichosis, as well as eyelash enhancers for a cosmetic improvement.20

aware from consultation if their patient is on this topical treatment, and particularly

is the key ingredient

Aesthetic practitioners therefore must be

when planning treatment to the periocular area.

Figure 3: Bimatoprost and deepening superior sulcus

Figure 2: Eyelash lifecycle27

3 years after stopping treatment

A C

B D

Shaft Root

Condition Causes

• Incidental

• Ageing

• Congenital syndromes e.g. Halo Naevus, Vogt-Koyanagi-Harada syndrome

Poliosis (colour loss)

• Staphylococcal infection • Melanocytic lesions

• Inflammatory systemic disorders • Blepharitis • Vernal keratoconjunctivitis (VKC) • Systemic/ophthalmic drug-induced (side effect of all topical prostaglandin analogues)

Trichiasis (misdirection)

• Trauma • Surgery • Lid margin inflammation • Conjunctival scarring diseases • Conjunctival burns • Variety of skin diseases

Milphosis/Madarosis (lash loss)

• Extensive list of systemic and drug-induced conditions e.g. chemotherapy • Several dermatological diseases e.g. discoid lupus, scleroderma • Inherited conditions • Lid infestation (staphylococcal spp., Demodex folliculorum, trachoma) • Lid inflammation (posterior blepharitis, ocular rosacea, seborrheic blepharitis) • Herpes zoster • Leprosy • HIV/AIDS • Malignant eyelid tumours • Hypothyroidism • Trichotillomania

Trichomegaly (enlargement of lashes)

• Congenital syndromes (Oliver-McFarlane and Cornelia de Lange) • Familial • Autoimmune: allergic rhinitis, atopic dermatitis, ichthyosis vulgaris • HIV infection • VKC

• Drug-induced: topical prostaglandin analogues, epidermal growth factor receptor (EGFR) inhibitors, afatinib

Table 1: Eyelash abnormalities and their aetiologies29

adenocarcinomas can also present with indistinct swelling but tend to be less focal.

Trichoepitheliomas are small skin-coloured nodules on the forehead or lids. When small they can be indistinguishable from papillomas or cutaneous horns, whilst larger ones can recruit blood vessels and resemble basal cell carcinoma.24

Trichofolliculomas are centrally umbilicated, dome shaped, skincoloured nodules which can have a lanugo hair emerging centrally. Trichilemmomas can look like viral warts and are filled with glycogen.23 They can occur familiarly in Cowden’s disease.

Finally, pilomatrixomas, or calcifying epitheliomas of Malherbe, arises from hair matrix cells and are uncommon and harmless. As they calcify they can develop an angulated shape – the so-called ‘tent’ sign. They occur on the head and neck, and are usually asymptomatic and around 5-10mm in size.27

Missing lashes

Missing lashes should remind the practitioner to consider unmissable diagnoses. Although madarosis can result from selfharm such as trichotillomania,28 trauma, or cancer chemotherapy, there are also a host of systemic causes with potentially lifethreatening sequelae (Table 1).29

Serious autoimmune causes include alopecia, scleroderma, discoid lupus and endocrine disease such as hypothyroidism. Infectious aetiologies include herpes zoster, leprosy, HIV/AIDS and trachoma.30 The neoplastic causes have been reviewed in a recent Aesthetics journal article by our colleagues Mr Richard Scawn and Miss Jennifer Doyle but given their importance, a brief recap should not go amiss.31

Basal cell carcinomas (BCCs) are the most common skin cancers annually in the UK, and on the eyelid they have an incidence of

around 4.51 per 100,000 or around 3,000 cases per year.32 They are more commonly found on the lower lid and can have different pigmentation and appearances including morpheiform, cystic, nodular and infiltrative. Even experienced individuals can mistake their appearance for a benign lesion, hence, it’s important to always excise and ensure histologically clear margins whenever there is lash loss.32 Though BCCs invade locally, and sometimes into the orbit, they do not generally metastasise. There are familial syndromes with multiple BCCs (GorlinGoltz syndrome) and they may also arise in immunocompromised states.32 Vismodegib is extremely effective and clinical experience has shown complete resolution of inoperable lesions even after spread, but it is not available on the NHS in the UK.33 Squamous cell carcinomas (SCCs) are less common than BCCs and represent about 5-10% of eyelid cancers. They have a higher metastatic potential and must be excised early, but some advocate the use of cryotherapy or imiquimod applications with good effect. Recently a PD-1 checkpoint inhibitor – Cemiplimab –has been approved by NICE via the UK’s Cancer Drug Fund for unresectable SCC.34 Sebaceous carcinoma represents 3% of eyelid tumours and are highly malignant, frequently affecting the upper lid.35 They most commonly occur in the eyelid and caruncle (fleshy bit of eyelid medially) with frequent ‘skip’ lesions, making it difficult to excise intact. It is an unmissable cause of unilateral blepharitis and has a crusty SCC-like or cauliflower appearance. A familial variant, Muir-Torre syndrome, can be associated with colon cancer and tumours of the genitourinary tract. Like sebaceous, Merkel cell carcinomas are a rare and highly malignant lesion affecting the upper lid preferentially. They arise from Merkel cells involved in touch sensation and are often purplish, painless lesions. They occasionally spare the eyelashes and can thus be mistaken for pyoderma. They grow rapidly and metastasise early and will not respond to steroid therapy. Adenocarcinoma of the glands in the lids is uncommon but potentially complex and is best treated with complete early excision. They can present with swelling of the lid, not unlike a chalazion, and with little surface pathology.22,32 A large well-conducted trial has shown that taking daily vitamin B3 can reduce the development of SCC, BCC and other nonmelanoma skin cancers.36 Melanoma is perhaps least frequent, as 1% of eyelid tumours are malignant, but most deadly and should prompt referral to an expert oculoplastic surgeon in a dedicated centre.36 However, biopsies can be surprising; some pigmented lesions can be BCCs as mentioned earlier and some melanomas are of course amelanotic. The peak incidence is in 50-80 year olds, with a lower eyelid location, being approximately 2.6 times more common than upper eyelid.37 Kaposi’s sarcoma – the AIDS associated malignancy – can appear on the lid with discoloration and cause lash loss. Another AIDS associated condition – lymphoma – can also result in madarosis but this is a rare occurrence.38

Enhancing lashes

X-ray imaging of lashes from 36 Japanese women aged 20-70 years whose use of eye makeup differed has shown that makeup use damages them. The frequency of mascara use correlated with the degree of cracking in the lash cuticle – the outermost part of the hair. Surprisingly, this isn’t the case for mechanical lash curlers which don’t seem to cause damage.39

Well-conducted research has shown that 0.03% bimatoprost treatment can make eyelashes grow longer, thicker, and darker.40 However, this eye pressure-lowering medication can also make the fatty tissue around the eye melt away – creating a deep hollow around the eyes.41 Being so close to the circulatory anastamoses it is a potentially dangerous area to treat with HA filler.42 Two derivatives of the prostaglandins, 15-Keto fluprostenol isopropyl ester and 15keto fluprostenol, have recently been shown to stimulate the same growth and thickening of the eyelashes without the disadvantages of darkening the edge of the eyelid or colouring the iris, even temporarily. Whether there is an effect on the orbital fat will need to be determined.43

False lashes

Traditionally, false lashes are either synthetic nylon or made from natural hair and then glued on with cyanoacrylate glue. Numerous reports of burns to the eye have been reported. More recently some fake lashes have been made to attach magnetically – something to be aware of before putting someone in an MRI machine.44 The added weight may also alter lid position and could adversely affect the decision to use neurotoxins, fillers or refer for blepharoplasty and ptosis surgery.

COVID-19 considerations for lashes

Any of the conditions above can result in ocular hyperaemia, which can also indicate inflammation of the eye. It is an early sign of conjunctivitis which if of viral origin can be contagious. At the time of writing this article, COVID-19 has been confirmed as a cause of conjunctivitis and viral RNA can be found in tears.45 It is recognised that any upper respiratory tract infection may result in viral conjunctivitis as a secondary complication, and this also appears to be the case with COVID-19.46 A Chinese expert who came down with Wuhan coronavirus after saying it was controllable thinks he was infected through his eyes.47

Although it is rare for conjunctivitis to be the initial presentation of COVID-19, there is a risk of viral transmission from contact with the tear film and ocular surface, and skin that has been in contact with tears.48 Asymptomatic COVID-19 patients, however, will more often have white eyes with no evidence of conjunctivitis.

Guidance recommends that for all patients having aesthetic treatments, scrupulous infection control and hand hygiene measures are employed.49 Where possible, eye protection should be used by practitioners, and stringent asepsis of the skin including the periocular area is critical. Critically, alcohol-based products must not be used near the eye as this can result in corneal de-epithelialisation and commonly used skin antiseptics such as chlorhexidine are toxic to the cornea.50

The empirical use of a safe non-alcohol based, anti-microbial ocular spray or drop, such as Purifeyes or minims povidone iodine 5% w/v solution may reduce the risk of viral transmission and is an added safety measure where close proximity to the eyes is required.17

Disclosure: the authors have developed and marketed the skin cleansing product Purifeyes by FaceRestoration.

Miss Rachna Murthy is a Cambridge and Londonbased consultant oculoplastic and aesthetic surgeon and co-owns FaceRestoration. She is regarded as an authority on thyroid eye disease, eyelids, skin cancer and is on Allergan’s Faculty for filler complications. Miss Murthy trained in Melbourne, Chelsea and Moorfields, and sits on the RSM Eye Council and IMCAS Alert Board.

Qual: BSc(Hons), MB, BS, FRCOphth

Professor Jonathan C P Roos is a Harvard, Cambridge and Moorfields-trained consultant oculoplastic surgeon and academic based in London at FaceRestoration. His work has been published in the world’s leading medical journals and he lectures internationally on aesthetics, eyelid diseases and thyroid eyes. With Miss Rachna Murthy, Professor Roos also runs a Cambridge dissection course for aesthetic filler safety called Aesthetic Clinical Training Academy.

Qual: BA(Hons), MB BChir, MA PhD(Cantab), FRCOphth FEBO

TO VIEW THE REFERENCES GO ONLINE AT WWW.AESTHETICSJOURNAL.COM

Test your knowledge!

Question

Which correctly describes the lifecycle of an eyelash?

Possible answer

A. A short anagen growth phase and long telogen resting phase

B. A short telogen resting phase and a long anagen growth phase C. A short catagen growth phase and long telogen resting phase D. A short telogen growth phase and long anagen resting phase

What is the main organism responsible for blepharitis and eyelash inflammation?

Which of the following eyelid lesions often causes loss of lashes?

Which of the following terms refers to misdirected lashes?

How can prostaglandin analogs affect eyelids and eye lashes?

A. Streptococcus commensals B. Staphylococcus commensals C. Demodex commensals D. Viral commensals

A. Cyst of Zeis B. Chalazion C. Cilium incarnatum externum D. Adenocarcinoma

A. Poliosis B. Madarosis C. Trichiasis D. Trichomegaly

A. Thinner shorter lashes and fat hypertrophy B. Thinner shorter lashes and fat atrophy

C. Thicker longer lashes and fat hypertrophy

D. Thicker longer lashes and fat atrophy

Answers: A, B, D, C, D

Treating

‘M-Shaped’ Lips

Many practitioners have faced the notoriously difficult ‘M-shaped’ lips. I myself see this lip shape regularly, however there is limited literature on these types of lips and little guidance on how to treat them successfully. I have found that because of this, some practitioners dread treating ‘M-shaped’ lips, or have been unable to meet the expectations of their patients.

How the ‘M-shaped’ lip presents

Although there are varying degrees of severity, I find this lip type classically presents in the upper lip with a dominant medial tubercle and thin, inverted lateral tubercles. In addition, the difference in vertical height between the upper and lower lip is usually far greater than the ideal 1:1.6 in Caucasian youthful lips.1,2 In my own personal experience, I have found that in the most severe cases, these patients also present with elongated philtral columns, as well as downturned lips (Figure 1).

Treatment

‘M-shaped’ lips are objectively difficult to treat. Given how thin the lateral aspects of the upper lip are, it can be difficult to volumise these to match the medial tubercle’s height. In my experience, practitioners tend to struggle when a simple linear threading approach is used. By dispersing product evenly across the vermillion border and body of the lip, the ‘M shape’ is simply volumised, rather than corrected. I have found that the key to a successful treatment is ensuring absolutely no product is placed in the medial tubercle and that the lips are treated over several visits, over a prolonged period, to gradually expand the lip tissue. Literature supports the concept that results can be enhanced by conducting treatments over a period of time.3 Given the length of time it takes and difficulty in completing an ‘M-shape’ treatment plan, it is paramount at the consultation stage to manage your patient’s expectations.4 In my experience, between two to five treatments spaced at least four to six weeks apart (or ideally longer) are required for correction of the ‘M-shaped’ lip. Increasing

the interval between appointments allows for the filler to fully integrate into the lip tissue.3 Patients need to be aware of this from the outset to avoid disappointment early in the treatment plan and to budget for full correction.

All lips are subject to high shear forces; hence it is imperative that a soft product able to adapt to these forces is used so the lips can move normally and not look stiff.5 Although practitioners may be tempted to use a more volumising product to achieve results sooner, I would advise a softer product with a slow approach, over multiple sessions, to reduce chances of lump formation or migration of lip filler.6 Although this applies to all lips, in my own experience this is even more important in ‘M-shaped’ lips. As the upper lip is exceptionally thin laterally, for successful treatment, a soft product that can slowly expand will volumise the lateral upper lip, whilst greatly reducing the risk of migration above the lip.

Case Study

Consultation

A 23-year-old female presented to the clinic with concerns about her lips. She felt her upper lip was considerably smaller than her lower lip and that the sides of her upper lip were thin and curled inwards. Upon assessment, it was clear that the patient presented with a classic ‘M-shaped’ lip (Figure 2). I started the consultation by carrying out a thorough medical history. The patient was fit and well, with no known allergies and had no history of previous aesthetic treatment. I then gauged the patient’s aesthetic expectations for her lips. The patient described herself as having thin lips and wanted to increase the volume of her upper lip so that it better balances her lower. I made the patient aware of the difficulty in treating this lip type and that, for full correction, treatment would require multiple sessions over a prolonged period. I told her that I estimated she would require three to four sessions over a course of six to eight months. The patient was happy with this and expected a gradual improvement over time.

Product selection

I chose to use STYLAGE Special Lips because, in my experience, at 18.5mg/g concentration, the product ensures a soft looking result comparable to natural lips, yet can still provide enough elasticity and volumisation to correct the deficiencies in the patient’s lips. The addition of the antioxidant mannitol also reduces the post-operative swelling and degradation of the product.7 Alternative low density products such as Juvéderm Volbella, Teosyal RHA 2, Belotero Balance and other comparable products may also have been used.

Dr Jasmin Taher describes her treatment approach for patients with ‘M-shaped’ lips and shares a successful case study

Figure 1: Example of a classic ‘M-shaped’ lip. Thin inverted lateral upper lip, dominant medial tubercle, elongated philtral columns and downturned lips.

Figure 2: The patient’s ‘M-shaped’ lips before treatment and the technique used during treatment. The vertical threads are demonstrated in blue, while the linear threads are displayed in white.

After

Figure 3: Patient before and after 3ml of STYLAGE Special Lips, split over three sessions three months apart. After image taken immediately after third treatment.

Treatment

I carried out the treatment over two sessions. Before commencing each one, I cleaned the lips thoroughly with Clinisept+ and applied LMX topically for anaesthesia. I used 1ml of STYLAGE Special Lips during each appointment with the 30 gauge needle supplied with the product. To treat her lips, I used a combination of vertical threads (tenting technique) into the lateral tubercles of the upper lip and linear threads. Placement was superficial into the subcutaneous tissue (Figure 2). In the first treatment session, in the areas that were deficient in the upper lip, I used several overlapping vertical threads through the vermillion border and tented upwards to both increase the vertical height of the lip and fill the curved border of the inner lip. The vertical threads were stopped short of the dry-wet border to reduce the occurrence of lumps. The first entry point was through the peak of the Cupid’s bow, however care was taken to make sure the thread was lateral to the medial tubercle and no product was placed medially. Multiple vertical threads were placed through single entry points in a fanning method, to reduce trauma to the lip. I did not place vertical threads through the entire width of the upper lip, stopping short by about 5-10mm of the oral commissure. Again, this was to ensure the ‘M shape’ was not enhanced and only the deficient areas just lateral to the medial tubercle were volumised. To complete the upper lip, I placed linear threads along the vermillion border medial to the peaks of the Cupid’s bow and medial to the oral commissure, where no vertical threads were placed. This was to ensure uniform definition along the upper lip. In the lower lip, no vertical threads were placed as I did not want to alter the height of the already dominant lower lip and nor did I want to widen the lower lip, which is often seen as a less aesthetically pleasing result.8 In the lateral aspects of the lower lip, there was a deficiency in volume. I chose to place linear threads here to gradually increase the volume and maintain the central roundness of her lower lip. To complete the lower lip, I placed small linear threads along the vermillion border to enhance its definition. I changed my needle four times throughout the treatment to reduce pain due to multiple thread placements. At the end of treatment, I massaged firmly to ensure the lips felt smooth throughout and no lumps could be palpated. I then cleaned the lips with Clinisept+ and applied Derma-Seal to reduce the chances of infection. The second treatment would normally be scheduled for four to six weeks later; however, due to COVID-19 there was a three month delay. Despite this, I believe it aided in the success of her result as the filler had more time to integrate into her lip, while the lip tissue had expanded and became more amenable to the filler. Although the ‘M shape’ remained, we were already prepared for this and embarked upon the second stage of treatment. Again, 1ml of STYLAGE Special Lips was used, however I did not place my vertical or linear threads through the vermillion border; instead, I placed them just inferior. This is because the border was already defined from our previous session, and I did not want to run the risk of overfilling a delicate structure and causing migration of the lip

filler above. The result immediately after our second session showed an improvement in volume and height of the upper lip. The ‘M shape’ of the upper lip had mostly been corrected, with an increase in volume in the lateral tubercles. The ratio between the upper and lower lip also improved. A further improvement was in the length of philtral columns, which considerably shortened, producing a more attractive and youthful appearance.8 Although the shape and volume had improved dramatically, there was still room for improvement as there was some lateral deficiency, so we planned for a further session to correct this area. I also warned the patient that her lips were currently swollen and once the inflammation subsides and the filler integrates fully, the ‘M shape’ may remain in part, hence will require follow-up treatment. Despite this, once the swelling had fully subsided three weeks later, the patient expressed her sincere happiness and gratitude for the treatment and was elated with the result, which had far exceeded her expectations.

When the patient presented a further three months later, on review, the ‘M shape’ had improved drastically with an increase in lateral volume in the upper lip. Although the patient was happy, she wanted full correction, so I proceeded with a similar approach as above, with a focus on correcting the remaining deficiencies in the upper lateral tubercles. The patient and I were happy with the final results and achieved near-full correction of the ‘M shape’, whilst improving the balance between the upper and lower lip. My treatment plan for this patient is now complete and apart from maintenance reviews at nine to 12 months I do not anticipate any additional treatment.

Conclusion

Lip filler can be used to improve an ‘M-shaped’ lip by adding vertical height to the lateral aspects of the upper lip. I encourage practitioners to take care and use a slow approach with a soft product over multiple sessions to ensure the lip tissue gradually expands, minimising the risk of lump formation and migration of lip filler. If practitioners feel they do not have the skills to treat this lip type, I suggest further practical training in lip augmentation, or refer to more experienced clinicians.

Dr Jasmin Taher is a Level 7-trained aesthetic practitioner who runs a clinic in Fulham, London. She is a brand ambassador for VIVACY, and a Derma Medical Trainer. Dr Taher is well known for treating difficult lip cases, such as the ‘M-shaped’ lip.

Qual: BDS(Hons), iBSc(Hons)

REFERENCES

1. Bisson M, Grobbelaar A. The esthetic properties of lips: a comparison of models and nonmodels Angle Orthod 2004;74:162-166.

2. Mandy S. Letter: Art of the Lip. Dermatol Surg. 2007;33:521-522.

3. Redbord, K., Busso, M. and Hanke, C. Soft-tissue augmentation with hyaluronic acid and calcium hydroxyl apatite fillers. Dermatologic Therapy 2011:4(1):71-81.

4. Sarnoff D. Six steps to the “perfect” lip. J Drugs Dermatol 2012; 1081-8.

5. Pierre, S., Liew, S. and Bernardin, A. Basics of Dermal Filler Rheology. Dermatologic Surgery 2015;41:120–126.

6. Lemperle G, Rullan P, Gauthier-Hazan N. Avoiding and treating dermal filler complications. Plast Reconstr Surg 2006;118(3):92S-107S.

7. Ramos-e-Silva, M., Fonteles, L., Lagalhard, C. and Fucci-da-Costa. STYLAGE®: a range of hyaluronic acid dermal fillers containing mannitol. Physical properties and review of the literature. Clin Cosmet Investig Dermatol, 2013;6:257-61.

8. Ivy, R.H. The Philtrum of the Upper Lip. Plastic and Reconstructive surgery, 1967;40(1):94–95.

SkinCeuticals Launches

Tripeptide-R Neck Repair: The Latest Innovation to Target the Neck and Décolletage

Learn more about the insights behind SkinCeuticals’ latest skincare innovation, Tripeptide-R Neck Repair, the award-winning formulation and Miss Jonquille Chantrey’s take on the neck newcomer

Words: Catherine Hufton

Research by SkinCeuticals conducted during a 56-day clinical study has shown that 35% of its consumers* are concerned about skin ageing on the neck, which is almost on par with their worries about crow’s feet around the eyes. Clinics have also reported an increase in requests for clinical neck rejuvenation treatments such as radiofrequency and cryolipolysis.

It was this insight that inspired SkinCeuticals to create Tripeptide-R Neck Repair – its latest innovation that can be used to complement professional treatments and help consumers care for this fragile area of skin from the comfort of their home.

So, what is Tripeptide-R Neck Repair and how does it work? This daily retinol cream is specifically formulated for the neck with a trifunctional formula containing 0.5% glaucine,

2.5% tripeptide and 0.2% pure retinol. Together these potent ingredients help to correct visible neck ageing and complement professional inclinic treatments.

In a 16-week clinical study, Tripeptide-R Neck Repair demonstrated significant improvement in early to advanced signs of neck ageing. Clinically proven to reduce the appearance of horizontal neck lines by up to 16%, neck skin crepiness by up to 27%, and improving neck skin firmness by up to 16%**.

The problem

Why is ageing neck skin such a concern for patients and consumers? First of all, treating ageing signs on the neck is particularly challenging due to its anatomy. From having three times more stretch than the face, lower levels of lipids, constant movement, slower cell turnover, and a thinner texture that leaves it more vulnerable to photodamage and

sensitivity, there are a lot of factors to consider. The skin on the neck is also often left unprotected. This is mainly due to consumers not being sure of which ingredients are suitable for the neck’s delicate skin as actives such as retinol and L-ascorbic acid can cause intolerance. This leads to the neck being neglected in a way that the face isn’t, resulting in pronounced ageing signs such as crepiness, wrinkles (that can manifest five times deeper than that of the face), sagging and discolouration which can be notoriously hard to treat.

The regime

How should it be applied?

Apply a pea-sized amount of Tripeptide-R Neck Repair after cleansing, to clean, dry skin in the morning and evening two to three times per week and build as tolerated. Massage it from the décolletage to the jowl, in an upwards direction, using gentle sweeps of the hand.

The solution

Tripeptide-R Neck Repair is designed to answer the needs of fragile neck skin with a formula featuring a hydrating delivery system combined with Tri-Functional Corrective Technology comprising three powerful ingredients: 0.5% glaucine, 2.5% tripeptide, and 0.2% pure slow-release retinol. Specifically formulated for the neck, it ensures it supports skin’s resistance and delivers improvement in visible signs of neck ageing.

2.5% Tripeptide is known to help increase the skin’s resistance to stretch, improve its capacity to return to its initial state after being stretched, and also increase overall skin firmness.

0.2% Retinol promotes cell turnover so is effective for improving the look of fine lines, wrinkles and discolouration on fragile neck skin, and in a slow release 0.2% potency, it helps minimise irritation. Research also shows that it can help to minimise the appearance of blemishes and refine pores leaving the skin feeling softer and smoother.

5% Glaucine helps reduce collagen-denaturing MMPs, which can be released during adipocyte (fat cell) synthesis.

In clinic: a Q&A with Miss Jonquille Chantrey

To learn more about SkinCeuticals

Tripeptide-R Neck Repair, we spoke to Miss Jonquille Chantrey, a surgeon and Global Key Opinion Leader. She explained how exactly the skin on the neck differs from that of the face, the ingredients to avoid applying directly to this area, and the feedback she’s received from her own patients.

How does the skin on the neck and face differ?

“Different subunits of the face and the neck have different thicknesses of the epidermis and dermis. Various studies have shown the anterior and lateral (front and side) areas of the neck have relatively thinner dermis than on certain areas of the face. As the dermis comprises the fundamental layer of the skin containing collagen and elastin, if this is thinner then early skin wrinkling, uneven texture and tone can be observed.”

Are there certain actives you should avoid putting on your neck?

“Some patients will commonly complain of irritability and redness when retinol is applied. Also certain vitamin C formulations and beta and alpha-hydroxy acids can irritate this area. It isn’t about avoiding the topicals but finding the right formulation at a dose that is efficacious.”

Are your patients concerned with neck ageing?

“Unquestionably. From around 40 across genders, many patients will notice fine crepiness, poor skin quality and a loss

What products can it be used alongside?

Start your morning routine with C E Ferulic serum and follow this with Tripeptide-R Neck Repair. As this treatment contains retinol, it can be used alongside a moisturiser for age-related dryness such as SkinCeuticals Triple Lipid Restore 2:4:2, both morning and night. If your concern is more about loss of firmness, substitute this for A.G.E Interrupter. Both of these rich creams will help to replenish lipids while acclimating skin to retinol usage. SkinCeuticals also recommends following it with a high-protection, broadspectrum sunscreen in the daytime.

How often should it be used?

Consumers are advised to start applying

of elasticity to their neck skin as well as the vertical platysma bands that can contribute to the loss of the mandibular line. Horizontal necklace lines may present much earlier and can often have a genetic component to them. Submental fullness, facial fat compartment descent, skin elastosis, class 2 occlusions and retrognathia can all impact the jawline and neck. With the advent of increased self-awareness on video calling, even more patients are concerned with the appearance of the area from mandible to décolletage.”

Do

you recommend any in-clinic treatments to correct neck ageing?

“I talk to my patients a lot about neck ageing and in this anatomical area, prevention is so important. First and foremost I educate patients regarding the skin. Using an antioxidant such as C E Ferulic paired with a sunscreen is obviously essential. Some peels may be used in certain patients feathered down onto the neck area. As we need to increase skin firmness and reduce the appearance of lines, a retinol is recommended, but until now it has been challenging to find a retinol topical that patients can tolerate on the thin neck skin. The new Tripeptide-R Neck Repair is therefore an exciting option for us to help our patients as it contains retinol at 0.2% which has been well tolerated and shown efficacy in early studies.”

“For the horizontal neck lines and skin hydration I use skin conditioning hyaluronic acid gel. I performed the seminal European study on this product and we treated the neck extensively. Finally, high focused ultrasound and radiofrequency platforms to help to target SMAS and dermal tightening.”

Tripeptide-R Neck Repair once or twice a week initially. After one week, consumers may wish to increase their usage to nightly then twice a day, but they should speak to their skincare professional for recommended advice and also take note of their skin’s tolerance levels.

Important notes for practitioners

This product includes retinol so it is important to advise patients to follow with a broad spectrum sunscreen.

The results

In a 16-week clinical study, conducted on 50 females aged between 40-60 with mild to moderate sagging on the neck, Tripeptide-R

This advertorial was written and supplied by SkinCeuticals

Email: maddy.lewis@loreal.com

Neck Repair was used nightly as tolerated in conjunction with sunscreen and increased to twice daily after one week. The study showed that the treatment significantly improved multiple visible signs of neck ageing:

• 27% average improvement in neck skin crepiness

• 16% average improvement in the appearance of horizontal neck lines

• 16% average improvement in neck skin firmness

• 13% average improvement in the appearance of neck skin sagging

• 28% average improvement in neck skin smoothness

*38% of SkinCeuticals customers are concerned about crow’s feet **56-day clinical study 50 subjects. Measuring improvement of score from visual grading

This article reflects the opinions of Miss Jonquille Chantrey and is intended as general information only. Patients should be encouraged to seek advice from a professional before starting any new regime or course of conduct.

Optimising Non-Surgical Threadlifting

One of the main demands of patients seeking cosmetic treatments is to achieve a lift. The drooping of cheeks results in formation of nasolabial folds, marionette lines and jowls which contribute to the ageing look. A lot of cosmetic treatments aim to tighten, pull and lift these to provide a youthful appearance. The use of polydioxanone (PDO) and poly-L-lactic acid (PLLA) threads is a common treatment approach that aims to offer a non-surgical facelift. In this article, I share two case studies to demonstrate the use of silicone-based permanent threads to achieve what I believe to be a greater lift that is longer lasting.

Risk profile of using permanent threads

Permanent threads are different from absorbable threads. The latter usually rely on bio-stimulation rather than suspension and provide shorter-term results. The aim of permanent threads is to mimic connective tissue that has become slack over the years. There are a number of practitioners who are hesitant to use permanent threads as they believe that permanent products cause permanent problems. However, the literature suggests that this is not necessarily true. A multi-centric study, performed in 2010 by Somerefs with 110 patients whose results corroborate those of international literature, showed that serious complications from permanent suspension threads are not common.1

The main complications of this procedure are infection, persistent pain, spontaneous extrusion of thread, visibility of the implanted thread and psychological problems, which are all correctable. Infection to the skin is treated with antibiotics such as flucloxacillin or clarithromycin. However, on the rare occasion that the thread itself is the source of infection, it must be surgically removed and antibiotics used to clear the remaining infection. Removal of the thread is performed by injecting local anaesthesia along the path of

the thread. A small lancet is used to open the skin and a Willis or Muller is used to catch the thread and pull it out, while massaging the skin to release the notches of the thread. This allows it to be removed in its entirety without breakage and without scarring.2 Persistent pain can arise around the temples if the thread crosses over the temporal branch of the facial nerve. If analgesics alone are not effective, a subcutaneous separation may be needed under local anaesthesia. In rare circumstances, thread removal may be needed. On occasion, the thread may migrate and protrude from the skin. In these cases, the thread can be easily removed by pulling it under local anaesthesia. If the thread is implanted too superficially or pulled too tight, it can be visible. A superficial thread would need removal and to be replanted. If the skin is under too much tension due to being pulled too tight, this tension can be released by simply massaging the area, as long as it is done within two weeks of the procedure before any fibrosis sets in. The dimpling of the tense skin can be disguised using hyaluronic acid filler.2 As with any treatment, patient selection is important. This treatment is suitable for patients who don’t want surgical lifting or have had a surgical lift previously with results starting to fade. I have found that the permanent thread works well for moderate ptosis with good skin quality. In my experience, it is best avoided in patients with severe ptosis, heavy tissue and extremely wrinkled skin. As with other threadlifting procedures, the usual contraindications of pregnancy, breast-feeding, isotretinoin and anticoagulants apply. Finally, the psychological impact of any cosmetic treatment needs to be appreciated. Sometimes, even if the result appears good to the practitioner and other people, the patient may find it difficult to adjust to the new, albeit improved, look and may consider it as a disfigurement. The fragile psyche is best judged pre-treatment during the consultation process. It is important to offer removal of the thread to empower the patient. The use of before and after pictures and explanation in a calm manner can help reduce anxiety.

Product selection

There are around five main permanent suspension threads on the market.2 These mostly use long needles, contain bi-directional notches, and are made of polypropylene.2 My product of choice is Spring Thread.

Figure 1: Location of thread placement

It is a flexible and elastic thread that is 300mm in length with long bluntend needles at each end and contains 24 tiny cogs per cm that point in four directions.3 The thread has a similar elasticity to skin of around 20%, allowing it to move with facial expressions.3 The thread suspends the underlying skin tissue, thus lifting sagging skin. It is made from siliconecoated polyester,2 which is

Dr Usman Qureshi demonstrates the treatment of facial ptosis using permanent silicone threads for longer lasting results

an inert biocompatible material that is readily accepted by the body. The thread remains in the skin permanently, increasing the longevity of the results and, as fibrosis forms around it, produces excellent fixation and collagen regeneration for several months, which means that results continue to improve after implanatation.1,4 The overall results last more than three years1,4 and with advanced techniques involving undermining and anchoring to the periosteum, the results can extend to five years, after which further threads can be implanted.1,4 This is a simple procedure that takes around two hours of clinic time, but around 30 minutes for actual insertion.

Case study one: female patient

A 63-year-old patient (Patient 1) with no significant past medical history presented to clinic. Her main complaint was sagging skin, forming jowls, nasolabial and marionette folds. She did not have much volume loss and her skin quality was good. She felt that facial heaviness in her lower face that made her appear older and tired and wanted the folds lifted up. During her consultation we established that permanent threads would be the best treatment option for her because she wanted tissue lifting, without the risks associated with a surgical facelift. There are several techniques used to implant these particular threads.5 The one used for Patient 1 is the basic straight lay technique which would give longevity of three years.5 The skin and scalp were prepared using a disinfectant (Inadine and Clinisept+). Three

entry points were marked 5mm apart over the zygomatic process of the temporal bone. The path of each thread was drawn using a permanent marker from the entry point to the exit point in the lower face. The thread from the most anterior entry point exited anterior to the nasolabial fold on the upper lip, the thread from the middle entry point exited in front of the marionette fold under the lower lip, and the most posterior thread exited in the jowl under the mandible (exemplified in Figure 1).

The skin was cleaned again and lidocaine 2% was injected in the three entry points on each side of the face. A 21 gauge needle was used to puncture holes at the entry points. A 22 gauge cannula was used to inject lidocaine 2% in the tract of the threads in the cheek and in the scalp. The blunt needle attached to the thread was inserted perpendicularly at the entry point to a depth of 2-3mm. It was then turned to be parallel to the skin in the subcutaneous fat layer. It was advanced towards the exit point in the lower face. A 21 gauge needle was used to puncture the exit point. The blunt needle was then advanced through this. The other end of the thread was advanced with the blunt needle and exited in the scalp at least 5cm away from the entry point. Once all six threads were placed, each thread was tightened by first pulling the end at the lower face, with counter traction applied to the cheek. Then the scalp end was pulled anchoring it into place. Six threads were used in total, with three on each side. A slight over-correction was left in place in the form of skin bunching anterior to the ear, which will resolve itself over two weeks and the initial over-correction allows maximum lift to be achieved. The thread ends were cut flush with the skin. The patient was advised to use paracetamol and ibuprofen to help with discomfort. She was asked to return in five days, at which point she felt that her left side was over-stretched. I released the tension by gently massaging over the cheek until clicking was felt and the skin appeared relaxed. In my experience, any correction is best done in the first week before fibrosis starts, so it is important to see the patient during this time. She was then seen again 14 days post treatment to check for any infection or delayed healing. No intervention was needed at that time. The patient was really pleased with the result and felt that she looked more youthful and less tired.

The patient had a good result from the procedure with improvement of the nasolabial fold, mouth corner, marionette area and the jowl. She maintained a natural appearance without signs of over tension. The repositioning of the skin also helped improve the tear trough area and produced more definition around the cheeks.

Case study two: male patient

A 47-year-old man with no significant past medical history presented to clinic. He felt that his mid and lower face heaviness aged him and gave him a grumpy look. He had previously had dermal fillers injected for cheek volume. The patient wanted to look good for his age, with the lower face jowls pulled back, and sought a procedure that enabled him to return to work in a week. He did not want to undergo surgery or general anaesthesia. He wanted lifting of the lower and mid-face that would last a few years.

The same procedure as Patient 1 was used; a total of six permanent threads were place with three on each side. I was able to apply a good amount of tension to the threads compared to Patient 1, without formation of skin folds at the ears. This was due to the firm nature of the male skin compare to a female.

The patient was seen at day five for review and no adjustment was needed. He was then seen at day 14 when the post-procedure pictures were taken. The patient was very happy with his appearance

This treatment is suitable for patients who don’t want surgical lifting or have had a surgical lift previously with results starting to fade

Figure 2: The 63-year-old patient before, immediately after and 14 days after the insertion of Spring Thread silicone-based permanent threads.

Before Immediately after 14 days after

and felt that it had taken 10 years off his age. He stated that the result was far greater than he had expected, especially given the fast procedure and recovery time.

The patient had a great result. He had a slight improvement in the nasolabial fold but a much greater lift around the marionette and jowls. The natural look of the face was maintained without an over stretched appearance.

Conclusion

Permanent threads can help to fill the gap between the dissolving PDO/PLLA threads and surgical facelift. The procedure can be performed under local anaesthetic, has a low downtime, the lift produced is substantial and the results can last three to five

years. I find that the procedure is well tolerated by patients and the basic straight lay technique is easy to master. The risk profile is broadly similar to PDO and PLLA. In my experience, the two biggest factors that stand it apart from dissolving threads is the longevity and the amount of lift achieved. I believe that more detailed peerreviewed studies with a large cohort of patients are needed to further substantiate these findings.

Dr Usman Qureshi is an aesthetic practitioner at Luxe Skin Clinic in Glasgow. He started cosmetic practice in 2012 and now carries out advanced toxin, dermal filler and threadlifting procedures. Dr Qureshi focuses on full face rejuvenation by combining the above procedures. He still works part-time as a GP in accident and emergency.

Qual: MBChB, DRCOG, MRCGP*

*Currently not a fee paying member of the Royal College of General Practitioners.

REFERENCES

1. J.P Foumentezee, D Guillo, G Jeanblanc, ‘Multi-centric retrospective clinic study for suspension thread SPRING THREAD’, Somerefs (2010).

2. D. Guillo et al. Notched suspension threads – typical complications and solutions. J. Méd. Esth. et Chir. Derna. Vol. XXXIX, 153, March 2012, 17-24.

3. Spring Thread <https://springthread.com/technology/>

4. Data on file with Dr Usman Qureshi and available from Mesostrata Limited.

5. D Guillo et al. Lifting via permanent notched suspension. J. Méd. Esth. et Chir. Derm. Vol. XXXXIII, 172, December 2016, 215-226.

Figure 3: The 47-year-old patient before, immediately after and 14 days after the insertion of Spring Thread silicone-based permanent threads.

Before Immediately after 14 days after

Managing Acne During Pregnancy

Dr Ravi Brar explores the best ways to treat pregnant women presenting with acne

Acne is one of the most commonly presented skin conditions worldwide, with more than 90% of the world’s population affected by the condition at some point during their lives. It usually starts at puberty and varies in severity on areas of the face (99%), back (60%) and chest (15%).1 Acne is also a common in pregnancy. More importantly, for women who are planning a pregnancy or who are already pregnant, it can be bothersome due to the unpredictability of the condition and the fact that the most effective treatments are contraindicated. This is because of the ethical concerns of testing on pregnant women where treatments could always have the potential to cause harm to the foetus.2 Because of its complexity, it is important for practitioners to be aware of the best ways to assess and treat pregnant women who present with acne.

What causes acne?

Acne is characterised by open comedones (blackheads) and/or closed comedones (whiteheads), in addition to papules and pustules (pus-filled spots). In cystic acne, patients develop more inflamed nodules and cysts.3 While acne can have a genetic predisposition, in most cases it is sporadic and occurs for unknown reasons. There is

still debate amongst specialists as to why acne develops, but we know it is a disorder of the pilosebaceous unit (hair shaft, the hair follicle, the sebaceous glands, and the erector pili muscle).2,3

Acne in pregnancy

Whilst acne can develop in pregnant women who have never experienced it before, it is more likely to develop in individuals who had acne in their early years, typically occurring in their third trimester.2,4 This is thought to be due to an increasing level of androgen hormones, which are important to prepare the cervix for delivery,4,5 causing an increase in the skin’s sebum production and triggering the acne-formation cycle.5

Case studies have shown that acne lesions tend to be more inflammatory than noninflammatory in pregnancy, and often have truncal involvement.6 A weaker immune system during pregnancy is one likely cause for this pattern of presentation.5,7,8

Examination

When thinking about the best treatment for acne it is imperative to carry out a thorough examination, during which five key features should be focused on:

1. Distribution: as acne is a disease of the pilosebaceous unit, the distribution

will correspond to those areas with the highest density of the units e.g. the face, back and chest. On the face, lesions usually cluster on the chin, cheeks and forehead.4

2. Lesions: these can be divided into noninflammatory and inflammatory, and any one patient can have a combination of different lesions. Non-inflammatory lesions can be closed where the follicular opening plugged with dark keratin and sebum is visible.6 Alternatively, the patient may have inflammatory lesions, meaning papules and pustules (superficial inflammatory lesions) or nodules and cysts (deep inflammatory lesions).4

3. Scarring: this can occur in those with severe acne and deep lesions (nodular/ cystic), who delay their treatment or who pick or squeeze the spots. It occurs secondary to the inflammatory reaction and, when the body tries to repair the skin, can lead to uneven deposition of new collagen with excessive raised areas or insufficient depressed areas, continuous redness from dilated blood vessels, and post-inflammatory hyperpigmentation.9

4. Erythema: this is important as it may be present secondary to underlying inflammation, however telangiectasia is NOT a feature of acne alone.4 If present, practitioners should consider a co-existing condition, for example rosacea.

5. Severity: acne may be classified as mild, moderate or severe. Comedones and inflammatory lesions are usually considered separately.4 In reality most medical professionals use their clinical judgement to define the severity, but these three classifications are used in research protocols:10

• Mild acne: <20 comedones

<15 inflammatory lesions Or total lesion count <30

• Moderate acne: 20-100 comedones

15-50 inflammatory lesions or total lesion count 30-125

• Severe acne: >5 pseudocysts >100 comedones

Total inflammatory count >50 or total lesion count >125

Treatment

When discussing acne treatment in pregnancy, it has to be balanced with the severity of the condition and the safety profile

of the treatment proposed. Topical therapies are generally accepted as the preferred treatment for mild to moderate acne, with more combination creams now available. Treatment ranges from topical through to oral medication in severe acne.

Topical therapy

Various topical therapies that can be used to treat pregnant women include:

• Azelaic acid: has antimicrobial, comedolytic and mild anti-inflammatory properties.2 In addition, it helps to reduce pigmentation (10% concentrations are available over the counter, higher strengths of 20% require a prescription).2,5,7

Animal studies have shown <4% of the medication is absorbed systemically.2 It is often the first choice of topical treatment during pregnancy and has an added benefit of helping post-inflammatory hyperpigmentation.2

• Benzoyl peroxide (up to 5%): acts in a similar way to azelaic acid. Moreover, it helps to prevent the development of resistance when used in conjunction with antibiotics (topical and oral) as its antimicrobial property is through generating oxygen radicals.2 Animal studies have shown <5% gets absorbed systemically, which then gets broken down very quickly and cleared rapidly via the kidneys.2 This low absorption and rapid clearance means the potential risk in pregnancy is low.2

• Alpha hydroxy acid (AHA) fruit acids: glycolic acid helps to exfoliate the skin, thus eliminating follicular obstruction.5 Reports have shown that it helps in both inflammatory and comedonal acne.5 Moreover, it increases the skin’s absorption of other topical agents.5 Published reports have documented the safe use of topical glycolic acid in pregnancy. One such study reported statistically non-significant absorption of the acid in 25 pregnant rats, thereby indicating its safe use.6

• Antibiotics: it is important to remember not to use antibiotics as monotherapy due to the increased concerns of resistance. The two key antibiotics that are safe and commonly used are clindamycin and erythromycin (both topically and orally).5 There have been no increased rates in adverse outcomes documented in several

studies evaluating topical and systemic use of clindamycin and erythromycin in all trimesters.2,5,7 An example being a surveillance study by Biggs et al., which reported no increased risk of malformations among 647 women using oral clindamycin.5

Case studies have shown that pregnant patients with mild acne, suffering from primarily non-inflammatory lesions, respond well to topical azelaic acid or benzoyl peroxide.5 If there are inflammatory lesions, a supplementary topical antibiotic can and should be introduced.7 In fact, a combination of benzoyl peroxide and clindamycin is shown to be superior to using them individually and decreases the risk of antibiotic resistance.5

Topical therapies to avoid

There are topical therapies not safe to use during pregnancy that practitioners should also be aware of, for example:

• Retinoids: there have been case reports of birth defects in babies from mothers who had prenatal exposure, similar to those who had taken oral vitamin A.2 As safety data is limited in the pregnant population and with the risk of teratogenicity, the general consensus is to avoid its use in women who are looking to become or are pregnant.

• Salicylic acid: rat studies have shown malformation changes in embryos (cardiac malformations).2 It is considered

that salicylic acid should not be the first treatment of choice and, if it was to be used, it should be done so in low concentrations (no more than 2%) for limited durations.2,4

It should be noted that although some of these treatments can be bought over the counter, patients must consult their medical practitioner before starting to confirm the safety of the active ingredients.

Oral therapy

Before starting systemic therapy, a discussion of risk versus benefit must be taken with the patient to help decision making. Moderate to severe acne, or acne not responding to the above topical treatments, often requires an addition of oral antibiotics. Erythromycin and clindamycin are again the antibiotics of choice for oral administration in view of their safety 2

Oral therapies to avoid

The following oral treatments must be avoided:

• Tetracyclines (e.g. doxycycline, minocycline, lymecycline): these are the most common types of antibiotics used in non-pregnant acne suffers. Animal studies have shown teratogenicity and fetotoxicity, including toxic effects on foetal bone and discolouration of teeth.2

• Trimethoprim: another very commonly used antibiotic in non-pregnant acne suffers. A cohort study by Anderson

It is extremely vital that we educate all patients on the importance of having a good skincare regime, especially pregnant patients as their options for active treatment are limited

et al. in 2012 highlighted that the use of trimethoprim doubled the rate of miscarriage especially if used in the first trimester.7 There has also been concern of its use in regards to increasing the risk of cardiac defects and oral cleft.2

• Oral retinoids (e.g. isotretinoin): must be avoided at all costs due to the risk of severe teratogenicity (craniofacial, cardiac and thymic malformations).2 This is evident by the pregnancy prevention programme that patients must sign when starting oral isotretinoin, and the advice that they should be using two forms of contraception.

Light therapy

Light-emitting diode (LED) therapy is also safe to use in pregnant patients and is done so in adjunct with other treatments (oral and topical).2,11 LED can treat acne by stimulating collagen formation, decreasing inflammation, shrinking sebaceous glands and killing bacteria:2,11

• Red light therapy penetrates more deeply than blue light, thereby stimulating fibroblast activity and leading to increased collagen production.2,11 It can also modify cytokine activity which decreases local inflammation.2,13

• Blue light therapy is especially effective against P.acnes, as this bacterium produces a porphyrin that is stimulated by the blue light leading to photoexcitation and thereby bacterial destruction.12

Further data on these methods is still required, especially when it comes to the optimal dosing for treatment.

Skincare

It is extremely vital that we educate all patients on the importance of having a good skincare regime, especially pregnant patients as their options for active treatment are limited. Patients who suffer from acne or who have acne-prone skin should use a light skincare regime, ideally products labelled ‘noncomedogenic’. There are no guarantees that these products won’t cause the skin to break out, but they have been shown to be better suited for this skin type. Non-comedogenic products avoid high comedogenicity acids and their salts, especially isopropyl form (myristic, stearic, palmitic, lauric acid), algae extracts, and foaming agent sodium lauryl sulphate (SLS), thereby lowering the risk of triggering

the acne formation cycle.12 There has been a shift to use paraben-free skincare products, in spite of paraben being non-comedogenic. This is because some studies have shown this preservative to be associated with skin damage.13

Follow up

Patient follow-up is vital and although there is no set guidance on this, I always arrange to see my patients four to six weeks after starting any treatment. The effects of the treatment may only be subtle but it allows for me to review how the patient is tolerating the treatment(s), check adherence and gives the patient an opportunity to ask any questions that they may have. Following this I schedule a follow-up depending on the patient’s severity, but all my patients have an emergency number that they can call so they have full access to the clinic.

Postpartum

There is no concrete timeframe to if/when the skin will clear postpartum, especially if the acne was present prior to the pregnancy. However, as hormone levels and other pregnancy-related changes return to baseline, the skin will likely start to clear. It is important that the skincare regime is continued and active ingredients, such as vitamin A, that could not be used during pregnancy, can be introduced. This is done after a review and another examination of the skin – essentially starting the process from the beginning as a ‘non-pregnant’ patient (taking breastfeeding into consideration).

Summary

It is very important to take a good history, perform a detailed examination, review the patient’s general skincare regime and discuss active ingredients in depth. In my opinion, each patient needs to understand their skin, especially in pregnancy as it can be unpredictable, and only then can you start to advise on treatment.

Acne treatment in pregnancy should focus on topical preparations, as they have the best safety profile and have the least risk of systemic absorption. Good results can be achieved if applied appropriately and patients adhere to the treatment plans. Nevertheless, we must remember that acne can have a psychological impact on any person and should not be ignored, in spite of the challenges in managing it.

Dr Ravi Brar is the co-director of sk:INSPIRE Medical Aesthetics and graduated from Guys and St Thomas’ Medical School. He is a member of the Royal College of General Practitioners and accomplished a Postgraduate Diploma in Clinical Dermatology from Queen Mary University London, with Distinction. Dr Brar continues to work within the NHS as well as running sk:INSPIRE. Qual: MBBS, Bsc (immune), MRCGP (Lon), PgDipClinDerm (Dist)

REFERENCES

1. Harald P.M Gollnick. Acne and Related Disorders. Textbook of Clinical Paediatrics. 2012. 1447-1446.

2. Fiona Meredeth and Anthony Ormerod. The management of Acne Vulgaris in Pregnancy. American Journal of Clinical Dermatology. 2013. 351 – 358.

3. Kurt Gebauer. Acne in Adolescents. Australian Family Physician 2017; 46(12): 892-895.

4. Amanda Oakley, Vanessa Ngan, Clare Morrison, 2014 <https:// dermnetnz.org/topics/acne-in-pregnancy/>

5. Anna L. Chien, MD, Ji Qi, BA, Barbara Rainer, MD, Dana L. Sachs, MD, and Yolanda R. Helfrich, MD. Treatment of Acne in Pregnancy. Journal of The American Board of Family Medicine March 2016, 29 (2) 254-262

6. Alan Andersen . Final report on the safety assessment of glycolic acid, ammonium, calcium, potassium, and sodium glycolates, methyl, ethyl, propyl, and butyl glycolates, and lactic acid, ammonium, calcium, potassium, sodium, and TEA-lactates, methyl, ethyl, isopropyl, and butyl lactates, and lauryl, myristyl, and cetyl lactates. Int J Toxicol. 1998;17:1–241.

7. Saqib Ejaz Awan and Jianchun Lu. Management of severe acne during pregnancy. A Case report and review of literature. International Journal of Women’s Dermatology. September 2017; 3 (3): 145-150.

8. NHS, <https://www.nhs.uk/common-health-questions/ pregnancy/why-are-pregnant-women-at-higher-risk-of-flucomplications/>. 2020

9. Dr Amanda Okley, <https://dermnetnz.org/topics/acnescarring/>, 2014

10. Dr Amanda Oakley, <https://dermnetnz.org/topics/acnevulgaris/>, 2014

11. Kate Rose, Naturopathic Doctor News and Review, <https://ndnr. com/womens-health/acne-during-pregnancy-safe-approachesto-treatment/> 2020

12. Varsha Naraya. Holistic skincare and selection of skincare products in acne. Archives of Clinical and Experimental Dermatology. 2020.

13. Natalia Matewiejczuk, Anna Galicka and Malgorzata Brzoska. Review of the safety of application of cosmetic products containing parabens. Journal of Applied Toxicology. 2020. 176-210.

Case Study: Delayed Onset Nodules

Independent

Complications caused by filler injections are generally categorised by their timing from when the initial injection took place. A complication which occurs within days post treatment will be classed as an early event, whereas a delayed reaction will be classified as an event that occurs weeks to years post injection.1

The variation between aetiology and clinical presentations can make delayed onset nodules (DONs) more challenging to address or prevent.2 A DON is described in the literature as a palpable or visible unintended mass that occurs close to or at the injection site of dermal filler. It may appear weeks or even years after the initial treatment.3 Once identified by the practitioner, a DON can then be further categorised as inflammatory or non-inflammatory. An inflammatory nodule may be characterised by pain, tenderness, swelling, heat and erythema.4

Even though DONs remain a rare complication, they are now being recognised more often. A four year retrospective study published in 2006 of 4,320 filler treatments found only a 0.6-0.8% incidence in hypersensitivity reactions; 5 however, a more recent study in 2019 found that of 1,250 patients receiving filler treatment the incidence of DONs were 1.0%.6

There is a lack of robust evidence as to which patients are more susceptible to DONs, but occurrence appears to be more common in immune reactive patients.7 As such, it would be reasonable to exercise a particularly cautious approach in treating a patient with an active autoimmune disease. Increasing evidence is emerging that shows a link between cold and flu viruses and the onset of delayed hypersensitive reactions, with some studies pointing to a rise in reported reactions in the autumn and winter ‘flu season’.8,9

It is important for practitioners to be aware of the possibility for DONs to occur and to be able to proficiently deal with the complication should it arise in their practice. It is also important to be able to inform and educate patients of any possible complications prior to treatment.

Case study

Initial treatment

My patient was a 50-year-old female, who had not previously had any non-surgical procedures. She came to see me concerned about sagging to the jowl area and loss of volume in the mid-face. My patient was fit and well, only taking hormone replacement therapy medication. Following her initial consultation we planned to inject 1ml of a 20mg/ml hyaluronic acid, high G-prime, high cohesivity filler into each cheek in order to support the mid-face, increase volume to the area and begin to improve the ‘sag’ of the jowl area.

On the day of the procedure the patient’s skin was cleaned with Clinisept+ and a sterile wound care procedure pack was used. No topical anaesthetic was used on the skin and the hyaluronic acid filler contained lidocaine. I injected the hyaluronic acid filler following the MD Codes technique. I injected each cheek with 3x0.1ml boluses to periosteum to CK1 with a 27 gauge needle, 0.3ml bolus to periosteum at CK3, followed by 0.4ml via a 25 gauge cannula to the deep dermis at CK3 using a fanning technique. The treatment presented no immediate issues and the patient was happy with the results. The patient was given standard post-procedure advice which included not touching/massaging the treated area, avoiding extreme heat/cold, vigorous exercise, avoiding make-up use for 24 hours and avoiding alcohol for 48 hours. The patient reported that she followed the aftercare advice.

The patient returned eight weeks later requesting further treatment. Her previous filler had settled well and she liked the increased volume to the mid-face area, requesting a further 0.5ml of hyaluronic acid filler to each side. Again, the MD Codes technique was used and a bolus to periosteum of 0.3ml of the same hyaluronic acid filler was injected to periosteum via a 27 gauge needle at CK3, 0.2ml bolus to periosteum at CK2. Once again, the patient experienced good results.

The complication

Four months after the initial treatment I was contacted by the patient to say she had developed swellings in the mid-face area, so I asked her to attend the clinic for a review. In this consultation, it is important to look at the patient holistically by conducting a physical examination and taking a full history.

Figure 1: Patient before and immediately after treatment, then four months later when she presented with DONs. Note that the DONs were not visible but could be felt.

You should ask them questions such as whether there had been any illness leading up to the event, if there had been any changes in medication or if they had undergone any surgery. It would also be wise to enquire if the patient had seen another practitioner following her initial treatment with yourself and had any further aesthetic treatments that you may not be aware of. The patient did not report any changes to their medical history, nor any periods of illness prior to the nodules appearing, although reported a period of increased stress in her personal life, which was unlikely to be related in this case. When examining the face, check for a normal barrier function or any skin problems in the area. There was a 4cm smooth palpable mass to the patient’s left cheek and a smaller 2cm smooth mass to the right cheek. Both cheeks were tender to touch, but no erythema was seen and no heat could be felt in the area. The nodules were not visible to the eye but the patient reported feeling self-conscious and was concerned that other people may be able to see them. Straightaway it is important to determine whether the nodules are inflammatory or non-inflammatory, as this will determine the treatment plan. A non-inflammatory nodule will generally present as a pain free, firm, cool, regular shaped mass and no redness will usually be seen. An inflammatory nodule will present itself with pain, heat, erythema and swelling.4,10 In this case it was determined that the nodules were inflammatory due to the delayed onset and the tenderness and discomfort to the patient. No other skin conditions were noted. Treatment options were discussed in detail, including the possibility of dissolving the filler, however the patient had been really happy with her results prior to this and so was keen to try to rectify the nodules without doing so. It was agreed that the plan would be to try to reduce them using a combination of treatments, but I could not rule out having to dissolve them in the future, so we agreed to review progress on a regular basis. If the nodules had been non-inflammatory then the suggested course of action would have been to watch and wait if they were not troublesome to the patient, or to dissolve using hyaluronidase if they were of concern.2

Initially, clarithromycin 500mg twice per day was prescribed to the patient for two weeks. The antibiotics were prescribed according to the Aesthetic Complications Expert (ACE) Group guidelines3 and their use as a first-line treatment is also recommended in a 2020 study on delayed onset inflammatory nodules.2 A further study carried out in 2009 supports the use of antibiotics as a first-line treatment for DONs. The study observed 55 patient reactions to polyacrylamide gels, thought to be caused by low virulence bacteria, and those patients who received steroids or non-steroidal anti-

inflammatory as a first-line treatment, rather than antibiotics, had a significantly worse prognosis in comparison to the group where antibiotics were used in the first instance.11

I kept in contact with the patient regularly and reviewed her face-to-face at two weeks following her completion of the prescribed antibiotics. The nodules had dramatically reduced and were 2cm on the left side and 1cm on the right side. There was no erythema or heat but some tenderness remained. I then prescribed prednisolone 40mg once a day for seven days, reducing by 5mg per day for a further seven days to reduce the nodules further. The use of steroids to reduce inflammatory conditions are well documented in traditional medicine, however in aesthetic medicine appear to be more at the discretion of the prescribing practitioner and are not documented in the ACE guideline algorithm for treatment of DONs,3 although several studies support their use in successfully resolving inflammatory nodules.2,9

I reviewed the patient again after another 14 days and the nodules were resolved following two weeks of antibiotics and two weeks of steroids. I checked up on the patient on a weekly basis for the next four weeks and the patient reported no further issues.

Summary

This is an example of successful management of DONs without the use of hyaluronidase. It’s widely accepted that delayed inflammatory nodules have infection as their underlying cause and first-line treatment with antibiotics is considered best practice. Practitioner variations will follow in further treatment and is best practised on a case-by-case basis, but treatment with steroids, non-steroidal anti-inflammatories and hyaluronidase are all supported as successful treatment options within the literature.

Caroline Hall is an independent nurse prescriber and the owner of R&R Aesthetics in Leeds. She worked as a nurse and midwife within the NHS for 14 years before becoming a full time aesthetic practitioner in 2016.

Qual: RGN, RM, Bsc Hons, INP

REFERENCES

1. Lowe NJ, Maxwell CA, Patnaik R. Adverse reactions to dermal fillers: review. Dermatol Surg. 2005;31(11 Pt 2):1616–1625.

2. Philipp-Dormston WG, Goodman GJ, De Boulle K, et al. Global Approaches to the Prevention and Management of Delayed-onset Adverse Reactions with Hyaluronic Acid-based Fillers. Plast Reconstr Surg Glob Open. 2020;8(4):e2730.

3. M King, S Bassett, E Davies, S King. Management of Delayed Onset Nodules. Aesthetic Complications Expert Group. Review date 2017.

4. Sclafani A, Fagien S. Treatment of injectable soft tissue filler complications. Dermatol Surg 2009;35:1672-1680

5. Funt D, Pavicic T. Dermal fillers in aesthetics: an overview of adverse events and treatment approaches. Clin Cosmet Investig Dermatol. 2013;6:295-316.

6. Sadeghpour M, Quatrano NA, Bonati LM, et al. Delayed-onset nodules to differentially crosslinked hyaluronic acids: comparative incidence and risk assessment. Dermatol Surg. 2019;45:1085–1094.

7. Ledon JA, Savas JA, Yang S, et al. Inflammatory nodules following soft tissue follow use: a review of causative agents, pathology and treatment options. Am J Clin Dermatol. 2013;14(5):401–411.

8. Humphrey S, Carruthers J, Carruthers A, Clinical experience with 11,460ml of 20mg/ml, smooth, highly cohesive, viscous hyaluronic acid filler. Dermatol Surg. 2015 Sep; 41(9):1060-7.

9. Turkmani MG, De Boulle K, Philipp-Dormston WG. Delayed hypersensitivity reaction to hyaluronic acid dermal filler following influenza-like illness. Clin Cosmet Investig Dermatol. 2019;12:277–283.

10. Bhojani-Lynch T. Late-Onset Inflammatory Response to Hyaluronic Acid Dermal Fillers. Plast Reconstr Surg Glob Open. 2017;5(12):e1532.

11. Christensen LH. Host Tissue Interaction, Fate, and Risks of Degradable and Nondegradable Gel Fillers. Dermatol Surg 2009;35:1612-1619.

Before Four months after, presenting with DONs Immediately after

Introducing Neofound

Following the success of their bio-remodelling product Profound, Love Cosmedical have gone one step further in their aim to provide high quality skin rejuvenation and bio-stimulation products that have a global approach. The brainchild of Italian surgeon Dr Roberto Amore, owner of Love Cosmedical, Neofound has been designed for maximum aesthetic effect.

Meet Neofound’s Creator

Dr Roberto Amore’s research and development over the last eight years has produced innovative products such as: Desobody, Desoface, Strikecell cellulite treatment, Profound, UP dermal filler and Peppermint Peel. He believes the integration of more preventative products can complement the already mature and existing curative market. With patient outcomes firmly in mind, he stresses current treatment plans should always include an element of bio-remodelling: laying and then building on those solid foundations.

The Neofound Concept

Neofound is a fully conceived bio-remodelling product, not just a volumiser. It has been designed to brighten, whiten and tighten the skin. It achieves this by targeting and feeding the skin at a cellular level, irrespective of age or skin type. The younger patient will experience a tighter feel, more volume with collagen stimulation providing a healthy, hydrated glow. Mature skin will also see more volume, improvements on hard and fine wrinkling as well as the restoration of elasticity. In addition, patients who suffer from severe pigmentation, such as melasma, have found huge benefit from Neofound’s global approach. With a full treatment plan, patients can see significant impact in lightening and equalising the skin tone. This is a far safer technique than using corrosive elements on the skin. Neofound provides practitioners with the perfect addition to their toolbox; it is both preventative and curative in its approach and aesthetic impact.

A Treatment For All Types

Treatment times are 15-20 minutes per area, and the dosage for each treatment may vary between 1.0-1.5ml, keeping cost and time to a minimum. With 20-30 minutes downtime, patients see fast results, making a huge difference to patients’ lives and confidence.

Suitable patients range from those presenting with mild Type I early photoageing, to severe Type IV photoageing with yellow-grey skin colour, prior skin malignancies, wrinkles throughout and limited ‘normal’ skin. Patients with Type I and Type II photoageing should be treated with 1.0ml every two weeks for 3-4 sessions. Type III and Type IV should be treated with 1.5ml every two weeks for 5-6 sessions. It is recommended to revisit the patient again 4-6 months after their treatment plan completes.

Q&A with Dr Kaly Jaff

Dr Kaly Jaff, UK ambassador and trainer for Neofound explains her approach to bio-remodelling and the part it plays in her treatments. She says, “Dermal fillers are fantastic for volume loss, fat migration, correction of asymmetry, contouring, enhancing, beautification and antiageing. But what about those fine, hard to treat, lines? And what about pigmentation, scarring and all the things on the surface of the skin that doesn’t allow me to appreciate the artwork of the HA filler treatment? There is no point in investing in an expensive pillow if your pillow

Before After

Patient after two sessions of Neofound two weeks apart

cover is stained, creased, doesn’t fit and looks tired.” Dr Jaff explains, “Why Neofound? It’s cocktail of antioxidants, anti-inflammatories, low weight and heavy weight HA, plus moisturisers. It is at the top of the market with no substitute that promises the same results. It has incredible effects on collagen stimulation, pigmentation, scarring, overall hydration, treatment of acne, reducing rosacea and ironing out those fine lines and wrinkles.” Using a nanoneedle she explains, “This allows me to inject all over the face, neck, chest and hands and is no worse than plucking a hair in terms of discomfort. I can get close to delicate areas such as the eye and it also gives me full autonomy of how deep or superficial I want to be! Used as a stand-alone treatment or in combination with dermal fillers and/or neurotoxins, Neofound provides me the perfect canvas and structure on which I can provide a total global approach for my patients.”

Neofound is available at a price point of £130.00 in a 5x3ml pack providing up to 15 treatments.

Neofound can be sourced from the official UK and Ireland stockists Teleta Pharma www.teleta.co.uk

This advertorial was written and supplied by Teleta Pharma

Phone: 01355 204448 email: support@teleta.co.uk visit: www.teleta.co.uk #lovecosmedical #teletapharma #DrKalyJaff

A new way to be profound with bio-remodelling

A summary of the latest clinical studies

Title: Filler Migration to the Orbit

Author: Scawn R, et al.

Published: Aesthetic Surgery Journal, September 2020

Keywords: Dermal filler, injection, injectables, rejuvenation

Abstract: Dermal filler injections continue to grow in popularity as a method of facial rejuvenation. With this increase in the number of injections, comes an increasing number of types of filler-related complications. We report a series of cases where dermal filler injected in the face migrated to the orbit. Treatment methods and possible mechanisms of this newly reported complication are discussed. Methods: A retrospective, multicenter analysis was performed on patients with dermal filler migration to the orbit after facial filler injections. Results: Seven patients presented with orbital symptoms after filler injection and were subsequently found to have dermal filler in the orbit. There were six females and one male, with an age range of 42-67 years. Four out of seven patients underwent orbitotomy surgery, one patient underwent lacrimal surgery, one patient had strabismus surgery and one patient was treated with hyalurodinase injections. All patients have remained stable postoperatively. Orbital complications secondary to migrated filler may occur long after the initial procedure. Since the site of the complication is distant from the injection site, patients and physicians may not immediately make the connection. Furthermore, this may lead to unnecessary examinations and a delay in diagnosis while looking for standard orbital masses. Thus, dermal fillers should be considered in the differential diagnosis of patients presenting with a new onset orbital masses.

Title: Hormonal Contraceptives and Dermatology

Authors: Williams N, et al.

Published: American Journal of Clinical Dermatology, September 2020

Keywords: Dermatology, skincare, hormones, acne

Abstract: Hormones play a significant role in normal skin physiology and many dermatologic conditions. As contraceptives and hormonal therapies continue to advance and increase in popularity, it is important for dermatologists to understand their mechanisms and dermatologic effects given the intricate interplay between hormones and the skin. This article reviews the dermatologic effects, both adverse and beneficial, of combined oral contraceptives (COCs), hormonal intrauterine devices (IUDs), implants, injections, and vaginal rings. Overall, the literature suggests that progesterone-only methods, such as implants and hormonal IUDs, tend to trigger or worsen many conditions, including acne, hirsutism, alopecia, and even rosacea. Therefore, it is worthwhile to obtain detailed medication and contraceptive histories on patients with these conditions. There is sufficient evidence that hormonal contraceptives, particularly COCs and vaginal rings, may effectively treat acne and hirsutism. While there are less data to support the role of hormonal contraceptives in other dermatologic disorders, they demonstrate potential in improving androgenetic alopecia and hidradenitis suppurativa.

Title: Effectiveness and Safety of 2940 nm Multifractional Er:YAG Laser on Acne Scars

Authors: Cenk H, Gulbahar S

Published: Dermatologic Therapy, September 2020

Keywords: Acne scars, CO2 laser, acne scar treatment, laser scar treatment

Abstract: Er:YAG laser treatment has been used in resurfacing the acne scars for a long time, however, we could not find any study reporting the recovery rates after each session of the treatment. In this study, we aimed to report the improvement rates after each session. We retrospectively analyzed the data of 35 patients with acne scars treated with fractional ablative Er:YAG laser. The patients received 1 to 4 sessions of treatment, with 4-week intervals and improvement rates were recorded after each session. Data is available on request from the authors. The improvement rate of the lesions varied between 1% and 25% in 34 patients at the end of the first session, while in one patient, the improvement rate was detected as 26-50%. At the end of the 4th session, the rate of improvement was 26-50% in 14 out of 24 patients and 51-75% in ten patients. None of the patients showed a 76-100% improvement at the end of the 4th session, whereas 48.6% of the patients were satisfied with the treatment. In patients with a high expectation of an excellent improvement, a higher number of sessions of the laser treatment and/or combination treatments with different treatment methods should be planned.

Title: An Overview of Sarecycline for the Treatment of Moderateto-Severe Acne Vulgaris

Authors: Sousa, I

Published: Expert Opinion on Pharmacotherapy, September 2020 Keywords: Acne vulgaris, acne treatment, doxycline, minocycline, oral acne treatment, sarecycline, tetracycline

Abstract: Sarecycline is a novel, tetracycline-class antibiotic specifically designed to treat inflammatory acne. It offers a narrow spectrum of activity (mainly against Cutinebacterium acnes), and it shows less in vitro activity than other tetracyclines against enteric Gram-negative bacteria, offering advantages over older tetracyclines by decreasing the disruption of the gastrointestinal microbiome and the likelihood of developing bacterial resistance. Areas covered: The drug’s pharmacology, safety profile, and clinical efficacy are discussed. Results of phase I, II and III clinical trials have shown that 1.5 mg/kg/day sarecycline is safe, well tolerated and more effective than placebo in treating inflammatory acne in patients 9 years old and older. Furthermore, sarecycline’s narrow spectrum of activity leads to a lower incidence of undesirable off-target antibacterial effects and consequently less adverse events such as diarrhea, fungal overgrowth and vaginal candidiasis. Sarecycline could become the first-line antibiotic therapy used in acne in the near future as it is an effective option for treating inflammatory acne lesions. Due to its narrow spectrum of activity, it could have a more adequate safety profile than older tetracyclines; however, head-to-head trials comparing the efficacy and safety profile of sarecycline with other tetracyclines are still needed to prove sarecycline’s superiority.

Incorporating Instagram Reels

Last month Instagram introduced a new video feature which allows users to create and share 15-second video clips to their timelines. While Instagram Reels is being dubbed as a copy of the Gen Z app Tik Tok,1 aesthetic marketers believe that it can also be an incredibly useful and creative business tool for promoting clinics and gaining new patients. Aesthetics spoke to Louis Meletiou, head of marketing at Medico Digital, and Alex Bugg, head of content at the Web Marketing Clinic, about how aesthetic businesses can incorporate this feature into their everyday social media strategies.

How to create a Reel

Instagram gives users two options when creating a Reel:2

1. Press and hold the record button to capture live footage

2. Upload pre-recorded videos from your phone’s camera roll

Reels can be recorded in a series of clips at different stages or all at once. These clips can then be added together and edited on the app using a variety of tools such as text, special effects, stickers and speed controls, with an option to align multiple clips for cleaner transitions.2,3 Like on Tik Tok, audio is a big part of creating an Instagram reel. The audio tool allows users to add music or other sounds from the Instagram music library, or sounds can be recorded as original audio by the user. If a Reel is posted from a public account, anyone on Instagram can record a reel reusing that original audio which gets added to the music library, allowing users to jump on any trends at the time.4

Uses in aesthetics

Meletiou believes that incorporating Reels into marketing and social media strategies will allow for a greater connection between the clinic or practitioner and the patient. He says, “I think Reels are going to be a really good way for clinics and practitioners

to create a personality online and bring them closer to their existing followers, as well as gaining new ones. If patients feel that they know you a little better, they’re more likely to go book with you over someone they’ve not seen the face or heard the voice of. It opens up the opportunity for more personal interaction.”

Bugg notes that Reels also have the potential to revolutionise the ways in which before and after images are communicated on social media. She comments, “One of the good things about this feature is that it’s an easy way for people to edit together a video taken a few hours before, with one taken more recently. Because of this, you can make an interesting transition when showing the difference between your before and after images. You can use the app to set them to music, fade them in and out of each other or use a voice over to give a small explanation of the procedure and its effects. It’s a lot more interesting for potential patients to see your work that way instead of just a static photo and it also breaks up your feed – I think it’s important to include a mixture of photos and videos to mix things up.”

Not only can video Reels showcase results, but they can also help businesses gain a new following by sharing educational content.

“Reels are the perfect way for clinics to

Aesthetics speaks to marketing professionals about Instagram’s newest video feature, exploring the ways it can be used for clinic promotion

“Giving a whole overview of something in 15 seconds can be very powerful. Every clinic should be able to market something in that time frame”

Alex Bugg

Ideas for your Reels content:6

1. Before and Afters: practitioners and clinics can use before and after videos or images, incorporating text or voiceovers to explain how the results were achieved

2. Behind the Scenes: followers can get to know a company or practitioner better by viewing behind the scenes moments or interviews to add a personal element to the account

3. Education: posting your advice can showcase your expertise in a certain area, for example five top tips in skincare. It will reassure your followers that you know what you’re talking about and encourage them to trust you

4. Reviews: companies can use Reels to communicate patient reviews by getting them to send across their own videos, or recording them in clinic following a treatment

5. Start a Challenge: use a hashtag to create an original challenge for the aesthetics community, and get everyone to join in!

If you try these ideas out, make sure to tag @aestheticsjournaluk and we’ll share your Reels!

deliver information and ‘how-to’ clips in a snappy and succinct way,” says Bugg. She continues, “Giving a whole overview of something in 15 seconds can be very powerful. Every clinic should be able to market something in that time frame – they should focus on one benefit or the main point of the product/device/procedure.

You also don’t have to waste any time at the end telling viewers how to book or get in touch – if the video is good enough to interest people then users can go to your profile, follow you and visit your website where you should have more in-depth information available for them. There is also the option to include a caption for your Reel, so any extra information can be added there.”

Meletiou agrees, stating, “The average human attention span is only eight seconds,5 so if it was any more than 15 seconds people probably wouldn’t pay attention to the whole thing and the overall meaning would be lost. Practitioners just need to focus on the most interesting and eye-catching part of what they’re trying to communicate.”

Getting your Reels seen

When it comes to sharing your Reel it will be posted onto your main Instagram feed for all your followers to see, and then can be added onto the Explore page, which appears on the same page as the search function, or on your Instagram Story, where you can post a photo or video that disappears after 24 hours.3 All the Reels that a user creates will also appear in a dedicated section on their profile under the

Reels Tab, similar to an IGTV post 2 Bugg advises users to ensure that Reels are going onto the Explore page as this opens up the opportunity for aesthetic businesses to get a wider reach. She says, “Sharing your Reel this way allows for people to find your account organically, because it’s not just for people who already follow you. It’s got a vertical scroll that is a mix of who you follow or accounts similar to those, and what Instagram thinks you’ll be interested in. The algorithm isn’t set yet and Instagram is still working this out, so ensure to keep updated on this to maximise the reach of your videos.”

Getting started

Meletiou believes that the best thing for aesthetic businesses to do is just to have a go, practise and discover what works for your followers. He says, “Just dive in to the world of Instagram Reels! If you want to practise, use a fake account or personal account until you get the hang of it. Then, when you feel more comfortable, you can start posting them for your business account followers. Watch Reels that are available as well as the videos on TikTok if you’re unsure of what you should be doing. You can search on the app for hashtags like ‘plastic surgery’ or ‘dermal filler’, and it will give you a good idea of the sorts of videos that are getting a good reception unique to your field.”

Bugg warns that not incorporating Instagram Reels into your social media strategy may be detrimental for business, saying, “If Instagram is an important part of your business and a main way for you to

gain your patients, then you really do need to start using Reels now. The best thing that you can do is to get the ball rolling by trying out ideas and learning how to edit. It’s like when Instagram Stories were first introduced – nobody was bothered about using them. Fast forward to now and if you see a clinic not using Stories they get completely lost online because, in my experience, everyone else is posting at least four a day. It’s become the norm and is an important part of business promotion, so don’t miss out because you’re scared! Just go for it.”

REFERENCES

1. Chen B, Lorenz T, We tested Instagram Reels the Tik Tok clone, The New York Times, 2020, <https://www.nytimes. com/2020/08/12/technology/personaltech/tested-facebookreels-tiktok-clone-dud.html>

2. Nguyen L, Hootsuite, 2020, <https://blog.hootsuite.com/ instagram-reels/>

3. Instagram, Introducing Instagram Reels, 2020, <https://about. instagram.com/blog/announcements/introducing-instagramreels-announcement>

4. What audio can I use in my real on Instagram?, Instagram, 2020, <https://help.instagram.com/329208821595430>

5. Cision, Are your declining attention spans killing your marketing strategy?, 2018, <https://www.cision.com/us/2018/01/decliningattention-killing-content-marketing-strategy/>

6. E Gutierrez, Digital Marketer, How to use Instagram Reels in your marketing strategy, <https://www.digitalmarketer.com/blog/ instagram-reels-marketing-strategy/ >

Treating the Hands this Autumn with Radiofrequency

In this digital age especially, hands are exposed both to the elements and to public scrutiny. According to award-winning cosmetic doctor Dr Rita Rakus,1 patient demand for treatment in this era of hand rejuvenation is only going to keep growing and so it's more important than ever to ensure an effective treatment offering. “We’re in a digital age now where patients are much more image focused and this extends to the hands too,” says Dr Rakus. “Patients are realising that they no longer have to endure hands that look older than their face. To ensure a fully holistic approach, it is absolutely vital to ensure effective treatments for the hands are available within the clinic.” According to Dr Rakus, patients are also much more knowledgeable too. “We are also working with a much more informed population as patients are now able to research potential treatments,” she explains. The skin on the hands, like skin elsewhere on the body, undergoes both intrinsic and extrinsic ageing. Extrinsic ageing is caused by environmental factors such as sun exposure, chemicals and smoking and will directly affect the epidermis and dermal layers leading to issues such as uneven pigmentation, solar lentigines, actinic keratosis, punctate hypopigmentation and solar purpura. On the contrary, intrinsic ageing is affected by genetics and nutrition, also by disease processes such as diabetes, peripheral arterial occlusive disease, autoimmune disorders and medication, including chemotherapy. Intrinsic changes alter the deeper soft tissue planes, decreasing skin elasticity, loss of the subcutaneous tissue (dermal and fat atrophy) and dermal vascularity. To treat the intrinsic signs of ageing – in particular skin elasticity of the hands – Dr Rakus recommends using non-invasive radiofrequency technology with Thermage FLX®. “Having seen such success with the original Thermage® technology, we are absolutely delighted to offer the new Thermage FLX® at our clinic,” says Dr Rakus. “The Thermage FLX® is a fantastic addition to our portfolio of treatments and offers a fantastic option for those wishing to tighten the skin on their hands this

Thermage FLX® offers new features:

25% faster treatments compared to the previous Thermage CPT® version: the new Total Tip 4.0 provides greater surface area coverage than the Total Tip 3.0.

AccuREP™ Technology: automatic calibration allows for optimised energy delivery, to provide consistent output.

Patient comfort:4 mechanical advancements provide vibration elements to assist with patient comfort. The treatment is 30% less painful than Thermage CPT®.

Single handpiece: consistent treatment from head to toe without the need to interchange any handpieces.

Touchscreen navigation: updated interface brings a modern look and functionality.

autumn,” she adds. Dr Rakus was the very first user of the original Thermage® technology at her clinic in Knightsbridge which is the second largest Thermage® clinic in the world.

“Thermage FLX® is great as a standalone treatment or as a combination therapy within a treatment plan. Best of all, patients only need one treatment2 to obtain the full benefits. In addition, there is no to little downtime,3 so they can quickly resume their daily routine. Thermage® is the only treatment option that rejuvenates the collagen deep within the skin, with none of the negative aspects of other treatments.”

What is Thermage FLX®?

Thermage FLX® is different to anything else available in the marketplace at the moment because it's the only radiofrequency treatment that requires a single treatment2 as opposed to a full course. Thermage® is noninvasive so there is no surgery or injections. The procedure offers significant clinical improvement5 with few potential side effects and little downtime,3 so patients can quickly return to their normal routine. In addition, Thermage® has demonstrated a good safety profile.5 The treatment can be used on all skin types and tones and can be done all year round. Thermage® uses radiofrequency technology to heat the deeper, collagenrich layers of the skin to offer a deep rejuvenation of tissues. Thermage® works across the entire face, including forehead, eyes, nasolabial folds, jawline, jowls and the area under the chin, as well as on the arms, buttocks, tummy and thighs. It can be used at different ages, in men and women.

REFERENCES

1. www.drritarakus.co.uk

2. R. Fitzpatrick et al. Multicenter study of noninvasive radiofrequency for periorbital tissue tightening. Lasers Surg Med. 2003;33(4):232-42.

3. M. Fritz and al. Radiofrequency treatment for middle and lower face laxity. Arch Facial Plast Surg. Nov-Dec 2004;6(6):370-3.

4. Solta Medical, 2009. Report on Gazelle Clinical Study 09-100GA-T ‘Validation of the Thermage 3.0 cm2 STC and DC Frame Tips, Comfort Software and Vibration Handpiece on the Face and Thighs’ (#09-019ER). Bothell.

5. E. Finzi, A. Spangler. Multipass vector (mpave) technique with nonablative radiofrequency to treat facial and neck laxity. rmatol Surg. 2005 Aug;31(8 Pt 1):916-22.

www.thermage.co.uk

its affiliates. THR.0032.UK.20

Dr Rita Rakus presents her advice for successfully rejuvenating ageing hands

This advertorial was written and supplied by Solta Medical®

This advertorial was written and supplied by Solta Medical®. ®/™ are trademarks of Bausch Health Companies Inc. or its affiliates. ©2020 Bausch Health Companies Inc. or

Using Pay-PerClick Marketing

Digital marketer Bradley Hall explains how aesthetic businesses can use pay-per-click marketing to secure new patient bookings

There are various methods you can use to market your aesthetic business for free online, such as through social media or e-newsletters. However, to help reach new potential customers, paid-for digital advertising can be an option to consider. Earlier this year, 68% of 3,400 global marketers surveyed said that paid advertising is ‘very important’ or ‘extremely important’ to their overall marketing strategy.1

Pay-per-click (PPC) marketing is a form of online advertising in which the advertiser pays the chosen platform every time a user clicks on their advert. This article will explore how you can best utilise PPC marketing to connect your business to new customers, and drive those currently interested in choosing your clinic.

How PPC works

Compared to other types of digital adverts which may charge you a flat fee, or based on the number of people it reaches, with PPC you only pay for the number of qualified leads generated – clicks to your desired URL. You can put caps on your ad spend to ensure the number of clicks do not exceed your advertising budget. Plus, it is possible to track which clicks turn into bookings or sales, so you can accurately measure return on investment. The cost-per-click associated with an ad is largely determined by the level of competition. When an ad space matching your specification becomes available, the platform will run an automated auction to determine which advertiser gets to secure the space and the associated cost-per-click. The spot does not necessarily go to the advertiser with the highest bid because it also considers factors like ad relevancy and landing page quality. PPC platforms typically give you a great level of control over what your ads look like and where and when they appear, and there are a variety of ad types available. This means that you can create highly targeted advertisements that engage different kinds of prospective patients, increasing your conversion rate and therefore maximising return on investment. Creatives, audience targeting, and bidding strategies can be easily tweaked, allowing you to hone campaigns as they progress. This also means that you can quickly react to any changes in your business or market. There are several ways you can utilise PPC, including paid search, display advertising, and social media advertising, which we will discuss. For more advice on the fundamentals, I recommend reading HubSpot’s Ultimate Guide to PPC.2

Paid search

Paid search or search advertising allows you to get your business in front of the highest-quality prospects on a search engine when people are actively searching for your specific products and services. Your ‘sponsored’ search result will generally have a more prominent position than, yet look near identical to, unpaid ‘organic’ results, increasing the chances of engagement.

One of the best ways to run a paid search campaign is through the Google Search Network.3 Using the Google Ads platform,4 previously known as Google AdWords, you can secure prominent positions on Google search engine results pages when people enter relevant queries. You can perform keyword research to see what types of queries you would like your website to rank for. As well as text ads, it is possible to appear in Google Play, Images, Shopping, and Maps. You can also try platforms like Microsoft Advertising5 and Amazon Advertising.6

Display advertising

Display advertising is a more traditional form of advertising in which image banners, videos, or similar are used to grab potential customers’ attention. Once you have defined your target audience, ads will be served in relevant locations on the platform’s network. For an aesthetics business, this could be the likes of beauty and lifestyle publications. Among the biggest display networks are Google Display Network, which reaches 90% of internet users worldwide7 and Microsoft Advertising,5 which allows you to advertise on Outlook, MSN, Xbox, and more.

Social media advertising

Social media advertising allows you to connect with potential customers through platforms like Facebook8 and Instagram.9 Sponsored posts typically appear on relevant users’ feeds alongside organic content they have actively subscribed to. There are 3.8 billion users10 spending an average of two hours and 24 minutes per day on social media,11 so there is a huge opportunity for aesthetics businesses to increase brand visibility and engage relevant audiences.

PPC for aesthetic businesses

Whether you are new to PPC marketing or you are looking to ramp up your campaigns, these tips will help you to minimise costs while maximising conversions.

Know the guidelines

There are a number of regulations that advertisers must follow on platforms like Google Ads, especially when it comes to industries like aesthetic medicine. Familiarising yourself with them, or seeking the help of a professional, is crucial to avoid wasting time on campaigns that go on to be rejected. Violating ad policies could even lead to account suspension. For example, it is prohibited to use personalised advertising for invasive medical procedures, including cosmetic surgery, on Google Ads.12 It is important to read all policies and terms and conditions on whatever platform you use. Of course, as with any advertisement, ensure to abide by ASA and CAP rules.13,14

Understand your audience

One of the biggest benefits of PPC marketing is that you can clearly define your target audience, taking advantage of platforms’ data on user demographics such as age, gender, location, and interests. For aesthetic businesses offering in-person services, I believe location is one of the most important factors. Harnessing your own customer data as well as doing your research will allow you to build a more accurate picture of the people interested in your products or services. For example, the International Society of Hair Restoration Surgery 2020 Practice Census shows that the majority of surgical hair restoration patients are males aged 30 to 39, so you may want to target ads for this service accordingly.15 Another valuable technique to try is retargeting; serving ads to people who have already visited your website. The strategy could be even more successful in the medical aesthetics field, where patients are likely to conduct a lot of research before making a decision. However, you have to be careful when targeting users based on potentially sensitive online behaviour. As mentioned above, Google prohibits personalised ads for cosmetic surgery for this reason. So, always read the policies and carefully consider how users will feel about your ads. Once your campaigns have been running for around 30 days – the time I believe you need to really determine your success – delve into the metrics to see what is working and what is not. Look out for results that stray from the average, good or bad. For example, you might see that a particular demographic is responding best to a specific ad and so decide to focus your budget on targeting those kinds of users only. Trial and error is a huge part of any successful PPC campaign.

Use Google Shopping for e-commerce

If you sell any products online, such as skincare and cosmeceuticals, Google Shopping is a great way to generate sales. This paid search channel generates highlyqualified leads because customers are already in the purchase phase of their buying journey and can learn a lot about the product before clicking through. The key thing is keeping your product feed optimised and up to date, ensuring that product information is accurate and out-of-stock items are not advertised. This will attract the highest quality leads and significantly increase the chance of conversion, maximising return on investment.

Take advantage of ad credits

Many online advertising platforms offer introductory ad credits so that you can effectively take a free trial. After you have tested the waters, you can build your budget gradually to reduce risk and ensure that the campaign grows successfully. For example, Google Ads is currently offering new users £120 in credit.16 Platforms may present you with an offer when you go to sign up. You might also be able to find coupons by searching for the name of the platform plus ‘credit’ or similar.

Work on ad quality

The quality of your PPC adverts not only determines how likely users are to click through and convert but also plays a role in ad visibility and costs. Google Ads, for example, rewards better quality scores with higher rankings and lower costs per click.

To get a high quality score, you will need to make sure that your ad delivers a good user experience from start to finish. That means only targeting audiences who are likely to be interested in your products or services, creating an attractive and representative advert, and delivering a useful page after click-through. For example, if you are a clinic offering lip fillers, you will likely want to target younger women located nearby who are actively searching for this type of procedure. The ad should set realistic expectations using error-free text and high-quality imagery, where applicable, and the linked landing page should provide detailed information about your dermal filler services and credentials.

Be adaptable

The flexibility and ability to quickly amend your advert is one of the many strengths of PPC advertising, so make sure to take advantage of this. For example, you can

quickly amend your PPC adverts according to the current coronavirus restrictions as they are constantly changing. By adding clear information about opening times, social distancing guidelines, and hygiene measures to your ads or sponsored listings, you can divert clicks from competitors who are not offering this level of reassurance to would-be patients. You can also amend your PPC to make the most of changing market trends. For example, if a celebrity is in the news for discussing a cosmetic procedure, you could take advantage of increased search interest by promoting related services, products, or resources.

Connect to new patients

Pay-per-click marketing offers an effective way for aesthetics businesses to connect with high-quality prospects and turn them into patients or customers. With many businesses scaling back their marketing efforts throughout the COVID-19 pandemic, and consumers spending more time than ever online, there has never been a better time to start or ramp up your campaign.

Bradley Hall is head of paid search at online marketing agency Glass Digital, a Google Premier partner and Microsoft Advertising partner. He has specialised in pay-per-click marketing for more than five years, helping clients across industries achieve return on investment through platforms like Google Ads, Microsoft Advertising, and Amazon Advertising.

REFERENCES

1. State of Marketing Report, The Ultimate List of Marketing Statistics for 2020. <https://www.hubspot.com/marketingstatistics>

2. HubSpot, ‘The Ultimate Guide to PPC’ <https://blog.hubspot. com/marketing/ppc>

3. Google Search Network, ‘About the Google Search Network. <https://support.google.com/google-ads/answer/1722047>

4. Google Ads, Grow you Business with Google Ads. <https://ads. google.com/home/>

5. Microsoft Advertising. <https://ads.microsoft.com/>

6. Amazon Advertising. <https://advertising.amazon.co.uk/>

7. Google, Reach more people in more places online. <https://ads. google.com/intl/en_uk/home/campaigns/display-ads/>

8. Facebook, Business Ads. <https://en-gb.facebook.com/ business/ads>

9. Instagram, Build Your Business On Instagram. <https://business. instagram.com/advertising/>

10. Kemp S, More Than Half of the People on Earth Now Use Social Media, 2020 <https://blog.hootsuite.com/simon-kemp-socialmedia/>

11. Global Web Index, Social media marketing trends in 2020. <https://www.globalwebindex.com/reports/social>

12. Google Ads Personalised advertising policies, <https://support. google.com/adspolicy/answer/143465?hl=en-GB>

13. ASA Codes and rulings, ASA. <https://www.asa.org.uk/codesand-rulings.html>

14. Kendrick, J, Maintaining Compliant Marketing in Aesthetic, Aesthetics journal, 2017. <https://aestheticsjournal.com/cpd/ module/maintaining-compliant-marketing-in-aesthetics>

15. International Society of Hair Restoration Surgery 2020 Practice Census. <https://ishrs.org/wp-content/uploads/2020/05/Report2020-ISHRS-Practice-Census-05-22-20.pdf>

16. Google, Claim your Google Ads coupon. <https://ads.google. com/intl/en_uk/lp/coupons/>

Planning Your Future Marketing

At the outset, 2020 brought much excitement about the possibilities of a new decade –only to become the most challenging year clinics have likely ever faced. Looking back, almost nobody – in or out of the world of aesthetics – was familiar with the expressions, ‘social distancing’, ‘reopening in phases’ or ‘COVID-19’ – yet they are now all but engrained into our everyday lexicon.

Perhaps more than in any market circumstance prior, promoting an aesthetic clinic is an everchanging, fluid and incredibly uncertain endeavour. While we may indeed find ourselves amid a chaotic climate – I am a firm believer that in business, the best way to predict the future is by envisioning it. This begs the question – how can you plan your marketing and communications, when none of us know what tomorrow will bring?

The good news is that you can still plan much of your clinic’s marketing even with an uncertain future. In working closely with clients – clinics large and small, across numerous regions of the US, Canada, and the EU – I have come to notice several key market trends which we have been able to successfully capitalise on in our current climate. These concepts, when put into action, can empower your clinic heading into quarter four and beyond – even as the world around us presents more unanswered questions. These may help you to ‘re-introduce’ your clinic to the marketplace, and now is the perfect time to do so. In a global survey by consulting firm McKinsey, 71% of 1,000 UK consumers indicated they tried a new brand or shopping experience since the start of the pandemic.1 You should be taking a closer look at your marketing positioning, the messaging you use across your promotional channels, the market segments and audience(s) you serve – and refine each of these facets to emerge stronger and more distinguished from competitors than ever.

Consider your pricing structure

While considering how to rise above competitors in the current climate is of the utmost importance, it is also crucial to be mindful of your new main competitor – your patient’s budget.

At every level of personal income, many consumers have felt the impact of COVID-19 on their finances. According to the McKinsey survey, 44% of 1,000 UK consumers indicated they are now more mindful of where they spend their money.1 More than ever, patients are increasingly concerned with value for every discretionary purchase they make; and are actively seeking out brands that make their offerings accessible, attainable and available to consumers at a wider range of price points. While it can be tempting to slash prices in an attempt to drive new patient enquiries, this can often be detrimental in the long-term. Once patients are used to a reduced fee for your treatments and procedures, they will rarely accept a standard price point upon return to a more typical economic climate.

One of my favourite strategies in this pursuit is what I refer to as a ‘diffusion offering’ (also known as downmarket offering) – which strikes a perfect harmony between offering an accessible price point without devaluing your skillset (or that of your providers) or the reputation you have built over time.2 In an aesthetic clinic setting, you can do this by bringing together several of your most affordable treatments (as an example, a chemical peel and dermaplaning treatment; or perhaps combining a medical facial with several skincare products) and giving this package a unique name. By doing this

Leading with education and creativity can ensure that your clinic’s marketing does not find itself lost among countless mediocre messages and advertisements

Brand marketing strategist Adam Haroun explores the ways in which you can utilise the current period of uncertainty to your clinic’s advantage and attract more patients

you avoid detracting from the price point of your clinic’s signature offerings, while still welcoming patients who may be more price-conscious than ever and give them that ‘little something special’ they can enjoy straight away. Be sure to promote this package as a ‘downsell’ across your social channels to patients who may be averse to higher-priced offerings, through your e-mail communications and at your reception desk to everyone who walks through your doors.

Shout about your qualifications and experience

Almost every negative situation comes with a silver lining, and in our current pandemic a much-awaited change is the return to recognising expertise and credentials. In its most recent survey of international internet users by global communications firm Edelman, 57% of consumers reported that they felt the media they consumed was contaminated with untrustworthy information.3 What’s more, even as early as late 2019 we saw the returns brands were realising from their influencer marketing efforts had declined 1.7%.4 This is potentially suggesting that the general public are starting to recognise influencers may not share the most trustworthy information.

I am known for saying that serious problems require serious expertise – and the COVID-19 crisis once again elevated credible experts to command respect and authority which they were always due. This trend has echoed into our industry and resonated with consumers. I am finding that consumers are less likely to be taking health advice from the ‘natural lifestyle blogger’ – nor are they valuing advice to turn back the clock and achieve their ideal appearance from those who are not credentialed cosmetic medical practitioners.

More than ever, your marketing must serve as a platform to credential providers, emphasise the expertise the patient receives with their treatments at your clinic, and underscore the value this presents to the patient. Besides focusing on treatments and devices alone, showcase your unique approaches and/or protocols, as well as your notable training or academic experience you bring to your patients via your website and on social media. While a competing clinic can easily promote the same injectable or laser, there are a myriad of elements only your clinic can offer – and this is where your marketing is best focused. This can make the world of difference between justifying a premium price point (even in our current market climate)

and struggling to compete with lower-end clinics. Patients are not simply purchasing your ‘tangible product’ – an injectable, a laser treatment or a surgical procedure –they are investing in your ‘offered product’, which encompasses all of the intangible (and distinct) elements that accompany the treatment; and which only your provider(s) and clinic can offer.

Showcase your ethos

Whether on social media, through a print advert, or inside your clinic – it is also of the utmost importance to reorient your marketing ethos.

In recent years, many clinics chose to focus their marketing around promotional offers, highlighting the latest and greatest devices available to patients, and showcasing results. While there is still value to each of these approaches, the COVID-19 consumer seeks something more from the brands with whom they engage. Market research by global consulting leader Bain & Company anticipates that consumer concern about sustainability and social issues is set to continue, consolidating the importance of environmental and social governance. Bain & Company suggests that ethics will become as important in aesthetics as consumers prioritise purposeful brands.5 No longer is it sufficient to simply ‘blast’ the marketplace with promotional messages – your clinic’s marketing ethos must evolve to foster goodwill and demonstrate omnipresence. The current pandemic has driven consumers to actively seek out brands that are a part of their community, supporting those in need, and are in business for the ‘greater good’.

In its research of global markets recovering from the pandemic, global consulting firm Bain & Company found the rise of the ‘postaspirational’ mindset among the primary consumer trends emerging.5 From donating to organisations that assist those in need, to honouring healthcare heroes on the frontlines – there are a myriad of ways your business can reach out and let patients know that you are looking to accomplish far more than a quick sale.

While it is simple and cost-effective to post a special offer on your social channels, too many providers find themselves caught in an endless cycle of taking marketing action without providing real value or insight to their audience. Being omnipresent means that your clinic is not simply ‘hiding’ behind a social media profile – but instead, is actively leveraging public relations, traditional media, digital marketing and retention

campaigns to capture patients’ attention and keep them engaged. Leading with education and creativity can ensure that your clinic’s marketing does not find itself lost among countless mediocre messages and advertisements. Think outside the ‘before and after’ – and draw inspiration from brands you love in other industries. Remember, marketing that looks and sounds like ‘just another clinic’ will easily be tuned out by the prospective patient – don’t be afraid of trying something new and unique. As a best practice, with my private clients we aim to make 75% of their marketing content educational and informative in nature, whereas only 25% would be more promotional in nature.

Summary

Despite the difficulties, the COVID-19 pandemic also presents opportunities. It can give you the unique chance to define the next phase of your clinic’s trajectory and emerge stronger than ever before. As many businesses retract, pull back on marketing, slash pricing and find themselves in ‘panic mode’ – there is indeed another option. Providers who see the unexpected opportunities presented by our current market, dedicate time and resources to evolution, and take strategic action now will be those who endure. The right decisions today can allow a clinic to emerge as market leaders when we gradually return to normalcy.

Adam Haroun is a marketing strategist, entrepreneur, and owner of BrandingMD. He has spoken for industry leading companies in the US and globally, including Allergan, Merz, Candela and BTL Aesthetics. He recently spoke at the Annual Society for Dermatologic Surgery annual meeting and the Global Aesthetics Conference. Haroun is also the author of Now The Patient Will See You – that serves as a strategic guide to branding and positioning for aesthetic practices.

REFERENCES

1. McKinsey, ‘Consumer sentiment and behavior continue to reflect the uncertainty of the COVID-19 crisis,’ 2020. <https:// www.mckinsey.com/business-functions/marketing-and-sales/ our-insights/a-global-view-of-how-consumer-behavior-ischanging-amid-covid-19>

2. Harvard Business Review ‘A Playbook for Moving Down Market’, 2008. <https://hbr.org/2008/04/a-playbook-for-moving-downmar>

3. Bain & Company, ‘Retooling Strategy for a Post-Pandemic World,’ 2020. <https://www.bain.com/insights/retooling-strategyfor-a-post-pandemic-world/>

4. The Wall Street Journal, ‘Online Influencers Tell You What to Buy, Advertisers Wonder Who’s Listening’, 2019 <https:// www.wsj.com/articles/online-influencers-tell-you-what-to-buyadvertisers-wonder-whos-listening-11571594003>

5. Bain & Company, Brief: Luxury after Covid-19: Changed for (the) Good, 2020. <https://www.bain.com/insights/luxury-aftercoronavirus/>

Utilising Smartphones for Photography

Aesthetic clinics typically document their work by showcasing before and after imagery on their social media channels and websites. However, aesthetic practitioners are medical professionals and not photographers, meaning they often lack the knowledge, space or equipment to take these images professionally. Although professional cameras can achieve good photo outcomes, they can be expensive and may require space in your clinic which you might not have. The easiest and quickest solution is to use smartphone photography. Although these devices can produce high-quality images given the right environment, a quick look on social media will yield an array of shocking before and after images. These images are of different exposures, colour and sizes, making it difficult to see results. Why are before and after images taken on smartphones sometimes so drastically different from each other? If practitioners try taking a photograph of a patient in the same place at different times of the day, there will be a significant alteration in colour, exposure and image quality, caused by changing ambient light. At times, the disparity can be so drastic that it makes it difficult to see which procedure has been carried out and the effects of that procedure. Inconsistency is exacerbated further by the lack of official guidance outlining patient photography in aesthetics.1

To understand how to take smartphone images in the most effective way possible, it is important to first have a basic knowledge of photography, the science of light and how to use the two together. Most important within this equation is consistency with both lighting sources and the distances and angles from the patient.

Lighting environments

Cameras on smartphones work in automatic mode, so depending on the colour and strength of the light entering the lens, the sensors will try to adjust your image based on a pre-set algorithm. If the light in the room is in any way influenced by light from outside the room, the colour temperature and exposure of the resulting image will be altered.

There are settings that we need to take into account in this changing environment:

1. Shutter speed: responsible for the sharpness of the image

2. Aperture: responsible for which part of the image is in focus

3. ISO: controls the sensitivity of the camera sensor

4. Colour temperature: controls how warm or cool your image appears2

The aperture settings on smartphones are fixed, so depending on the environment you provide, your smartphone (which is in auto by default) will try to correctly expose the image with shutter speed and ISO, and adjust the colour temperature automatically for the final image. So, unless we can control the environment, we are at

the mercy of the sensors and the automatic settings to give us accurate results for our documentation. And whilst we cannot manually control the settings on these devices, we can influence them by providing a stable lighting environment so that the camera’s shutter speed, ISO and the resulting colour temperature are identical between sessions.

Solutions

So how can practitioners provide a stable lighting environment in clinics? Firstly, there needs to be a dedicated constant light source. LED lighting provides this consistent source, but clinics should avoid anything on a tripod which has height, angle and tilt adjustments, unless they can leave it exactly as it is between photographs, as practitioners will need to replicate this later and there are too many variables to control accurately.

To make sure we get our lighting right, let’s take a quick look at the ‘inverse square law of light’ which describes the intensity of light at different distances from a light source. If the light source is twice the distance from the subject, the illumination on the subject will be one quarter of the intensity based on this law.3 So we can’t place the subject at roughly the same distance from the light between sessions, as it has to be exactly the same, or the subject will be at completely different levels of illumination between sessions.

In order to create a stable lighting environment in clinics without specialised equipment, practitioners firstly have to use a room that is shielded from any outside light, so an inner room without windows will be the best choice, or at worst, close all curtains and blinds.

In my experience, the ideal light source would be two upright LED lights, tall enough to illuminate the area on the patient you want to photograph without making height adjustments (Figure 1). They can be secured to a heavy metal base and marked so that they are always at 45 degrees to the patient when moved, which can be done using an octagonal floor marker, detailed below.

Existing overhead lights may provide a reasonable light source, but they can create shadows from above. Practitioners will also have to take note of the colour temperature of this light and may have to experiment with different types of lamps or bulbs, until they have an acceptable colour to the images.

The ideal positioning of the subject in the room will depend on the size of the room and where overhead lights are located. But once this area has been found, it should remain the same for all patients. To keep your angles consistent, you can use an octagonal marker on the floor which will not only keep the patient in the same position, but will also let you document your patient at every 45 degree angle to the camera (Figure 2). The following tips will help to find the ideal position:

• Don’t place your patient directly under the ceiling lamps – this will throw very

Photographer Clint Singh outlines solutions for the common mistakes aesthetic clinics make taking before and after images on their smartphones

Figure 1: Example of a person lit with two upright LED lights photographed on a smartphone

Figure 2: An octagonal floor marker to keep your patient in the same position between sessions

Figure 3:

Figure 4: The same patient lit using overhead LED ceiling office lights reflected off walls. The patient is positioned between two of the overhead lights; the colour temperature of the lamps are much cooler and the image is well exposed

strong shadows onto the patient and the camera will also struggle to expose the hotspots which the light from above will throw (Figure 3)

• Use light that has been reflected off walls – the brighter the room the better (Figure 4) – and always use the same room for your before and after images to avoid changing lighting conditions

Consistency is key

Consistency with before and after documentation is crucial and there are a number of factors that need to be considered. Once clinics have a stable lighting environment, they will then need to address angles, colours and distances.

Angles

As discussed above, to keep your angles consistent, you can use an octagonal marker on the floor which will let you document your patient at every 45 degrees to the camera (Figure 2). While this will keep the patient’s body in the same position between sessions, if you are doing headshots, using additional markers that correspond with the octagonal floor marker at eye level will help to keep the patient’s head position consistent. The additional markers should be placed on walls at eye level around the room and correspond to the numbers on the floor marker.

Colours

When smartphones take an image, the sensors pick up reflected light and try to calculate appropriate colour temperature.4 Whatever light that falls on the camera’s sensor will be taken into account in this calculation. Not only is keeping this colour temperature and environment consistency important, but this calculation will have an impact on skin tones too. In my experience, to minimise the impact of vastly differing skin tones between shoots, use a white background, or a white wall if available. This is because the camera’s auto settings work by taking a reading of the entire scene, including the background, shown in Figure 5. The background heavily influences the colour of the resulting image. While using a black background might give a decent image, as can be seen in Figure 6, it can result in the image being oversaturated. Use a cape to cover the subject’s clothes for headshots, so the field of vision of the camera between sessions is limited to the patient’s face. If you are documenting the abdominal area or lower body, ensure the patient uses the same garments between sessions.

Distances

Clinics want to ensure that the proportional size of your subject in both images is consistent, which can be done by maintaining the same distance between the smartphone and the patient. If the octagonal floor marker is used, the patient should be in the same position between sessions, but an additional marker should be used (tape will do) on the floor to keep the smartphone in the same position between sessions. Also, ensure the camera isn’t too close, ideally at around 60cm from the subject, as smartphone cameras suffer from very noticeable perspective distortion. Keep the smartphone level to the area on the subject you are photographing, which will give you consistency even if you have staff of different heights.

Conclusion

Given the right environment, modern smartphones can produce accurate images to document patient procedures. Once stable lighting has been established to keep the exposure and colour temperature consistent, it is possible to implement a set of standardised protocols to maintain consistency between sessions for angles and distance, ensuring accurate and precise documentation. Smartphones’ ease of use and simple point and shoot capabilities, combined with industry-established patient management apps and the right lighting conditions, make them an ideal tool to capture before and after images accurately, while maximising your time with your patients. Remember, consistency is key!

Clint Singh is the founder of Clinical PhotoPro, which produces photography lighting systems for the aesthetic industry. Before he got involved in this market, his job as a professional photographer involved training in ‘off the grid adventure photography workshops’ in the Arctic.

REFERENCES

1. Elard, E, ‘The Last Word: Standardised Photography’, Aesthetics Journal Aesthetics, 2016 <https:// aestheticsjournal.com/feature/the-last-word-standardised-photography>

2. Präkel, D, Basics Photography 02. Lighting, 2nd edn, 2013.

3. Nave, R, “Inverse Square Law For Light”, Hyperphysics, <http://hyperphysics.phy-astr.gsu.edu/hbase/ vision/isql.html>

4. McHugh, S, Understanding Camera Metering And Exposure, <https://www.cambridgeincolour.com/ tutorials/camera-metering.html>

An overhead downlight throwing harsh shadows on a patient and the colour temperature of the lamp is too warm

Figure 6: Patient standing in front of a black background. Both images were taken using the same smartphone, using the same upright LED lights, and at the same distance and angle.

Figure 5: Patient standing in front of a white background

Mr Naveen Cavale’s family members have had medical careers spanning seven generations, so medicine really is in his blood. However, while he’s now a consultant plastic surgeon and surgical trainer, the path to achieving his career did not start smoothly. After completing his A-levels, Mr Cavale was rejected from every medical school that he applied to. However after continuing to apply for the next two years, his perseverance and determination finally paid off. He was accepted into University College London (UCL) to study Anatomy and Neuroscience, and then an MBBS, graduating in 1995. He went onto complete an MSC in Surgical Science and an MRCS at the Royal College of Surgeons, specialising in plastic surgery. On his decision to go into plastic surgery after

On the increasing popularity of plastic surgery, he says, “I think it’s just become less taboo. People used to have a misconception that aesthetic procedures were only for vain people or strange people. Now it’s much more normalised, and people realise that these can be done subtly and well.”

Mr Cavale is the national secretary for the International Society of Aesthetic Plastic Surgery (ISAPS), president of the Royal Society of Medicine, trustee for the British Foundation for International Reconstructive Surgery and patron for King’s College London Medical School.

Despite his love of plastic surgery, Mr Cavale refutes the sometimes assumed notion that surgically-trained practitioners are of higher standing than non-surgical, stating, “I

speaking the same language. Particularly, we are now seeing more and more surgeons on social media, which is brilliant, as this means more messages relating to safety are now being publicised by both surgeons and our non-surgical colleagues.”

Mr Cavale believes that aesthetic conferences are a key part of bringing together surgical and non-surgical practitioners, commenting, “The annual London ISAPS Symposium I organise has been great for bringing the two together properly, as well as the CCR Expo done in conjunction with BAAPS, and I would encourage all practitioners to attend, even if just virtually this year. I’m proud to be a part of creating a community that encourages the sharing of knowledge and expertise with all colleagues.”

The most challenging thing about my career…

Patient expectations! You need to manage these in consultations, or the patient will always end up being disappointed.

Favourite procedure to perform…

At the moment it’s rhinoplasties – they’ve become a lot more popular and are now the most common surgery for me to perform.

Words of advice…

Never let yourself become bored! You’ve got the rest of your life to do that. Branch out.

graduating, Mr Cavale says, “For my first real job, I worked as junior house officer in plastics at The Middlesex Hospital. I really enjoyed working there and I could see how much the people I was working for loved their job too. What interested me the most was the fact that plastic surgery focuses on something different every time. Normally when you specialise in something medical, it focuses on just one part of the body – for example being an eye surgeon or a heart surgeon. Working in plastic surgery means you get to be a head to toe surgeon!”

He now has an NHS plastic and reconstructive practice in King’s College Hospital, London as well as working privately for the Cadogan Clinic in central London, specialising in breast surgery, rhinoplasty, blepharoplasty and prominent ear correction.

don’t think plastic surgeons are experts in everything, which has been an argument that has been put forward before. The way I see it, the gap should not be between surgical and non-surgical and instead should be between clinician and non-clinician. I think both surgeons and non-surgeon practitioners all agree that ‘non-medical’ people should not be offering treatments that are medical.”

He believes that it’s important for surgical and non-surgical practitioners to learn from each other, stating, “I think aesthetic surgeons and non-surgical aesthetic clinicians should definitely work together more. We have loads to learn from each other and have our own clear areas of expertise. Surgeons are also becoming more commercially minded, which is something that non-surgeons have always led on. This is great as it means we are finally

Alongside his surgical work, Mr Cavale has been doing humanitarian work in Gaza, a Palestinian territory, since 2014. The project sees him, and other British surgeons, help in local hospitals to treat war wounds and damaged limbs.

On adapting to the environment, Mr Cavale comments, “It was really tough at first. We were helping three-year-old children that had been damaged by bomb explosions and who faced life threatening injuries – of course that affects you. But it also helped me to grow as a person, because I was in a situation so far out of my usual comfort zone. I’ve been doing these trips for six years now, so I’ve got a lot more used to being around those kinds of things and I intend on going back out there once we can start travelling again.”

On his plans for the future, Mr Cavale says, “I never want to become complacent or bored, so I’m always looking for a new way to expand my skillset. I’d hate for my job or my life to become routine and repetitive –that’s why I have to keep taking part in new projects. I think it’s important for people to do that when working in this industry especially, because it’s a speciality that’s constantly changing and evolving.”

“I’m always looking for new ways to expand my skillset”

Mr Naveen Cavale explains how he went from went from medical school reject to esteemed plastic surgeon

The Last Word

The aesthetics specialty is exploding in size and scope with more practitioners than ever before. Patients are seeking more comprehensive and complicated treatments with potentially higher risks. With more competition, it’s vital for clinicians to differentiate themselves while ensuring their practices are running safely and smoothly. So what’s the obvious way to achieve this? Some may say, a Master’s in Aesthetic Medicine.

It’s not uncommon for universities to promise to ‘take your career to the next level’ and ‘significantly advance your clinical practice’.1 But your Master’s is a significant investment, financially and in terms of time. So, is it worth it?

The pros and cons of doing your Master’s in Aesthetic Medicine

Many practitioners want the same things. We want more and better patients, to be recognised for our hard work and, hopefully, one day be ‘known’ in the industry. We want a profitable practice that runs like a Swiss watch, and, most importantly, we want the confidence to treat patients safely and advance our scope of practice.

To become a master in any given field of medicine requires a deep understanding of the theoretical basics. Following this, you must pursue practical or vocational training followed by a lifetime of CPD, trial and error, hard graft and mentorship. There’s no doubting the prestige that comes with obtaining a master’s degree. It will elevate your standing within professional circles and help get you the recognition you deserve. It will also likely help you to improve the level of care to your patients. However, does it mean anything to our patients? Aesthetic medicine is progressing in complexity and patients are becoming more aware of the need to be treated by medical practitioners, perhaps because of the worrying number of accounts of botched procedures in the national press.2

Surely patients are going to be drawn to those letters? If they are deciding between two medical professionals, it might make a difference, but the hordes of non-medical practitioners doing a rip-roaring trade with not two GCSEs to rub together would

suggest otherwise. The other consideration is around practical learning. When we’re undertaking a Master’s in Aesthetic Medicine we’re starting at the beginning again and attaining the underlying theoretical skills, and these skills only. Be under no misconceptions; a master’s degree is an academic exercise. This means essays, scientific journals and research, and often very little practical teaching, certainly not focused on technical injecting skills. So, I believe that it remains to be seen how this can ‘significantly advance clinical practice’. If you’re at the start of your aesthetic medicine career, one could say there are much more effective routes to practical mastery including small-group practical courses and mentoring, rather than doing your Master’s straight away.

The real cost of university education

There is no getting away from the fact that aesthetic practitioners are small business owners. So it follows that any investment must be considered in terms of cost versus benefit.

The cost of a master’s degree is high. The final bill for the average master’s in aesthetic medicine is currently upwards of £16,000.3,4,5 This is a significant investment for most, and must be carefully balanced with the amount of additional revenue likely to be generated in practice. But let’s consider the real cost. What an economist might term the ‘opportunity’ cost.6 This is the cost associated with the time spent on this course versus time spent working on your business.

To achieve a decent grade, an averagely bright student would likely have to spend around two days a week on assignments for the 24-month period of study. In my practice, this equates to around £300,000 in lost revenue.

So, is it worth it?

When I am wrestling with the problems of growing my practice and developing a solid patient base I often ask myself whether it was all worth it. I completed my MSc in Aesthetic Medicine from Queen Mary University of London in 2016 after working in aesthetics for around six years. It was a hard-won academic achievement and made me extremely proud. I wanted to develop my

love for the subject because I love academic study and have a successful practice that generates enough profit. My knowledge was vastly expanded by doing my MSc, but from a practical point of view the exercise was futile, as I gained no technical injecting skills form the course. However, I was able to incorporate the knowledge into the daily care of my patients, which no doubt shaped me into a more comprehensive practitioner. I do think that it may not be the right choice for clinicians starting out because often novice practitioners lack the scope of practice or patients to apply the background knowledge they would learn in an MSc. Moreover, if you think it will transform you from a beginner to an expert, in my experience, you should think again. Remember as small business owners we’re trying to improve our practice, serve our patients better and create a profitable business. You have to ask yourself the question: by studying for an MSc are we solving any of these problems? What do those postnominal letters really mean for your practice?

Dr MJ Rowland-Warmann is the founder and lead clinician at Smileworks, based in Liverpool. In 2016 she completed her MSc in Aesthetic Medicine (with a distinction) from Queen Mary University of London. She has a special interest in the management of complications; writing extensively on the subject. She is also an trainer and expert witness in aesthetic medicine.

Qual: BSc, BDS, MSc Aes.Med. MClinDent Orthod. PGDip Endod. MJDF RCS (Eng)

REFERENCES

1. London, Q.M.U., Masters in Aesthetic Medicine - Course information, 2020. <https://www.qmul.ac.uk/postgraduate/ taught/coursefinder/courses/aesthetic-medicine-online-msc/>

2. Eley, A. and P. Walker, Campaign to tackle ‘botched’ cosmetic procedures. <https://www.bbc.co.uk/news/health-47967968>

3. University of South Wales, MSc Cosmetic Medicine (Online Delivery). <https://www.diploma-msc.com/p/msc-in-cosmeticmedicine

4. The University of Manchester, MSc Skin Ageing and Aesthetic Medicine. <https://www.manchester.ac.uk/study/masters/ courses/list/09805/msc-skin-ageing-and-aesthetic-medicine/>

5. Queen Mary University of London, Aesthetic Medicine Online MSc. <https://www.qmul.ac.uk/postgraduate/taught/ coursefinder/courses/aesthetic-medicine-online-msc/>

6. Investopedia, Opportunity Cost - definition, 2020. <https://www. investopedia.com/terms/o/opportunitycost.asp>

Dr MJ Rowland-Warmann asks, is a Master’s in Aesthetic Medicine worth it?

A

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