OCTOBER 2021: The Diversity Issue by Aesthetics

Model for illustrative purposes only.

VOLUME 8/ISSUE 11 - OCTOBER 2021

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Adverse Events in SOC CPD

Fillers for Darker Skin

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Dr Emmaline Ashley and Dr Amiee Vyas discuss skin of colour concerns

How to make skin of colour patients feel confident seeking filler treatment

Treating the Calf with Toxin Dr Varna Kugan explores the use of toxin to treat the lower leg and calf muscle

Making16/09/2020 Tax Digital

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Contents • October 2021 08 News The latest product and industry news 19 AMWC Conference Report

Aesthetics reports on the highlights from the 19th Aesthetic & Anti-Aging Medicine World Congress

20 Aesthetic Trends and Innovations at CCR

CCR puts the spotlight on future trends and innovations

23 Let’s Make 2022 Yours!

Get the recognition you deserve at the Aesthetics Awards

CLINICAL PRACTICE 25 Special Feature: Treating SOC Patients with Fillers

Three practitioners discuss making skin of colour patients feel confident seeking filler treatments

Aesthetic Trends at CCR Page 20

31 CPD: Diagnosing Adverse Events in Darker Skin

Dr Emmaline Ashley and Dr Aimee Vyas outline the management of adverse events in SOC patients

37 Treating the Breast

Mr Taimur Shoaib introduces modern approaches to breast augmentation

40 RELIFE Results: Top Tips for Business Success

Reinvigorate your business with RELIFE Definisse

45 Case Study: Lips in Skin of Colour Patients

Aesthetic nurse Lucy Williams discusses her method for treating SOC lips

51 Treating the Calf with Botulinum Toxin

Dr Varna Kugan explores the use of toxin to treat the lower leg and calf

56 BELOTERO Balance & BELOTERO Revive

Dr Chris Hutton shares his approach to using BELOTERO products

59 Managing Dark Circles in SOC

Dr Stephen Humble recalls the aetiology of dark circles in SOC patients

Special Feature: Treating SOC Patients with Fillers Page 25

63 Rejuvenating the Eye Area

Dr Angelica Kavouni outlines using Thermage FLX to treat the eye area

64 New Lip Filler STYLAGE Lips Plus

Dr Jasmin Taher discusses her experience with VIVACY’s new lip filler

65 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 67 Advertising vs. PR Julia Kendrick goes back to marketing 101 and how to use these tools in

your business

71 Making Tax Digital Jonathan Bardolph advises on the changes to taxation 74 Using Google My Business Rick O’Neill explains how Google My Business helps generate enquiries 76 In the Life Of Dr Dev Patel The Merz Innovation Partner talks about balancing his work/life schedule 77 In Profile: Dr Ifeoma Ejikeme Dr Ifeoma Ejikeme recalls her specialist training in aesthetics 78 The Last Word: Limitations in Training for SOC Khatra Paterson provides improvements for SOC training NEXT MONTH IN FOCUS: SKIN HEALTH • Peptides in Skincare • Understanding Hydroxy Acids

Clinical Contributors Dr Emmaline J Ashley holds a first-class honour’s degree in biology from Carleton College in the US and completed her honour’s degree in medicine from University College Dublin, and a Master’s in Surgery with the Royal College of Surgeons Ireland. Dr Amiee Vyas is the founder of Doctor Amiee Facial Aesthetics and Skin. She is a KOL and trainer in cosmetic dermatology, the founder of the Ultimate Aesthetics Mentorship Programme and a founding member of the Black Aesthetics Advisory Board. Mr Taimur Shoaib has been a consultant plastic surgeon for 15 years. Shoaib works in full time aesthetic private practice, where he has a surgical and non-surgical practice based in London and Glasgow. Lucy Williams is the founder and director of Aurielle Aesthetics. She has more than 10 years’ experience as a nurse and more than three years’ experience as an aesthetic injector. Williams has recently completed the Lee Walker Aesthetics Academy. Dr Varna Kugan is a JCCP-registered aesthetic practitioner with more than five years of experience and a special interest in East Asian aesthetics, based in Shanghai. He is the clinical director at PICO Clinics, with clinics in Europe and China. Dr Stephen Humble is a consultant and honorary senior lecturer in anaesthetics and pain medicine at Charing Cross Hospital. He qualified in Medicine at the University of Aberdeen in 2000 and holds a Level 7 qualification in Aesthetic Medicine.

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• @revisionskincareUK • #revisionskincareUK • #healthybeautifulskin

Editor’s letter This month, live events are back! It’s been a long time coming, but finally things are starting to feel a bit more ‘normal’. We know how hard the COVID-19 era has been for everyone, so we are delighted to be able to support your business and clinical learning once again, Shannon Kilgariff Acting Editor & as well as reconnect you to the aesthetic Content Manager community at CCR this October 14-15! You can @shannonkilgariff find out more and register for free on p.20. The past few weeks have really started to feel like the good old ‘conference season’ is back, which we all remember and love. The team have recently been to events by BCAM, IAPCAM, 5CC, ISAPS and AMWC, which all took place in September both in the UK and abroad – see our reports from p.17 to read the highlights. In the journal this month, we are aligning with October Diversity Awareness Month, a month to celebrate and increase awareness about the diversity of cultures and ethnicities. Last year, a survey by the

Black Aesthetics Advisory Board highlighted a lack of understanding of how to successfully treat and manage patients with skin of colour, so this month we aim to help shorten this gap and strengthen the industry’s knowledge. Read about treating patients with skin of colour using dermal fillers on p.25, recognising adverse events on p.31, and addressing dark under-eyes on p.59, with plenty more for you to learn throughout this issue! October also sees the release of the Autumn issue of Beyond Beauty magazine! Featuring the inspirational Katie Piper, who talks all things body confidence, we are delighted to release this resource to help open the world of aesthetic medicine to your patients. If you are a Full Member or medical professional subscriber within our database, you will receive a free copy with this journal. If you would like to order more copies that you can retail from your clinic – get in touch with Abigail.Larkin@easyfairs.com. Are you interested in seeing your name in print? We would love to hear from you! Contact us via email: editorial@aestheticsjournal.com

Clinical Advisory Board

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

WE WANT TO HEAR FROM YOU!

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

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

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

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.

Miss Elizabeth Hawkes is a consultant ophthalmologist and oculoplastic surgeon at the Cadogan Clinic in Chelsea. She specialises in blepharoplasty surgery and facial aesthetics. Miss Hawkes was clinical lead for the emergency eye care service for the Royal Berkshire NHS Foundation Trust. She is an examiner for the Royal College of Ophthalmologists.

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

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

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

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.

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.

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Education

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

#Aestheticsjournal Dr Victoria Manning @drvix.manning Honoured to have our article published in this month’s @aestheticsjournaluk on complication management following a COVID-19 vaccination

#Conference Dr Bhavjit Kaur @drbhavjitkaur Just finished presenting at @britishcollegeofaestheticmed conference 2021. Looking forward to learning from two days of jam-packed knowledge from other speakers

#Education Dr Xavier Goodarzian @drxavierg.md Training session for the amazing Wigmore Pharmacy team in SkinTech chemical peels and RRS mesotherapy #aesthetictraining

#Qualification Dr MJ Rowland-Warmann @dr_mj_smileworks Graduating a la 2021! I chose to do my postgraduate degree in Medical Education to be able to deliver better teaching #knowledge

#Teaching Dr Raul Cetto @drcetto It truly feels amazing to be back doing what I love, being live onstage sharing knowledge, meeting colleagues and interacting in person!

BCAM forms new committee The British College of Aesthetic Medicine (BCAM) has formed a new committee to inform and advise the board of trustees. The BCAM Regulatory, Ethics and Professional Standards Committee is chaired by Dr John Curran and comprises nine other BCAM members. These include aesthetic practitioners Dr Paul Cronin, Dr Eithne Deignan, Dr Bhavjit Kaur, Professor Rhoda Mackenzie, Dr Rita Rakus, Dr Julia Sevi, Dr Sam Robson, Dr Richard Sibthorpe and laser eye surgeon and ophthalmologist Dr Tahera Bhojani-Lynch. The committee will review stakeholder reports and statements, inform BCAM of decision-making on campaigning and ensure that the College’s Code of Conduct reflects the professional standards expected of its members. Dr Curran said, “I was honoured to be asked to lead this advisory group, which will focus on all areas of regulation and ethics pertaining to aesthetic medicine. The committee members have a great breadth of experience and are well placed to guide and advise BCAM’s board on these issues.” BCAM will be exhibiting at CCR on October 14-15, turn to p.20 to register. Business

Galderma releases procurement platform Pharmaceutical company Galderma has created a new e-platform named ONEBUY for all procurement activities. According to the company, these are related to The Indirect, Research and Development goods and services. ONEBUY will be used across Galderma entities and will become the access point for Source-to-Pay, from responding to and sourcing events, receiving orders, to getting paid, explains Galderma. For customers, Galderma explains ONEBUY will confirm receipt of any purchase orders online, send invoices electronically and free of charge, monitor the payment date of invoices online, update your vendor contact details and participate in any sourcing events. Galderma is the headline sponsor at CCR on October 14-15 – go to p.20 for more information. Distribution

Neauvia launches to UK market Medical aesthetics company Neauvia is launching Neauvia UK as its new sales affiliate in the UK market. Since 2012, the company has manufactured a hyaluronic acid filler with polyethylene glycol (PEG) along with devices and cosmeceuticals. As a result of its growth, Neauvia’s production sites and subsidiaries have extended to the UK and Germany this year. Tatiana Pala, marketing manager at Neauvia, commented, “I am delighted to announce the launch of ‘Neauvia UK’ at CCR. This will be the start of an exciting journey for the brand in the UK as an innovative medical aesthetics company.” Neauvia will be exhibiting at CCR on October 14-15.

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

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Injectables

Healthxchange to distribute Revanesse fillers Aesthetic supplier Healthxchange is now the official UK distributor for Canadian dermal filler brand Revanesse. Manufactured by Prollenium, Revanesse has been used in the US and Canada. The company explains that the dermal filler has spherical particles which provide a safety profile due to their shape and low levels of modification, aiming to reduce irritation, pain and swelling. The Revanesse range includes four products with different sphere sizes which address multiple indications. These include KISS with a low life capacity for lips and perioral lines; ULTRA with a moderate lift capacity for lips, nasolabial folds, marionette lines and temples; CONTOUR with a moderate/high lift capacity to volumise cheeks, chin, jawline and temples and SHAPE with a very high lift capacity to project cheeks, chin and jawline. Katie Bennett, head of marketing for Prollenium UK, commented, “We’re so excited to launch Revanesse into the UK. Working with such high-quality products and a company that truly listens to its customers is refreshing and thrilling to be a part of this forward-thinking team.” Prollenium and Healthxchange will be at CCR on October 14-15 – go to p.20 for more information. Filler

Croma unveils new injectable Aesthetic manufacturer Croma-Pharma has launched a new polynucleotide based injectable named juvenus. According to the company, the injectable has been developed for the treatment of various skin concerns of the face and body, including wrinkles, loss of skin firmness and skin tone. The aim is to hydrate the skin whilst restoring tissue elasticity, explains Croma. juvenus is available in two concentrations: juvenus 2% polynucleotide which treats deeper wrinkles, such as superficial perioral wrinkles, cheek wrinkles and medium scars; and the juvenus 2.5% polynucleotide which can treat medium-deep wrinkles and larger areas of the body such as the neck, back of the hands, abdomen, cleavage, thighs and glutes, and deep/large scars. Croma will market the product within its network of affiliated sales companies, including the UK, followed by other European markets via independent distribution partners. Andreas Prinz, managing director at Croma, commented, “Croma always strives to bring exceptional products to the market that meet the growing demands of our customers. With juvenus, we can offer a new and safe injectable with an innovative mode of action that targets the signs of skin ageing.” Croma-Pharma will be exhibiting at CCR – go to p.20 to register.

Vital Statistics The five-year melanoma survival rate for black people is only 67%, versus 92% for white people (American Cancer Society, 2021)

In a survey of 2,000 people, 30% are dedicated to more self-care since the pandemic began last year, including skincare, waxing and facials (Champneys, 2021)

In a survey of 7,878 people, 71% with a disability reported feeling negative about their body image, compared to 60% of people without a disability (House of Commons, 2021)

An average of 2.5 hours per day is spent on social networks and messaging (DataReportal, 2021)

92% of 201 people would welcome more research into all types of skin diseases, including skin cancer (British Skin Foundation, 2021)

Almost 2 million men in Britain are considering a cosmetic treatment, but don’t want to introduce unnatural substances into their body (Uvence, 2021)

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

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Events Diary 13th November 2021 The British Association of Sclerotherapy virtual workshop bassclerotherapy.com

20th November 2021 Aesthetics United Charity Conference 2021 aucc.co.uk

11th-12th March 2022 Aesthetics Conference and Exhibition 2022 aestheticconference.com

12th March 2022 Aesthetics Awards aestheticawards.com

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Periorbital

Revision Skincare releases eye serum Clinical distributor AestheticSource has launched the new Revox Line Relaxer for men and women wanting to reduce expression and under-eye lines. The serum aims to hydrate the skin, improve skin texture, reduce periorbital wrinkle length and area as well as reduce horizontal and vertical expression rhytids. In a clinical study, there was a 38% average reduction in the appearance of expression lines and under-eye rhytids after 12 weeks of using the Revox Line Relaxer with neuromodulator technology. Lorna Bowes, CEO of AestheticSource, said, “Revox Line Relaxer is a product specifically formulated to be paired with neuromodulators and is clinically-proven to enhance the neuromodulators to deliver significant improvement in expression lines, wrinkles and under-eye lines. This product is an exceptionally interesting new addition.” AestheticSource officially launches Revox Line Relaxer at CCR on October 14-15 – go to p.20 for more information. Device

14 & 15 October, ExCeL www.ccrlondon.com

Recruitment

Sofwave Medical expands team Aesthetic medical device company Sofwave Medical has appointed a new country director for the UK and Ireland. The company distributes Synchronous Ultrasound Parallel Beam technology through its device which remodels collagen and improves facial lines and wrinkles, explains Sofwave. Matt Hubball has joined the company after being a UK and international sales manager with Aesthetic Technology, and started his career as a sales representative at BTL Aesthetics. Hubball has seven years of experience within the aesthetic industry focusing on the commercialisation of products, establishing partnerships with surgeons, doctors and clinic owners throughout the UK and Ireland. Hubball commented, “This is an exciting time to join the Sofwave team given the company’s growth plans. I look forward to bringing my experience to help solidify Sofwave’s position as a global leader in the aesthetic space.” Sofwave will be exhibiting at CCR on October 14-15.

Lutronic launches in the UK Laser and energy-device company Lutronic has started selling directly to clinics. Previously, the company went through a UK distributor but are now distributing themselves. Products include the Spectra XT, a picosecond laser with four true-picosecond wavelengths; the Clarity II, a laser hair removal system with its IntelliTrak technology; LaseMD, a laser device to create microchannels in the epidermis to ensure penetration of Lutronic’s cosmeceuticals and the Genius, a dermal volumiser which acts on the dermis to re-densify the tissues and boost neocollagenesis. General manager of Lutronic UK and Ireland Dr Scott Julian said, “It’s a privilege to represent and lead Lutronic in the UK and Ireland as one of the world’s fastest growing aesthetic brands. I believe we go further than any other brand to standby our commitment to quality. We provide a minimum two-year comprehensive warranty on all systems.” Lutronic will be officially launching at CCR on October 14-15. Injectables

VIVACY introduces new lip filler Aesthetic product manufacturer VIVACY Laboratories has added STYLAGE Lips Plus to its lip filler range. According to the company, the STYLAGE Lips Plus is a cross-linked hyaluronic acid filler with added mannitol and lidocaine. The Lips Plus aims to provide volume to the lips whilst keeping them natural. It can be used to contour and add volume, explains VIVACY. Camille Nadal, director of VIVACY UK, commented, “We are thrilled to be launching the new STYLAGE Lips Plus in the UK. Lips are one of the most performed cosmetic treatments and we listened to the feedback from our practitioners to see what they had to say about it. We wanted to expand the lip range and give them the necessary volumising tool to perform glamorous yet natural results on their patients.” The filler will be available for distribution directly through VIVACY UK as well as Wigmore Medical and Church Pharmacy. You can learn more about STYLAGE Lips Plus at the VIVACY stand at CCR on October 15 and at VIVACY’s Symposium ‘The New Glam by VIVACY.’

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

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Celebration

Aesthetics Awards entry opens Entry for the Aesthetics Awards 2022 has officially opened. Acting editor and content manager Shannon Kilgariff commented, “We are so excited to welcome industry professionals and aesthetic companies back to the Aesthetics Awards in 2022. After a successful virtual event this year, we can’t wait to host our annual in-person awards ceremony to celebrate all the achievements and successes of the aesthetics specialty.” Three new sponsors for the Awards categories have been announced so far. DigitRx by aesthetic distributor Church Pharmacy will be sponsoring the Product Innovation Award. Professional skincare and antioxidant company SkinCeuticals will be supporting the Energy Device Award and aesthetic pharmacy SpringPharm will be sponsoring the Nurse Practitioner Award. Don’t forget to enter to be in with a chance of becoming a finalist, which will be announced in the January 2022 issue of the Aesthetics journal. For more information, and to enter, go to www.aestheticsawards.com or speak to the team at CCR. Entry closes on October 30. Education

Teoxane launches new consumer website Aesthetic manufacturer Teoxane has launched a new website on its products to enhance consumer education. The company conducted consumer research to find out commonly asked questions raised by the general public in order to create an educational hub for potential consumers to discover more about Teoxane products. The website also finds practitioners who stock their products within a 100-mile radius for patients. The feature within the website answers key questions to help determine what ideal treatment and product is most suitable for a patient’s skin concerns. The model images, which are used throughout the questions relate to the individual’s answers, highlighting different ethnicities, ages, gender and skin quality. After the questions, a Teoxane product will be recommended along with an in-depth overview. Video content has been incorporated into the site with industry experts adding their knowledge and answering frequently asked questions regarding the aesthetic treatments, as well as real-life testimonials from patients. Jordan Sheals, deputy country manager, commented, “We’ve conducted UK consumer research on a mass-scale, reaching more than 10,000 consumers in the process. It’s become clear that when it comes to dermal filler treatments, the landscape and mindset of the consumer is complex, and the consumer needs more from the aesthetic industry. Teoxane’s overarching goal is to aid the understanding of consumers when it comes to the evolution of dermal filler possibilities by humanising science.”

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

OCTOBER EVENTS Throughout October, the BACN is partnering with Church Pharmacy to deliver a full month of events looking at using a combination of skincare and injectables within your clinic. The BACN In Conversation With video series will be taking place on Tuesday 19th October via Instagram Live, and the InFocus digital webinar on Tuesday 26th October via Zoom. All BACN members have access to the events and are encouraged to take part. More details can be found on the BACN events page along with information on how to book.

CCR The BACN will be attending CCR in October and showcasing its Networking Hub at the conference. This is the first chance for BACN members to get together and it’s a real opportunity for newer members to introduce themselves and meet the team. CCR also has a range of members speaking over the two days: • Building strong patient relationships through effective consultations ― Mel Recchia • Becoming an independent nurse prescriber ― Anna Baker • Becoming a KOL or brand ambassador ― Anna Baker and Sharon Bennett • Tips for cost effective marketing and PR ― Emma Coleman • Emotionally dealing with causing an aesthetic complication ― Linda Mather

NEW STAFF The BACN has recently appointed two new staff members to the team at Head Office. Bec Coleman is the new marketing coordinator and has a strong background in event marketing, content creation, and customer service. Bec will be working on several exciting new projects at the end of 2021 and beyond as the BACN looks to deliver more services for its members. The BACN has also appointed Laura Watt as event coordinator after Tara Glover left in August. Laura has a wide range of skills along with a strong background within the events industry. She will be looking to run more events than ever in 2022, along with relaunching our physical events, whilst working closely with Gareth Lewis, BACN operations manager, to deliver the BACN Autumn Aesthetic Conference next year. The full team will be at CCR on October 14-15 so come and say hello and introduce yourself! This column is written and supported by the BACN

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

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Hygiene

Clinisept+ partners with CCR Clinisept+, an antimicrobial solution from product manufacturer Clinical Health Technologies, will be sponsoring CCR as the Skin Prep Partner. The company will have Clinisept+ products included in the show bags, which will be given away to delegates on October 14-15. Products include the Prep & Procedure to use before, during and following an aesthetic procedure and the Procedure Aftercare to help promote rapid recovery following an aesthetic or cosmetic procedure. The range is endorsed by the Joint Council of Cosmetic Practitioners (JCCP) and the Aesthetics Complications Expert (ACE) Group World due to its standards of hygiene and patient care, explains the company. Clinical Health Technologies director Ross Walker, commented, “I am delighted that Clinisept+ Skin is the official Skin Prep Partner of CCR this year. This is a fitting collaboration that reflects the industry-wide recognition that Clinisept+ has built as the leading skin prep and aftercare solution for aesthetic and cosmetic procedures.” Serum

Medik8 unveils new peptide Skincare company Medik8 has launched the Oxy-R Peptides. The peptides aim to address visible ageing, areas of hyperpigmentation, post-inflammatory pigmentation and uneven skin tone, explains Medik8. The key ingredient oxyresveratrol is an antioxidant that has brightening and anti-inflammatory properties. Due to its instability at high concentrations, Medik8 has 1% of the ingredient in the serum, distributed into two 10ml bottles, notes the company. Daniel Isaacs, director of research at Medik8, commented, “At Medik8 we tackle hyperpigmentation with gold-standard brightening agent oxyresveratrol. A gentle yet powerful antioxidant, in recent studies it has been found to be 33 times more effective than kojic acid, and it works by helping to block the enzyme tyrosinase from functioning – the key enzyme responsible for forming pigment in the skin.” Virtual

BAS to hold workshop The British Association of Sclerotherapists (BAS) is holding an online workshop. Consultant vascular surgeon Mr Philip Coleridge Smith will stream live demonstrations of foam sclerotherapy and microsclerotherapy whilst answering questions from the panel and audience. BAS board member Dr Martyn King said, “Many practitioners have carried out fewer sclerotherapy treatments due to the pandemic restrictions and there is a demand for sclerotherapy CPD to refresh skills and knowledge. This event aims to meet this need in an interactive format that encourages audience and panel participation.” The Early Bird rate ends on October 23 and the event is open to members and non-members. International guests are also welcome. The event will take place on November 13 at 11am-12:30pm GMT.

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Mistakes to Avoid with Your Photography

Photographer Hannah McClune’s monthly tips on how to strengthen your business through branding

1. Not showing yourself, your team or clinic Being a faceless business hiding behind a logo absolutely suits some companies. But not for those wanting to build a personal connection with their audience. 2. Only sharing before and after photos Visual proof of your work is important. Sharing patient results is an excellent way to do this. However, it isn’t the only thing to share and can feel repetitive. 3. Inconsistent photography style Having images that are different in style can make the photos feel disjoined, whether they are amateur/professional, dark and shadowy/light and airy, vibrant/muted. Keeping the images you share similar in style gives a polished impression. 4. Having an unplanned photoshoot Booking professional pictures in a rush won’t solve all the above problems. A photoshoot needs to be planned out over several weeks to meet all your needs and strengthen your brand effectively. 5. Not considering your brand or your ideal patient Most importantly, all marketing needs to be led by your branding and knowing your brand’s position, values and identity. This fits with knowing who the patient you are trying to reach is. These two things combined are powerful at leading your choice of imagery. This column is written and supported by Hannah McClune, owner of brand photography company Visible by Hannah. www.visiblebyhannah.com

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

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Education

New book on patient selection released Aesthetic practitioner Dr Vincent Wong has released a book discussing how practitioners can determine the appropriate procedures for patients. Decision Making in Aesthetic Practice: The Right Procedures for the Right Patients aims to guide healthcare professionals in selecting the most appropriate options for any patient. Topics include the cosmetic consultation, the skin, forehead, nose, cheeks, perioral region, chin, jawline and neck, scalp and balancing non-surgical and surgical clinical approaches. Dr Wong commented, “Releasing this book is a dream come true for me. I am grateful for the opportunity to publish with CRC Press, and thoroughly enjoyed working with a group of talented contributors. This book is written to be patient-centric, explore combination modalities for each area of the face, and to celebrate diversity and inclusion within the aesthetic industry.” To win a free copy of Dr Wong’s book, register for CCR and comment on our Instagram post! Collagen

LABthetics to launch LABpen at CCR Skincare company LABthetics will unveil its LABpen microneedling device at CCR in October. The device is CE marked and approved by the US Food and Drug Administration (FDA). LABthetics explains that the device works with the LABthetics active serums to induce collagen therapy and aid the transepidermal penetration of active ingredients. The LABpen has changeable headpieces which create micro-canals to deliver results. The device is an addition to a new line of microneedling products which include professional cleansers, toners, masks, and specialist serums, explains the company. Emma Caine, founder of LABthetics, commented, “We are so excited for a CCR launch. We have been working hard on our microneedling product line and are excited to introduce this to new potential clients. The microneedling line complements our professional range perfectly with our chemical peels and clinical facials.” CCR will take place on October 14-15 at ExCeL London – go to p.20 for more information. COVID-19

SpringPharm expands vaccination services Aesthetic pharmacy SpringPharm has extended its vaccination services for COVID-19. The clinic has been offering AstraZeneca vaccines since February but has applied to support Phase Three of the vaccination programme, which enables them to offer booster vaccines. The team have ensured additional space for the 15-minute post-vaccination observation area, as well as increasing the number of staff on site. Lee Ison, director of SpringPharm said, “We have ensured that patients have easy access to the site and that the process is as efficient as possible with minimal waiting times.” SpringPharm will be exhibiting at CCR on October 14-15 – go to p.20 for more information.

Dr Munir Somji, director of MediSpa Tell us about what you do... At my clinics I perform a wide range of procedures from hair transplant surgery to facial aesthetics. I am passionate about new and innovative treatments and Emerald Laser is the clinic’s newest addition. Can you tell us a little more about the science behind the Emerald Laser? Emerald is ‘non-thermal’ and uses harmless light energy at a specific wavelength that works systemically on a cellular level with your body. The effect of the laser creates a small transitory pore for emulsified fatty liquids in your fat cells to seep out, then your body processes the liquids through your lymphatic system naturally. The fat cells are shrunk not killed, so there will be no regeneration in other areas of the body. Why did you decide to get the Emerald laser into your clinic? We’re so proud to be one of the first in the country to offer such an innovative treatment. Patients love that all they need to do is lie down and let the machine do all the work. I also like the fact that it works in tandem with the patient’s body to help to improve their general health and wellbeing, empowering the body to repair, rejuvenate and restore itself. Erchonia has gold standard clinical evidence via placebo controlled, double blind, randomised, multi-centre clinical research which also was a big factor for me. How is it different from other fat loss devices available on the market? It’s proven to be enormously effective technology and it doesn’t use excessive heat or cooling preserving the endocrine function of the fat cell – which is really unique. Emerald can produce noticeable results in a short space of time and is the only technology to be given US FDA market clearance for overall body circumference reduction in patients up to 40 BMI, whilst also treating small pockets of fat and cellulite. The system is truly inspired by nature! This column is written and supported by

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

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Skincare

CellDerma skincare unveiled A new skincare line created by aesthetic practitioner Dr Dev Patel called CellDerma will be launching at CCR. The CellDerma products have been created to be used in combination with common aesthetic treatments to give natural results, Dr Patel explains. The range includes products for all skin types including two SPFs, a Hyaluronic Cream, Collagen Restore cream and the GF5 serum to name a few. According to Dr Patel, his patients have reported better healing from procedures such as ablative laser, gas-plasma and radiofrequency microneedling after using the serum. Dr Patel said, “We have brought together the science, technology, and intellect of leading labs from Switzerland and South Korea, to bring our patients and the wider public, skincare formulations that will take you towards perfect skin. I wanted to ensure that our formulations incorporated ‘clean science’ with only sustainable ingredients being used.” Partnership

GetHarley to distribute Meder Beauty Skincare platform GetHarley has partnered with skincare line Meder Beauty. According to the company, products and ranges are designed for specific skin concerns, and include the Red Apax for redness, Hydra-Fill for hydration, Lipo Oval for facial slimming, the peptide cream Myo Fix Concentrate to reduce deep wrinkles and lines on the forehead and around the eyes, Circa-Night Cream to rejuvenate skin and the antiageing Vita-Long Oil. Dr Tiina Meder, founder of Meder Beauty, commented, “We are thrilled to now be selling Meder Beauty through GetHarley as the platform houses the best skin professionals who are so knowledgeable about skin. After training with us, we trust them to recommend the best Meder products to their patients.” GetHarley will be at CCR on October 14-15 – go to p.20 for more information. Skin

Joddor London launches at CCR Professional skincare company Joddor London will be introducing its skincare line at CCR on October 14-15. The range includes seven products in its Skin Therapy System. Products include a cleanser, toner, exfoliator, a two-part dynamic treatment which aims to improve the appearance of sun damage and hyperpigmentation, a moisturiser and a SPF 50. Some of the ingredients include glutathione, an antioxidant to defend against environmental damage as well as vitamin C and E within the products. Founder of Joddor London Soumia El-Bouziani said, “As a physician, I have a duty to improve the quality of life of those who come to me for aid. I conceived the idea to create a skincare product that alleviated many, of the most common adverse skin conditions patients complain to me about. I believe that people will benefit from the initiative in a move toward making people’s lives much better.” Joddor London will be exhibiting at CCR on October 14-15 – go to p.20 to find out more.

K EEPI N G YO U S A F E AT CC R CCR is the flagship event for the surgical and non-surgical medical aesthetic communities bringing together the world’s leading practitioners to share and learn best-practice, discover the latest clinical developments and source new products from leading global brands. Health and safety are of paramount importance, and want to ensure that our attendees have absolute peace of mind whilst being able to experience the event, attend the conference sessions and see the latest products and innovations in a safe and sound environment. CCR’s steps to keeping you safe:

• COVID-19 status – proof of double vaccination or negative lateral flow test will be required to gain entry into ExCeL, as with all UK venues • Comprehensive cleaning protocols – all surfaces treated with hospital-grade disinfectants • Hand sanitisers – available throughout the exhibition floor as well as seminar and conference theatres • Online registration – register online and either print out your voucher or bring on your mobile and scan the barcode at our touchless scanning stations • Registration timeslot – choose your arrival time slot when registering so we can efficiently manage your entry into CCR • Smart badge – CCR’s smart badge requires no physical contact and enables you to swipe your badge to gather product and event information throughout the event • Face masks & social distancing – we encourage attendees to wear face masks in the venue and to observe social distancing Thank you for observing these guidelines – stay safe and we look forward to seeing you on October 14-15! Find out more and register now at

c c r lo n d o n . c om

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

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Conference report

BCAM Virtual Conference The British College of Aesthetic Medicine (BCAM) held its two-day Virtual Conference on September 10-11. Sessions, including skincare, fat reduction, injectable innovations, radiofrequency and microneedling were discussed. The skincare session opened with aesthetic practitioner and appointed appraiser and mentor for BCAM Dr Bhavjit Kaur exploring ‘Treating Hyperpigmentation with Efficacious Skincare’, followed by aesthetic practitioner Dr Manav Bawa. Consultant pharmacist prescriber Mary Keltai spoke on ‘The Science Behind Skincare’, defining what ‘organic vs. safe’ skincare means. She noted, “Close to 80% of the ingredients used within skincare products are from petra chemicals. You will retain patients if you can explain the science behind the skincare you recommend.” Aesthetic practitioner Dr Sophie Shotter discussed ‘Skin Conditions for the NonDermatologist’, adding, “Have a good network of professionals you can contact once you have reached the end of your expertise so you can pass patients on to them.” The session ended with immunologist Dr Ahmed Al-Qahtani. Kicking off the afternoon session was aesthetic practitioner Dr Selena Langdon, and national medical advisor for Novo Nordisk Nigel Morgan as well as consultant plastic, reconstructive and burn surgeon Dr William Van Niekerk discussing ‘Body Contouring and Weight Loss’. Conference report

IAPCAM, London On September 3, the International Association for Prevention of Complications in Aesthetic Medicine (IAPCAM) held its first live event in two years. The fourth symposium was held over Zoom, with delegates having access to all sessions, as well as a digital platform where they could visit virtual exhibitor stands. The day opened with Dr Beatriz Molina welcoming attendees. Presentations from Dr Ofir Artzi, Dr Tahera Bhojani-Lynch, Dr Emma Ravichandran, Dr Sophie Shotter, and Dr George Krompouzos followed. Following a coffee break and networking opportunity, session two, focusing on dermatology, was opened by Dr Ivor Lim. Dr Sandeep Cliff interviewed Dr Patrick Treacy, discussing his favourite methods for managing skin necrosis. Dr Xavier Goodarzian, outlined potential chemical peel complications, and Dr Cliff presented some dermatology case studies. Finishing the session, Dr Cliff, Dr Goodarzian, and Dr Treacy held a panel discussion. Session three focused on techniques on the upper, middle, and lower face. Talks were hosted by Dr Simon Ravichandran, Dr Francesco Romeo, Dr Bhojani-Lynch, and Dr Eyal Kramer. After a lunch break, Dr Sarah Hart discussed lower face fillers, and Dr Molina debated the use of cannulas and needles for the lower face. The fourth session concentrated on toxin. Dr Goodarzian explored how to avoid complications when using toxin in the upper face, and Dr Ravichandran outlined the common complications experienced in the upper face. Professor Bob Khanna discussed bruxism, and presented case studies of lower face complications using toxin. The final session was a welcome to IMCAS, hosted by Dr Treacy, member of the IMCAS Academic Board. The day was rounded off with a live Q&A with attendees.

News in Brief Lynton to host masterclass Laser and IPL manufacturer Lynton has partnered with DEKA to conduct a VIP SmartXide CO2 masterclass. The event will be open to medical practitioners interested in introducing DEKA CO2 into their clinics and will take place at the Royal Society of Medicine in London on October 13. Guest speakers include clinical director at Lynton, Dr Samantha Hills, and consultant, plastic, and aesthetic surgeon Mr Ali Ghanem. The masterclass will be followed by a champagne reception and private dining experience at Claridge’s. KYSENSE unveils new KOL Dermal filler company KYSENSE has announced consultant, plastic and reconstructive surgeon Mr David Gateley as its new KOL. According to KYSENSE, Mr Gateley is one of the key injectors in the next KYSENSE clinical trial in Lyon, which will be published once collected. Mr Gateley said, “The quality of the product through the science is unparalleled and therefore the characteristics meet all the requirements of a non-permanent injectable filler.” Acquisition Aesthetics expands to Ireland Aesthetic training provider Acquisition Aesthetics has expanded its training academy to Dublin. The faculty will be headed by nurse and facial aesthetics practitioner Patricia Molloy. Molloy has more than 20 years’ experience in aesthetic medicine and is the chairperson of the Dermatology Aesthetics Nurses Association Ireland (DANAI). The portfolio of courses will be available at the Dublin facility, and the first training date is scheduled for December 2021. The JTMS celebrates final mentorship day The Junior Trainee Mentorship Scheme (JTMS) by training provider Interface Aesthetics has completed its final Mentorship Day for its first cohort. The scheme was created to help junior health professionals gain training in aesthetics. As the first cohort nears the end of its course, each mentee will meet with one mentor to devise a personal development plan and organise the next stage of training, which means undergraduates can move to the next stage of the JTMS Mentorship (JTMS Advanced).

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

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Conference report

5CC Virtual World Congress The 13th 5CC Virtual World Congress took place on September 4-5, allowing delegates to access knowledge on dermatology and aesthetic medicine. The conference opened with a discussion on ‘How Covid has Changed the Face of Aesthetic Medicine’ through the use of mask-wearing. Numerous speakers participated, including dermatologist Dr Vanesa Piquero-Casals, Dr Tahl Humes and plastic surgeon Dr Thomas Rappl. Sessions on ‘Generation Z Entering the Market’ and ‘Thread Lifting’ followed. The afternoon kicked off with a business agenda held by marketing consultant Wendy Lewis. A talk on ‘The Digitised Aesthetics Practice: From Telemedicine to TikTok’ took place with congress president Dr Michael Gold, aesthetic practitioner Dr Uliana Gout, dermatologist Dr Didac Barco and Dr Vivian Bucay. Dr Gold, president of the congress, commented, “The 5CC has proven again that healthcare providers are excited to hear and learn from experts in aesthetics and medical dermatology from the best in the world. The event was a great success.”

ISAPS World Congress, Vienna The International Society of Aesthetic Plastic Surgery (ISAPS) held its annual international meeting as an in-person and digital event on September 11-13 in Vienna. Speakers at the event from the UK included Miss Rieka Taghizadeh, who discussed aesthetic ideals in autologous breast reconstruction and lipomodelling, Mr Nigel Mercer on BIA-ALCL, and Mr Paul Harris on breast implant selection, as well as others. A highlight was Mr Patrick Mallucci, who did several sessions all focused on breast implants, including how to achieve natural results, round vs. anatomical implants, and how to approach difficult breast cases. Plastic and reconstructive surgeon Mr Naveen Cavale, ISAPS UK national secretary, attended the event and was also a speaker. He commented, “It was great to see the ISAPS ‘family’ at work once more – it’s a truly global organisation that works so hard to represent plastic surgery. The content was world class and with it being face-to-face, it really did feel like a return to the ‘oldnormal’. Now we are working on ISAPS UK – which is being co-located with CCR on October 14 and 15 and will be another unmissable event, bringing surgical and non-surgical practitioners together!” Honorary president Dr Dirk Richter added, “In addition to a top-class programme featuring the best speakers in the world and the latest topics, the event had parallel live operations on pre-operated complication cases. Delegates enjoyed the reunion of the many friends and colleagues who were yearning to talk and meet with one another again.” ISAPS will have its co-located annual UK meeting at CCR on October 14-15. To register free for CCR and to get ISAPS tickets, go to p.20.

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

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AMWC, Monaco Aesthetics reports on the highlights from the 19th Aesthetic & Anti-Aging Medicine World Congress After two years of living in a mostly virtual world and being separated from career counterparts across the pond, industry professionals from around the globe were finally reunited at the 19th Aesthetic & Anti-Aging Medicine World Congress (AMWC), on the seafront at Monte Carlo, Monaco. Taking place between September 15-18, the conference hosted delegates from 130 countries, featured hundreds of speakers and held around 300 company exhibitors. Due to some countries still having COVID-19 restrictions in place, the event was hosted in a hybrid format this year, with co-founders Catherine Decuyper and Christophe Luino stating, “Moving to a hybrid model, this edition of the AMWC offered a unified meeting platform combining elements of a physical and virtual event, with the flexibility and choice to participate in person or remotely.”

Why perform one treatment, when you can do two? This was certainly a major theme throughout Thursday’s agenda, with Spanish dermatologist Dr Silvia Zimbres stating that using a combination of botulinum toxin and hyaluronic acid (HA) fillers is “always a good idea” during her talk for the day’s first session ‘Botulinum Toxin: Updates and Improvements’, which was co-chaired by Professor Bob Khanna. This was then followed by a session dedicated to combination treatments, chaired by ENT surgeon and aesthetic practitioner Dr Simon Ravichandran, which included discussions on the impact of combination treatments on patient satisfaction, combined treatments for lower face contouring: creating interesting shades and angles, and how to use HA combined with calcium hydroxyapatite in the same syringe. In a later session which covered the current hot topics in lasers and energy-based devices, Italian dermatologist Professor Leonardo Marini focused on chemical photopeels, presenting delegates with several case studies showing the positive outcomes of combining IPL and chemical peels for rejuvenation. The Thursday Croma-Pharma symposium featured a talk from its German key opinion leader Dr Matthias Aust, who provided delegates with a masterclass in all-natural facial rejuvenation using PRP and microfat, particularly focusing on their use around the perioral area. He noted that advancements in fat grafting have made it a safer treatment option, and although he doesn’t believe it will overtake other treatments due to its downtime, it’s something that will begin to grow in popularity. The Q&A portion of the session again highlighted the growing interest in combination treatments, with Dr Aust receiving five separate questions about his opinions on combining PRP and microfat injections with other procedures, for example with botulinum toxin and lasers. He responded, “As it’s a superficial treatment I love to combine PRP with other treatments for optimal results, and I do it very often in my practice. To me the question isn’t whether we should combine treatments, but more how we should combine them, and what techniques we should use.” The focus on combinations also continued into the second day of the congress, with aesthetic brand Neauvia discussing its new #NLIFT protocol. The presentation explained how the company has found that combining its HA fillers with its laser devices and topical skincare enables practitioners to achieve the best results, comparing each individual element to an

instrument in an orchestra which needs to work in synergy to create the ‘perfect sound.’ The UK launch of Neauvia will take place at CCR on October 14 and 15, turn to p.20 for more information. Advancements in dermal filler dominated the congress on Friday, playing host to two brand new launches. Aesthetic product manufacturer Laboratories VIVACY UK held a two-hour symposium featuring several live demonstrations to promote STYLAGE Lips Plus. You can read more about the product on p.64. Later on, Croma-Pharma introduced its very first injectable to the aesthetics market, a new polynucleotide filler named juvenus. More information on the filler can be found on p.8. Hosted by the company’s key opinion leaders Dr Agnieszka Surowiecka and Professor Wioletta Barańska-Rybak, the session discussed their favourite techniques and benefits of combining juvenus with the company’s new skincare range, croma farewell, and a following session showed case studies using the range, presented by Dr Monika Sulovsky. Discussing the two-day symposium, Dr Rita Rakus commented, “It was a delight to be back in Monaco at the AMWC congress and to reconnect with industry colleagues and peers. The team at Croma extended us a very warm welcome and were excellent hosts at the congress and the faculty events, and it was great to see the upcoming product launches including the exciting new PDRN technology and new Croma skincare.” Other highlights from the second day of the congress included a session on temple injections, chaired by UK aesthetic practitioner Dr Dev Patel, and a discussion on the most talked about topics among practitioners and patients surrounding thread treatments, featuring a presentation from clinical lead of the Aesthetics Clinical Advisory Board, Mr Dalvi Humzah, in which he provided delegates with advice on how to know whether a patient should be treated with threads or a surgical face lift. On the congress, Dr Patel commented, “As always, AMWC has delivered sessions suitable for all levels, from the best practitioners across the world. It’s amazing to have the opportunity to share our knowledge with one another. You throw all of that into an unbeatable, glamourous location, and you really do have the perfect conference! If you’ve never been before, I can’t recommend going to AMWC next year enough.” The 20th AMWC congress will take place in April next year, at the Grimaldi Forum, Monte-Carlo, Monaco.

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

Event Focus CCR

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AESTHETIC TRENDS AND INNOVATION UNDER THE SPOTLIGHT AT CCR

CCR puts the spotlight on future trends and innovation when the doors open in our new home at ExCeL London on October 14-15. This year is set to be the best year yet, reuniting an industry that has had such a turbulent 18 months, offering inspirational speakers, more than 150 leading aesthetic brands on the showfloor, new and exciting launches along with live demos and symposia set to motivate and educate.

Start-ups and new faces CCR is set to welcome several new and innovative brands this year. These include electronic companies aiming to make the patient experience more streamlined. Tap2App lets merchants use NFC-enabled smartphones as credit and debit card readers without plug-ins or wireless hardware whilst the SafeAP offers a new way to search and book your favourite medical aesthetic treatments. MAPIQ unites employees and aims to take your workplace to the next level, MeTime is an online platform that makes it easier for patients to find cosmetic treatments in their area and Collums is a new cloud-based practice management software helping practitioners and clinic owners run and grow their businesses. We are also welcoming The Aesthetics Accountant, who offer expert insight into the ins and outs of the medical aesthetics industry.

CCR will feature injectable trends, the latest and greatest in energy delivery devices, surgical protocols, skincare and more!

Aesthetics | October 2021

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Event Focus CCR

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CCR looks to inspire and advance the industry with a host of exciting brands, new launches, live demos, insightful symposia and events! CCR is also home to new skincare brands including LABthetics, a medical grade cosmeceutical skincare, created by professionals who formulate, test and manufacture all products in-house using only scientifically proven medical-grade aesthetic ingredients backed by scientific research. CellDerma, a brand born out of passion for all things skin, offers a range of skincare products based on ‘clean science’ whilst Prima Ultima offer unique premium dermal fillers. Dermafocus provides a range of innovative and diverse solutions to treat numerous indications through advanced skincare and non-invasive therapies and you also have the opportunity to see EvoCyte who distribute the multi-award winning VIVACE Microneedling RF device.

Big brands, symposiums, demos & more!

14 + 15 Octobe

CCR offers an excitin speakers, discussi non-surg

Leading brands Galderma, Vivacy, Lumenis, Allergan, Prollenium, RELIFE and more take to the stage at CCR with a variety of live demos and symposia. Ones to watch out for include RELIFE which will be hosting Dr Vincent Wong demonstrating the efficacy of the brand with a celebrity case study, Galderma KOLs Miss Priyanka Chadha and Miss Lara Watson discussing the secrets of lower facial transformations and worldrenowned Dr Arthur Swift delivering a Prollenium Symposium on OMGEE Curve, Mastering of the mid-face with Revanesse.

Aesthetic surgeries trending! 2021 sees the introduction of the first ever CCR Trends Report focused on future trends and innovations in aesthetics with the findings presented at the CCR Press Conference, taking place on October 14 between 10am and 12pm. Hosted by Francesca White, Beauty Editor-at-Large of Tatler and Editor of Tatler’s Beauty and Cosmetic Guide, the press briefing will detail all that’s new and exciting in both the invasive and non-invasive aesthetic disciplines and is sponsored by iconic brand Neauvia, a vibrant medical aesthetics company launching in the UK in 2021. Incorporating injectable trends, the latest and greatest in energy delivery devices, surgical Dr from Raj Acquilla protocols, skincare and other aesthetic services and with Q&As leading practitioners, this ground-breaking event is set to become a perennial mustGlobal attend.Key Opinion

Dr Qian Xu Clinical Lead Ai B Clinic

Leader

Recharge and reconnect! Attendees can make the most of an array of networking events celebrating the big reunion at CCR. Visit the Onsite Networking Hub, sponsored by Galderma and join the Networking Drinks from 17:00 on Day 1 sponsored by MedFX. As always, CCR looks to inspire and advance the industry with a host of exciting brands, new launches, live demos, insightful symposia and events which look to the future of the medical aesthetic industry.

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SCAN THE QR CODE TO REGISTER! CCRLONDON.COM

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Aesthetics | October 2021

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Aesthetics Awards Prepare Your Entry

Let’s Make 2022 Yours! Get the recognition you deserve at the most prestigious awards ceremony in aesthetics! Now is the perfect time to take stock of everything you’ve accomplished in the past year. Why not tell us about everything you’ve achieved and receive a reward for your efforts? The Aesthetics Awards brings together the very best in medical aesthetics and is open to those new and established to celebrate the achievements of the past year. Winning an Aesthetics Award, or even being named a finalist, is a significant acknowledgement of your efforts in the field. It can help you raise your profile and expand your marketing and PR prospects while presenting the perfect opportunity to be recognised by fellow professionals, peers and customers as the best in medical aesthetics. As limitations continue to lessen, we have decided to bring back the live Aesthetics Awards ceremony, with additional health and safety precautions in place. Entry will be open from September 30 to October 30, and the ceremony will take place following the second day of the Aesthetics Conference & Exhibition on March 12 at the Royal Lancaster Hotel, London. More than 800 people are expected to attend the stylish ceremony, which promises to be another memorable evening filled with entertainment, networking opportunities, and recognition of the industry’s toughest workers. In front of hundreds of like-minded peers, you may be awarded a Commendation, Highly Commended, or perhaps the Winner’s trophy, before dancing the night away in celebration.

W H AT DID L A ST YEA R’S F I N ALISTS THINK? “The Aesthetics Awards is a reward for everyone’s hard work all through the year. On the back of a really successful year, it’s really nice to have a party and to celebrate, whether or not we come home with the award. It’s great to just see people out of the clinic and out of professional conferences, to just have a really good night!” - Emma Chan “Congratulations to the Aesthetic Awards team for putting together such a great event in what are such difficult times! We certainly missed the usual fun of the live event, but hopefully, we can do that again really soon”- Jackie Partridge “I think this is probably one of the most well-known awards ceremonies within the industry so it’s always amazing to be associated with such a huge organisation and event. It’s incredible!” - Dr Sanjay Trikha and Dr Zoya Diwan “Fabulous afternoon! We really enjoyed watching our friends and colleagues in the aesthetics industry relax and enjoy and be awarded for all their efforts and hard work during COVID-19” - Melissa Pye

TO P TIPS O N ENTERI N G THIS YE AR TEOXANE UK The Aesthetics Awards panel are looking for a comprehensive, honest, and scientific entry. Our advice would be to include all the data that makes your product or service stand out – your authentic point of difference is what will ensure the judges understand your brand the way you would like them to. Be honest with your entry! Ask for customer/ colleague opinions to help write your entry statements and answers so that you know you are answering from real-life experience. ALISON TELFER The entry process is really straightforward; my advice is to start it early and allow a trusted friend or colleague to have a look at it. Even better if you can get a previous winner to cast their eye over it. Life very often gets in the way, so don’t leave it to the last minute, and don’t be shy – this is the time to shout from the rooftops about all the good stuff you do! DR EMMA RAVICHANDRAN AND DR SIMON RAVICHANDRAN • Involve your staff in brainstorming content for each answer • Collect written or video testimonials from patients and colleagues who will support your entry • Read each question several times, taking time to reflect on how you can answer concisely. Provide relevant and accurate information which you can support.

FIND YOUR CATEGORIES AND DOWNLOAD THE QUESTIONS SO YOU CAN START PREPARING YOUR SUBMISSION! If you have any questions please call our team on 0203 096 1228 or email contact@aestheticsjournal.com

O UR TO P TIP! What makes you stand out from the crowd?! Your entry should not only be supported by evidence, but judges will be looking for new and exciting developments, so be sure to highlight what makes you different from the rest! Aesthetics | October 2021

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So, if they come into your clinic requesting a Caucasian look for example, it’s important to be able to tell them what a realistic outcome of the treatment would be and explain why this is the case,” she adds.

Making your patients comfortable

Treating Skin of Colour Patients with Fillers Three practitioners discuss how you can make skin of colour patients feel confident seeking filler treatment in your clinic “Black people have never been treated fairly, and aesthetics is no different,” says Sharron Brown, aesthetic nurse prescriber and secretary for the British Association of Cosmetic Nurses (BACN). This is a sentiment reflected throughout the industry, with last year’s survey by the Black Aesthetics Advisory Board (BAAB) showing that there was a lack of knowledge, training and literature on treating skin of colour patients (SOC). In addition, 7/10 black patients said they had difficulties finding practitioners who were confident in treating their skin type, and 86% said aesthetic brands needed to be more culturally aware.1 With injectables remaining a hugely popular aesthetic treatment,2 Aesthetics spoke to Dr Simi Adedeji and Dr Tijion Esho, alongside Brown, to find out how practitioners can appropriately consult, assess, and treat SOC patients using dermal fillers.

Differences between ethnicities Knowing the anatomical differences between Caucasian skin and SOC patients is integral to a successful treatment, according to Dr Adedeji. This is also emphasised by aesthetic practitioners Dr Amiee Vyas and Dr Emmaline Ashley, who discuss how to recognise adverse events in SOC on p.31. Dr Adedeji explains that the signs of ageing are different depending on your skin tone, as with darker skin there is less wrinkling and less laxity, and often volume loss will occur later in life than in Caucasian skin. In terms of specific features, she explains that SOC lips have a ratio of 1:1 rather than 1:1:6 and have a greater projection. “Noses also have fundamental differences,” she says, “Because black patients tend to have a wider nose, the bridge is flatter with a less pointy tip, and in general it’s a lot shorter than Caucasian noses.” Knowing the anatomical differences between ethnicities helps to manage patient expectations, says Dr Adedeji. “We’ve all been there as practitioners where a patient brings you an image of someone famous and says, ‘I want this nose’ or ‘I want these lips’. Because SOC patients are anatomically structured differently to Caucasian patients, it’s not realistic for everyone to be able to get the same results from fillers. A black patient won’t be able to get a tiny, pointed nose with non-surgical interventions – it just isn’t possible because of the structural differences.

Filler treatments are something often not spoken about by people of SOC, says Dr Adedeji, and so going for a consultation can cause feelings of shame and guilt, greater than Caucasian patients. She explains, “Many black patients don’t view aesthetics as being for them and I have had patients who worry that getting work done betrays their heritage and culture. For example, I have one woman who’s been coming to me for years and never has she told a soul that she has any work done, because she feels that she would be massively judged by her community for it. This isn’t uncommon, because there’s a huge push in black culture about accepting who we are and embracing our culture/ heritage, so aesthetics may be viewed by some as going against that. Because a lot of SOC patients that present to clinics will be experiencing negative feelings around the experience, it’s even more important to make the patient feel confident and at ease.”

“You don’t have to be a practitioner with a darker skin tone to treat SOC patients, you just need to be knowledgeable on it!” Dr Simi Adedeji

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

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promotional materials, they have no black or SOC patients, or if they do, they’ll just have the odd one just thrown in. If a patient researches the dermal filler you’re using and is unable to find any examples of people who resemble them on their website, they’re not going to feel confident that this product will work for them and are unlikely to trust you to treat them using it. Even though it may well be perfectly fine, there’s no way for them to know this! You should only endorse what reflects you and your values, so clinics need to think carefully about using a brand/range that only uses Caucasian models.”

Marketing fillers to SOC patients

Figure 1: An example of inclusive marketing showing a range of skin tones

Dr Esho also emphasises the importance of practitioners making a conscious effort to understand the needs and wants of different communities. He says, “I do find that SOC patients are more nervous when presenting to clinic, but as I’m a black doctor I think patients feel more comfortable to discuss this with me, as they know I will automatically be empathetic and understand these concerns. For non-black practitioners this may be more difficult, and so ensuring that you understand these concerns prior to consultation can help alleviate worries that a patient may or may not tell you. Understanding what preconceived issues a patient group may have will help to increase the ability to reassure the patient, and therefore gives a better outcome for the consult and subsequent treatment.”

Potential complications Dr Adedeji emphasises that individuals with SOC have melanosomes and more active melanocyte cells, which create dark marks if the skin is pierced or damaged. “Black patients are more prone to certain complications, for example keloid scars or hypertrophic scars,” she says, “Because of this, practitioners need to make sure they’re gaining a comprehensive overview of the patient, medically and personally, before they agree to filler treatment. For example, it’s important to ask them how their body reacted when it experienced any other kind of trauma, such as any kind of body piercing or vaccine injection. If this sort of treatment left them with scarring, then it’s usually not appropriate to be giving them fillers.”

Dr Adedeji adds that when taking history from patients, it’s important to use terminology that they will understand. She explains, “Once I asked a patient whether she’d ever had any keloid scarring and she said no, but she did say that she’d had some small, raised bumps – which is exactly what keloid scars are! As practitioners we sometimes forget that patients don’t speak our language, and this could potentially lead to missing something vital. I also always ask patients to show me exactly what they’re talking about, so I can assess and diagnose it myself. Doing this can prevent SOC patients from potentially having to experience complications and negative effects.” On p.31, you can read more about how adverse events differ in SOC patients.

Product selection In terms of choosing what dermal filler to use, Brown has no preference based on a patient’s skin colour. She says, “As with anything in aesthetics, there isn’t a onesize-fits all approach. The important thing is knowing how to assess the patient correctly, and that practitioners are educated in anatomy, physiology and how the skin may react in various ways.” Dr Adedeji advises that when it comes to choosing what products or treatments to offer in your clinic, practitioners should take into consideration whether the company itself presents as being inclusive. She says, “As a practitioner, I don’t want to align myself with companies that don’t align with my ethos. There are a lot of brands that I think about using in my clinic, but when I look into their

All three practitioners agree that aesthetic marketing needs to be more inclusive of all skin types, but are conscious of ensuring this doesn’t result in SOC patients feeling separated from other ethnicities. “This reduces the risk of black patients being made to feel like ‘the other’,” says Brown. “If you make a big song and dance about being able to treat black and Asian patients, then it singles them out as a separate group to everyone else. So, while we absolutely need aesthetic marketing to be inclusive of all ethnic groups, it shouldn’t become a different strategy altogether,” she adds. Dr Adedeji agrees, noting that SOC should be integrated into all usual clinic campaigns. She says, “If you’re making an advert, don’t just have Caucasian models in the advert. If you’re posting images on Instagram, make sure you’re showing a diverse range of patients with different skin tones and colours. If you want to attract SOC patients to your clinic, they need to be able to see that you are inclusive and have experience in treating SOC.” Dr Adedeji advises that before and after images in your marketing can be a great way to showcase to patients that you can offer them good results. She comments, “What they need is to look at these images and be able to see themselves in the people that you’re showing. If they go on your Instagram and all they can see are Caucasian lips, noses, cheeks, how can they feel confident that you’re going to treat them effectively? There’s no evidence of you doing so! People like to recognise themselves in what they see, so ensuring that you show a variety of skin colours on your feed will help to reassure SOC patients that you know how to treat them and can also show what sort of

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

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“Understanding what preconceived concerns a patient group may have will help to increase the ability to reassure the patient, and therefore gives a better outcome for the consult and subsequent treatment”

notes, “Practice makes perfect! The more immersed a practitioner becomes in seeing black patients the better they will be at understanding the concerns, expectations, and anatomical differences. There’s only so much a book can show. As with anything in aesthetics, practical experience is invaluable!”

Resources for SOC education… • Black Aesthetics Advisory Board

Dr Tijion Esho

• Black Skin Directory

outcomes they can expect.” Dr Esho agrees, noting, “If we as black people don’t see us, we don’t feel it’s for us and that’s very important for practitioners and clinics to understand if they want to attract black patients.” As such, he encourages clinics to also ensure that they have diverse clinic staff in order to be able to appeal to people of different ethnicities. He says, “Being proactive in making sure your website and social media is inclusive can be hard as it needs to become a subconscious process to work long term. Making sure you have people on your team that reflect different cultures and listening to their thoughts can help, and if that isn’t possible, I would recommend consulting companies with services that specialise in this area, for example the BAAB or the Black Skin Directory.” Brown notes that this inclusion into marketing can also help to normalise the concept of black patients getting fillers. She says, “The more it’s spoken about and shown, the less we will have the stigma that I mentioned earlier. Promoting SOC injectables can make the whole thing less taboo and make patients realise it’s perfectly normal and fine to do – they’re not the only ones from their community who are getting procedures!”

people with skin of colour, there are definitely resources such as the British Association of Dermatology Skin Diversity Sub Comittee and an upcoming book by Dija Ayodele from the Black Skin Directory. It’s just a case of researching! Other useful resources are search engines such as, Google Scholar and PubMed which are completely free for people to use, there are studies and articles available. I also urge more practitioners to write articles, present case studies and conduct trials, so that we can get more information out there.” As discussed on p.78, Dr Adedeji agrees that practitioner education is paramount and believes that more training courses should integrate SOC into their curriculum. She says, “You don’t have to be a practitioner with a darker skin tone to treat SOC patients, you just need to be knowledgeable on it! Something I’m very passionate about is making SOC more mainstream in aesthetic training and education. For practitioners entering the industry, this is the best way to equip them with the correct knowledge needed to be able to treat patients with darker skin tones in the most effective way. Again, this doesn’t mean that there has to be completely separate courses that single different skin colours out, but rather it just be incorporated into the existing programmes.”

• Skin of Colour Update

• Centre of Evidence Based Dermatology Skin of Colour Resource3 REFERENCES 1. Chloé Gronow, Voicing the Specialty’s Diversity Concerns, Aesthetics journal, 2020, <https://aestheticsjournal.com/feature/ voicing-the-specialty-s-diversity-concerns> 2. American Society of Plastic Surgeons, National Cosmetic Procedures, 2020, <https://www.plasticsurgery.org/news/plasticsurgery-statistics> 3. University of Nottingham, Centre of Evidence Based Dermatology, <https://www.nottingham.ac.uk/research/ groups/cebd/resources/skin-of-colour/index.aspx>

Keeping educated Brown urges fellow aesthetic practitioners to expand their knowledge base to have the correct information to include all skin types. She says, “While there is a definite lack of resources out there on treating

While he also believes that practitioners should conduct research, Dr Esho advises that the best thing you can do is not to shy away from treating black patients, so that you can gain the necessary experience. He

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

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Diagnosing Adverse Events in Skin of Colour Dr Emmaline Ashley and Dr Amiee Vyas discuss the importance of recognition and management of aesthetic adverse events in patients with skin of colour Within the field of aesthetic medicine, there has recently been a growing recognition of a gap in clinician knowledge around skin of colour (SOC).1 This is partly due to a historical bias in Western medicine’s approach to dermatology, where white skin was considered the standard and default, and darker skin tones were relegated to being a curious footnote. This has led to a glaring lack of representation of SOC in the traditional medical curriculum and research journals.2 In fact, dermatology textbooks depict most skin diseases with images of light skin, with many textbooks containing no photographs of common concerns – like acne or dermatitis – in darker skin tones.3 Consequently many clinicians are not well-equipped to treat SOC, and our patients lack confidence that their skin concerns can be competently handled.2 To gain this trust, research suggests that patients with SOC disproportionately approach clinicians of the same race for treatment, if given a choice.4,5 A survey by the Black Aesthetics Advisory Board (BAAB) revealed the ongoing existence of knowledge gaps and myths concerning facial aesthetic treatments in SOC, and the need for clinicians to recognise nuances when approaching treatments in order to prevent and reduce the risk of adverse events in this patient population.5 Seven out of 10 black patients said they had difficulties finding a practitioner confident in treating their skin.5 Clinicians have a responsibility to be aware of these nuances, to avoid treating SOC homogenously, and recognise there is a wide spectrum of diversity within these groups.6 In this article, we summarise SOC nuances and how to recognise common and important complications when they present in patients with SOC.

Considerations in skin of colour Anatomy and physiology Skin colour and its response to sun exposure, as well as other superficial phenotypic differences, have long been used to classify people into different races.7 While it is acknowledged that these classifications are largely arbitrary, they are still used as the basis of broad racial and ethnic categorisations for SOC – including African and Afro-Caribbean, Asian and Pacific Islander, Latinx or Hispanic, South Asian and Middle Eastern.7 Most clinicians will be very familiar with Fitzpatrick skin typing – a classification system based on skin’s reaction to UV exposure.8 However, as the field of aesthetic medicine has expanded, there is growing recognition that the Fitzpatrick Scale is an oversimplified and outdated system to categorise SOC, lacking both consistency and understanding

of variation and photosensitivity in darker skin types.7,9 Broadly speaking, the unique colours and tones inherent in our skin are a consequence of the density and distribution of melanin pigment, haemoglobin, bilirubin, and carotenoids.8,10 All skin types have the same number of melanocytes: in darker skin melanocytes are highly active producing more melanin in a wider distribution.10 Melanosomes in SOC tend to be larger, more individually dispersed, and degrade more slowly than light skin.10 While the thickness of the stratum corneum is the same in all types of skin, the cells of the stratum corneum in SOC are more compact with more layers and greater intercellular cohesion.10 Additionally, the lipid content of darker skin tones has been described to be higher than lighter counterparts, while ceramide content is lower.10 The data on differences in transepidermal water loss and water content are inconclusive.10 In the dermis, evidence suggests that fibroblasts are larger and exist in greater number in SOC.10 This may explain why there is a greater propensity for hypertrophic and keloid scar formation.7 Additionally, collagen fibres are smaller and more compact in comparison to lighter skin tones, where they are larger with propensity for fibre fragmentation.10 There has not been a demonstrable difference in the elastin content between skin types.10 Additionally, there is huge diversity and variability between and within ethnic groups, and studies discussing the differences in anatomy and physiology thus far are small and methodologically flawed.7,10 It is therefore difficult to draw definitive conclusions, and is an area of expanding research and interest. Cultural considerations Clinicians should be aware of cultural practices relevant to the skin health of our SOC patients. This includes cultural stigmas, including concepts like ‘colourism’. Colourism is still prevalent in many communities – the misconception within people of the same ethnicity that lighter skin tones are preferable to darker ones.11,12 This may lead to the use of commercial and non-prescribed skin lightening or bleaching treatments, often found under-the-counter in beauty supply stores. The practice of skin bleaching is a public health concern affecting many SOC communities throughout the world and is harmful beyond the skin potentially causing systemic complications.7,11,12 Clinicians should also have familiarity with traditional beauty products and practices. For example, hair pomades popular in some African and Afro-Caribbean communities may contain mixtures of petrolatum or different oils, which can lead to seborrheic dermatitis of the scalp

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

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or acne formation.7 Many Asian communities still use traditional beauty practices like coining, cupping, or gua sha, an alternative therapy which involves scraping the skin with a massage tool to improve circulation.7 These practices can lead to characteristic, temporary skin changes, petechiae, and ecchymoses that clinicians should learn to recognise.13

Dyschromias Multiple epidemiological studies have revealed that dyschromias occur more commonly in SOC.14,15-17 Dyschromias are acquired conditions where cutaneous inflammation from a variety of different aetiologies can lead to hyperpigmentation, hypopigmentation, or a combination of the two – depending on the number and activity of the affected melanocytes.14 Post-inflammatory hyperpigmentation (PIH) is a very common skin concern in SOC, where there is an increased production of melanin in response to skin insult. It can be classified as either epidermal, dermal, or mixed depending on the location of the pigment. It is theorised that the degree of hyperpigmentation correlates to the severity and duration of the inflammation the skin has endured.18 The lesions typically present as small, darkened macules at the site of the original injury.14 Post-inflammatory hypopigmentation is not well-described in the literature, and the pathogenesis is not well understood. These lesions present as acquired areas of reduced pigmentation at the site of original injury to the skin. It is proposed that postinflammatory hypopigmentation occurs after inflammation or insult to the skin and leads to decreased melanin production, blocked transfer of melanosomes to keratinocytes, and melanocyte loss.19 The theory is that each patient has an individual chromatic tendency, with a predisposition towards either over- or underproduction of melanin in response to inflammation due to the inheritance of either ‘weak’ or ‘strong’ melanocytes. Weak melanocytes exposed to inflammation will produce less pigment, and strong melanocytes will produce more.20 There have not been alternative hypotheses proposed to this date to explain why some patients suffer hypopigmentation versus hyperpigmentation. The cornerstone of good management for all dyschromias is the prevention of further inflammation and excellent sun protection.21 Prompt initiation of treatments when managing dyschromias also aids faster resolution and prevents worsening of the condition.18 In addition, for aesthetic injectable therapies proper injection technique and using fewer injection sites will help decrease the trauma that could lead to risk of dyschromia.6 Prevention and management of dyschromias Evidence supports topical skincare treatments as first-line, with chemical peels and laser therapies as second-line treatments for refractory or dermal pigmentation.18,21 It is important to bear in mind that pigmentation disorders can be exacerbated by irritation caused by over-aggressive treatment,18,19 a slow and stepwise approach is therefore essential. There are a multitude of skincare ingredients that play a role in the treatment of PIH. Treatment often focuses on the use of tyrosinase inhibitors which halt the melanin synthesis pathway. The strongest evidence supports the use of triple combination therapies of hydroquinone (HQ), retinoids, and steroids, or monotherapy with retinoids or HQ.14 Topical retinoid use has also been supported by

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many studies in the treatment of acne-associated PIH in SOC.22 Topical hydroquinone is particularly effective when combined with a retinoid.22 Overuse or incorrect application of HQ can lead to side effects or complications (discussed below). For this reason, over-the-counter HQ is even banned for use in cosmetic products in Europe, Japan, and Australia,23 and it is vitally important that clinicians are well educated and its appropriate use. Azelaic acid has also shown promising results in early investigations into the treatment of acne-related PIH.22 Other tyrosinase inhibitors used to treat PIH include kojic acid, liquorice extract, arbutin, ascorbic acid and N-acetyl glucosamine.18 Niacinamide is another effective agent which inhibits melanin transfer.23 Chemical peels work by creating a controlled chemical injury, stimulating new skin growth, regulating the thickness of the epidermis, improving the uniformity of melanin in the basal layer, and inducing neocollagenesis.18,24 Safe and effective peel treatments for hyperpigmentation include glycolic and mandelic acid peels. It is a common misconception that these hydroxy acids cannot be used in SOC, due to the fear of triggering PIH. Proper counselling, patient education and informed consent are crucial.21 Skin should be appropriately prepared over a period of two to four weeks with a homecare regimen to protect and strengthen the skin barrier prior to their use. This priming can be done with topical depigmenting agents as described above.25,26 This reduces healing time, improves the uniform penetration of the peel, and reduces the risk inducing or worsening PIH.24 Salicylic acid peels (20-30%) have been shown to be a well-tolerated and safe option for treating SOC patients.24,27 While monotherapy has not been shown to be effective at PIH, combination treatments with hydroquinone and tretinoin may be beneficial.22 Glycolic acid peels are composed of the smallest molecular size of alpha hydroxy acid, so are able to penetrate more deeply into the skin.26 These peels can be both superficial and medium depth, depending on the concentration and length of time the peel is applied. When the skin is properly prepared, there are very minor side effects.26 A recent review of its efficacy showed complete resolution of PIH after six to eight peel treatments in SOC patients.26 It is particularly effective in combination treatment with tretinoin and hydroquinone.22,28,29 Using lasers to treat PIH carries significant risk of exacerbating the dyschromia, as some studies show either no improvement, or worsening of pigment after laser treatment.30 There is a lack of large randomised clinical trials in this area, and most studies reviewed were methodologically flawed.22,30 This is still an area that requires further research to determine the true benefits. However, current recommendations are that lasers may have a role to play in treating dermal pigment.14 A recent systematic review of lasers in treating post-inflammatory found that the best evidence supported the use of the Q-switched Nd:YAG laser.30 There is a lack of evidence on the treatment of hypopigmentation, hence treatment focuses on managing patient expectations, managing the underlying cause of the inflammation and advice on camouflaging methods.19 Some cases of hypopigmentation will self-resolve weeks to months after the inciting cause is treated.19 Topical therapies that have been trialled with varying success in case reports or small case series include calcineurin inhibitors, prostaglandin analogues, and psoralen plus UVA (PUVA) photochemotherapy.19 The use of laser therapy has shown some success in treating hypopigmentation with both non-ablative and ablative lasers in small studies.19,31-34

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

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Complication

Post-inflammatory hyperpigmentation

Epidermal

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Presentation

A darkened, red-brown papule in the area of the original insult to the skin

Prevention

- UV protection broad spectrum SPF 30+ daily - Avoidance/ treatment of drivers of skin inflammation - Good injection technique Skin priming - Skin preparation 2-4 weeks prior to cosmetic treatments

Dermal

Post-inflammatory hypopigmentation

Skin bleaching

First line - Triple therapy (8 weeks)14 or - Retinoid daily (12-18wks)14 or - HQ 4% BD (12 wks)14 or - 15% azelaic acid BD (16wks)14 Second line - Glycolic acid peel every six weeks14 - 4% HQ and salicylic acid peel14 Q-switched Nd:YAG laser (3-12 treatments)22,30

Acquired area of reduced pigmentation at a site of original insult to the skin

Skin – exogenous ochronosis, patchy depigmentation, dermatitis, black colloid milia and skin atrophy, reduced wound healing, infection Systemic – nephropathy, neurotoxicity, endocrine complications of long-term steroid use

Hypertrophic – raised, red areas confined to the edges of the original wound Hypertrophic and keloid scars

Management

Keloid – progressive scar tissue that extends beyond the edges of the original injury

- UV protection broad spectrum SPF 30+ daily - Avoidance/ treatment of drivers of skin inflammation - Good injection technique

First line - Conservative management and reassurance - Camouflage advice Second line (limited evidence) - Pimecrolimus 1% BD (16 wks)19

- Understanding of the culture and historical context of these practices - Patient-centred approach taking into account individual psychological and social factors - Non-judgmental communication - Patient education into harmful side effects of skin bleaching

First line - UV protection - Tension-free skin closure40 - Taping or silicone sheeting 12hr/day (2-3 months)18, 19 Second line (Limited evidence) - Flavonoids BD (4-6 months)18 - Pressure therapy 23hr/day (6 months)18

First line - Intralesional corticosteroid (TAC) injections 1-2x/ mo (2-3 sessions)40 Second line/Adjunct therapies - Scar revision (1 yr post primary closure)18 - Adjuvant radiotherapy (1-2 day after scar revision)18 - 585 nm pulsed dye laser (2-6 sessions) every 3-4wks18 - Cryotherapy (10-20s freeze-thaw cycles) in combination18 - 5-FU injections 50mg/mL once weekly (12 wks) in combination18

Table 1: How to recognise, treat and prevent common skin of colour issues

Skin bleaching and management Skin bleaching is the process of depigmentation of the skin through the use of topical and oral products.12 Long-term and incorrect use of products, which include prescription-strength hydroquinone, banned ingredients like mercury, and potent corticosteroids, are known to have serious health implications.35 This includes ochronosis (a blue-black hyperpigmentation consisting of macules), patchy depigmentation, dermatitis, black colloid milia and skin atrophy.12,35 Skin bleaching can also cause a deterioration in overall skin health, with impaired wound healing and wound dehiscence, as well as a predisposition to skin infections.35 Skin bleaching can cause systemic complications. Mercury use can lead to nephropathy, neurotoxicity, and memory loss.12,35 Widespread and prolonged corticosteroid use leads to steroid addiction syndrome, where withdrawal of a topical steroid causes severe burning only relieved by further steroid use.37 Long-term steroid application also leads to endocrine complications such as suppression of the hypothalamic-pituitaryadrenal axis, glucose intolerance, hypertension, and features of Cushing’s syndrome.12,35 The management of skin bleaching begins with open communication, establishing a relationship of trust where SOC patients are comfortable disclosing and discussing skin bleaching practices. A blanket recommendation to avoid skin bleaching is often completely ineffective if a clinician has no understanding of the cultural and historical context in which these practices take place.12 Rejecting or criticising the use of skin bleaching products will only further stigmatise patients.12 It is important to be aware that skin colour is often linked to concepts like socioeconomic status or marital prospects.12 There are also individual psychosocial

drivers for skin lightening, including feelings of being unattractive and pressure from relatives or friends.12 Clinicians should also be aware of the prevalence of these products on social media platforms, where health information tends to neglect to mention any harmful side effects.12 Current recommendations ask that clinicians adopt a multifaceted approach. Neutral, non-judgmental advice that is patient-centred and tailored to each individual is vitally important in discussing the health risks of skin bleaching.12,36-38

Hypertrophic and keloid scarring Hypertrophic and keloid scarring are the consequence of abnormal, pathological wound healing where there is disordered regulation of collagen production.39 This is a fibroproliferative disorder, causing both cosmetic and functional problems.40 In hypertrophic scars, this fibroproliferation is limited to the borders of the original scar, whereas in keloid scarring the scar tissue can extend far beyond these borders. Particularly in keloids, fibroblasts in these abnormal scars are more resistant to apoptosis.41 Keloid scarring occurs up to five to 15 times more frequently in SOC.7,42 However, in the case of aesthetic injectable therapies, it is important to note that the development of keloids following filler or botulinum toxin is rare in SOC, and dermal injury from needles is not associated with a significant keloid risk.6 Prevention and management of abnormal scarring For aesthetic treatments, it is advisable to avoid injectables and microneedling in patients if they have a known history of abnormal scarring to prevent its occurrence. Intralesional corticosteroid injections have an anti-inflammatory effect and reduce collagen synthesis and fibroblast proliferation.40 This is

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

THEIR LOOK

*Juvéderm® offers a range of facial fillers to answer a variety of needs, each of which is administered at a different dermal layer. We believe natural-looking, long lasting results are achieved by enhancing your client’s features, not changing them. The Juvéderm® Vycross® range of fillers includes five tailored products designed for a specific area of the face at the optimum dermal level. Which means you can offer your clients a bespoke and tailored treatment to help suit their needs.

To find out why Juvéderm® could work for your clients and your clinic on every level, visit juvederm.co.uk

Produced and Funded by Juvéderm®. UK-JUV-2150067 March 2021 ©2021 Allergan. All rights reserved. Model treated with Juvéderm®. Individual patient results may vary. Adverse events should be reported. Reporting forms and information can be found at https://yellowcard.mhra.gov.uk/ Adverse events should also be reported to Allergan Ltd. UK_Medinfo@allergan.com or 01628 494026.

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one of the first-line treatment options, but can be excessively painful leading to patient non-compliance.43 The most studied treatment is triamcinolone acetonide (TAC), injected from 10-40mg/mL one to two times a month.40 Between 50-100% of patients respond to this treatment, with approximately 9-50% suffering recurrence.43 There is also a growing amount of evidence supporting the use of more novel agents in scar treatment, including bleomycin, 5-fluorouracil, onion extract, imiquimod, and mitomycin C.43,44 Laser therapy can be used to improve the appearance of erythema, telangiectasia, or hyperpigmentation in abnormal scarring. The greatest evidence supports the use of pulsed dye laser 585 nm, particularly in combination with compression or steroid therapies.43,45,46 This is another area that requires further research to elucidate the exact devices and regimens that would be most beneficial for abnormal scarring. Additionally, radiotherapy and cryotherapy have been used as adjuvant or combination treatment modalities.40 Surgical revision of abnormal scarring used to be a common method of management. However, surgical intervention alone usually leads to disappointing results and high recurrence rates of keloid scars.40 Because these scars arise as a result of abnormal wound healing, recreating the original injury often leads to more pathological scarring. It does still have a role to play in some cases in combination with other therapies.

Final thoughts Initiatives like the BAAB, together with resources like the Centre for Evidence-Based Dermatology’s Skin of Colour Resource47 and Mind the Gap: A Handbook of Clinical Signs in Black and Brown Skin48 are trying to address shortcomings in medical education. Moving forward as clinicians, we must ensure we are both competent and confident in managing complications in skin of colour. Aesthetic brands must also ensure their devices and treatments have been safety tested on a diverse population and ensure this evidence is readily available to clinicians. This means that ultimately the responsibility is ours to seek out the knowledge and training needed to provide the best care for all our patients, no matter what their background or skin type. Dr Emmaline J Ashley holds a first-class honour’s degree in biology from Carleton College in the US and completed her honour’s degree in medicine from University College Dublin, a Master’s in Surgery with the Royal College of Surgeons Ireland, and a Professional Certificate in Clinical Dermatological at University College Dublin. She is completing her Level 7 Diploma in Aesthetic Injectable Therapies with Acquisition Aesthetics. She divides her time between working for the NHS and developing her own private aesthetics practice, Ashley Aesthetics. Qual: BA, MCh, MBBChBAO, PGCert Dermatology

Test your knowledge!

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

Which of the following structures has shown no demonstrable difference between skin types and colours?

Possible answers

a. Fibroblasts b. Elastin c. Collagen d. Melanosomes

2. Which of the following treatments

a. Glycolic acid b. Steroids c. Azelaic acid 15% d. CO2 lasers

3. Which of the following is not a known

a. Ochronosis b. Nephropathy c. Hepatitis d. Cushing’s syndrome

4. What percentage of patients suffer

a. 25-30% b. 11-15% c. 66-70% d. 9-50%

5. Which of the following statements

a. Patients with SOC

is not recommended in the management of post-inflammatory hyperpigmentation? complication of skin bleaching agents?

from abnormal scarring recurrence after treatment with triamcinolone acetonide? is false?

disproportionately approach clinicians of the same race for treatment. b. A blanket recommendation to avoid skin bleaching is the best approach. c. Colourism is still prevalent in many communities. d. Dermatology textbooks depict most skin disease with images of light skin.

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

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TO VIEW THE REFERENCES GO ONLINE AT WWW.AESTHETICSJOURNAL.COM The Black Aesthetics Advisory Board will be speaking at CCR on October 14 about diversifying your patient base. Go to p.21 to register for free!

Dr Amiee Vyas is the founder of Doctor Amiee Facial Aesthetics and Skin, Mayfair. She is a KOL and trainer in cosmetic dermatology, an expert trainer in injectables, the founder of the Ultimate Aesthetics Mentorship Programme and a founding member of the Black Aesthetics Advisory Board. She serves an international patient base in her clinics. Her passion is empowering skin confidence regardless of skin colour or concern, and she champions understanding skin of colour in her training courses, mentoring programmes and patient consultations. Qual: MBBS, BSc.

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

BELIEVE IN THE POWER OF SEEING. Ultherapy® is the only FDA cleared microfocused ultrasound technology that has real time visualisation (MFU-V).1,2 Real-time visualisation, enabling treatment customisation, precision targeting of tissues, and optimised patient outcomes 3 FDA-cleared and CE-marked so you can be confident of Ultherapy®’s good safety profile1

REAL-TIME VISUALISATION

The Gold Standard for non-surgical lifting and skin tightening, as determined by an expert consensus panel3

For more information visit Ultherapy.co.uk

@merzaesthetics.uki Merz Aesthetics UK & Ireland REFERENCES: 1. www.accessdata.fda.gov/cdrh_docs/pdf13/k134032.pdf Accessed September 2019 2. Ulthera release: Ultherapy® décolletage treatment now FDA-cleared. BioSpace website. https://www.biospace.com/ article/releases/ulthera-release-ultherapy-and-0174-d%C3%A9colletage-treatment-now-fda-cleared-/. Accessed January 21, 2020. 3. Fabi SG, Joseph J, Sevi J, Green JB, Peterson JD. Optimizing patient outcomes by customizing treatment with microfocused ultrasound with visualization: gold standard consensus guidelines from an expert panel. J Drugs Dermatol. 2019;18(5):426-432

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

Refer to the Instructions for Use (IFU) for complete instructions on operating the Ultherapy® System The non-invasive Ultherapy® procedure is U.S. FDA-cleared to lift skin on the neck, on the eyebrow and under the chin as well as to improve lines and wrinkles on the décolleté. The CE Mark indications for use for the Ulthera® System include non-invasive dermatological sculpting and lifting of the dermis on the upper face, lower face, neck and décolleté. Reported adverse events from postmarketing surveillance are available in the Instructions for Use (IFU ). Please see the available IFU in your country for product and safety information, including a full list of these events. © 2018 Ulthera, Inc. The Merz Aesthetics logo is a registered trademark of Merz Pharma GmbH & Co. Ulthera, Ultherapy, DeepSEE, SEE THE BEAUTY OF SOUND and the Ultherapy logo are trademarks or registered trademarks of Ulthera, Inc., in the U .S. and /or certain foreign countries. Merz Pharma UK Ltd. 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire, WD6 3SR Tel: +44 (0) 333 200 4140 M-ULT-UKI-0914 Date of Preparation March 2021

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Treating the Breast Mr Taimur Shoaib introduces the modern approaches to breast augmentation surgery Knowledge of surgical procedures is an important part of the skillset of all aesthetic practitioners, whether they are primarily surgical or non-surgical professionals. In an audit performed at my clinic, La Belle Forme in Glasgow, we reported that 22% of our patients who attended initially for a non-surgical treatment subsequently underwent a surgical procedure at our clinic. On average, the patient would wait 18 months after their first encounter at the clinic to undergo surgery. Patients often ask their non-surgical practitioner for advice on which plastic surgeon they recommend for surgical treatments. Non-surgical practitioners may feel that they are seeing a patient who wants a result that cannot be obtained non-surgically will need to refer the patient to a surgical practitioner instead to achieve optimum results. This article will provide non-surgical practitioners with an introduction and understanding of what surgeons are currently doing to maintain patient safety and excellent treatment outcomes for breast augmentation procedures.

Manufacturing breast implants A breast implant consists of a shell and filler material, which can be either silicone or saline. All implants, however, have a silicone shell. Breast implants are made through a mould, or mandrel, which shapes the liquid silicone. The mandrel has a mildly rough texture to hold onto the liquid silicone and this is heated to change its structure to solid

silicone. This action is repeated, creating a few layers in the implant. The layering structure prevents leakage of the filler material from the implant to the breast, and the implant shell is then filled with silicone. Nowadays, the majority of medical-grade silicone in the world is produced by Dow Corning, and is always cohesive gel silicone. Therefore, the silicone cannot leak out of the implant into the surrounding breast tissue, if the implant shell ruptures. The shell of a breast implant is given a roughened texture, and this is performed to reduce the likelihood of the long-term complication of capsular contracture (capcon), where the implant feels hard and distorts the shape of the breast.1,2 Any implant inserted into the body will elicit a reaction in which the body surrounds the implant with scar tissue. This scar tissue is completely normal but may thicken and harden over the years. It is believed that 1% of women every year will develop significant capsular contracture – after five years 5% of women, after 10 years 10% of women, and so on.1

the breast tissue. The reported risk was very low (1:24,000)3 and the disease was not aggressive in most women, with cures discovered from simply removing the thickened capsule.4 ALCL in association with breast implants was first diagnosed at around the beginning of the century but has gained increased attention among plastic surgeons in the past few years.5-7 The association with ALCL was seen with scepticism and surgeons were unsure of the relevance of the association. Practitioners did not know whether the disease and implant were linked; however, over the past few years, studies have shown that these links are correct.8 Implants associated with ALCL have textured surfaces, whilst implants that do not have this association are smooth with no texture.8 Smooth implants, however, have higher rates of capcon.3 This created a problem for surgeons as the decision to use smooth implants and risk capcon rates meant a high proportion of women would need to pay several thousands of pounds for surgery every time they suffer from capcon, or use highly textured implants and run the risk of ALCL. In the past few years, however, a new texture of implant has arisen – the nanotextured implant. The US Food and Drug Administration (FDA) and the International Standards Organisation (ISO) considers this texture pattern to be completely smooth.9 The texture depth, when studied under a scanning electron microscope, is around 16 nanometres or less, but compared with completely smooth implants, the surface areas of comparable implants are the same.9 The nanotextured pattern is made by turning the implant inside out once it comes off the mandrel. The slight roughness of the mandrel creates a pattern on the implant and is used to create the nanotexture. Currently, Nagor and Motiva are two breast implant manufacturers producing minimallytextured implants, which are considered to be smooth walled by the US FDA. The additional advantage of nanotextured implants is the low rates of capcon reported with the Motiva range, which has been out for long enough for reasonable data to be gathered.10-13

Modern techniques Breast implants and ALCL Until a few years ago, many plastic surgeons were using highly textured implants, until these became associated with anaplastic large cell lymphoma (ALCL). This refers to a very rare form of cancer that occurs in the breast lining but does not occur in

In my clinical experience, high quality and long-term outcomes are closely linked to modern techniques in performing breast implant surgery. We understand that implants with bacteria on them will more likely cause long-term problems. Accordingly, myself and many other surgeons now use methods

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

PROVEN POWERFUL PROFITABLE REAL RESULTS. PAIN FREE. MEDICALLY CE CERTIFIED.

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to reduce the bacterial load on an implant and reduce tissue trauma associated with surgery. These techniques include using intravenous antibiotics (an antiseptic solution to soak the implant), using nipple shields to prevent bacterial seeding from the nipple to the implant, changing gloves before handling implants, using a funnel to slide the implant into the pocket thereby preventing implant contact with skin, using meticulous dissection to create a precisely fitted pocket without blood clots, and using precise closure methods once the procedure is completed. Whilst some of these surgical methods are not new, in my experience, the combination of using all or most of them allows the surgeon to use the best techniques to give the best outcomes. In my view, the combined use of these methods has arguably led to a better, safer, and higher quality of care we can offer our patients.

Complications Despite surgeons being able to perform surgeries smoothly, there may be complications which arise that are associated with breast implant surgery. Early complications, such as infection and haematomas are rare and long-term complications can be reduced with some of the modern techniques described. Medium term complications can still occur and with the cost associated with breast implant surgery, it is not unreasonable to expect a certain amount of aftercare associated with cosmetic surgery. Medium term complications include implant movement and displacement, early capsular contracture, and skin stretching resulting from increased weight within the breast itself.14 Many surgeons offer an aftercare package for their patients. However, some surgeons will go as far as stating they will correct any complication they can within a year or so after surgery. Beyond that time, the complications are classed as long-term. These complications include changes with the ageing breast, the post-pregnancy breast and capsular contracture.14 Medium complication rates are low in breast implant surgery, and if a patient suffers through no fault of their own and through no fault of the surgeon, it seems fair to include a no-fault compensation scheme as part of the cost of surgery.15 The compensation would normally cover the cost of performing surgery within a fixed time frame, rather than compensation for other monetary losses. It is worth mentioning that Breast Implant Illness (BII) is a relatively new concern that

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has been gaining momentum in recent years. Symptoms can include hair loss, tiredness joint pain and headaches but there is debate among the community as to whether this is a genuine medical condition, or whether the symptoms actually relate to other reasons.16,17 There is limited data around the subject and more research is needed to fully understand the potential link between the individual patient and these symptoms. If a patient does experience any of these symptoms it is important that they report them to their surgeon.

Predicting outcomes One of the key questions patients will ask is: what will I look like after surgery? In my view, this is a question that can be answered through the experience of the surgeon, using computer simulation and using external expanders. Surgeon experience is a traditional approach to answering this question. The surgeon will ask the patient what look they are hoping to achieve, the patient is examined, and the surgeon maps a journey from where the patient is, to where the patient wants to be. Almost every patient in my practice, when asked what look they are hoping to achieve, says natural. However, this word has a wide range of acceptability that it is important to explore further by asking the patient what increase in size they want, what they want in the upper pole of the breast and whether an inner cleavage is important to the patient. Computer simulation devices are now available for predicting outcomes. These systems take photographs of the patient, adding volume to the breast so the patient can see what the computer thinks they will look like after surgery. Although they are a useful tool, clearly these systems have their limitations. They fail to consider the inevitable stretching of skin following expansion of the breast and no person or device can predict the effects of an increased volume within the breast and how this relates to time. All breasts will change with weight loss, weight gain, pregnancy, breastfeeding and time. Many manufacturers will provide external expansion devices to help inform the patient on what size they will be after surgery with a particular implant. These expanders are similar to the padding used in bras. The patient attends with fitting clothes, wears a non-padded bra and the external expanders are placed within the bra to give an approximation of the appearance in clothes, after using an implant size that correlates to the size of the expander.

Using a combination of some or all three of these allows the patient to have a rough idea of the results they will have after surgery. Predictability of outcomes is steadily improving as technology advances and is, of course, one of the most important aspects of breast augmentation surgery.

Wider relevance Measurement of quality is a fundamental part of every healthcare professional’s practice. The quality of outcomes can be measured in many different ways and for breast implant surgery, some of these measurements include the reduction of complications, improving patient satisfaction and long-term safety. Readers of this article are likely to be non-surgical practitioners, and you may be asking a very relevant question to yourself, which is: ‘Why do I need to know about breast implant surgery when I don’t do any of it myself’? The answer is that many patients I see have discussed surgery with their non-surgical practitioners prior to seeing me. The fact remains that your patients trust you and they want your advice. They will often follow your recommendations for non-surgical treatments, and they will also ask you about surgery. Although the discussion may not go into a high level of detail, your patients will appreciate any help you can give them in helping with decision making. Disclosure: Mr Shoaib has worked as a consultant for Nagor and Allergan, which manufacture breast implants. Mr Taimur Shoaib has been a consultant plastic surgeon for 15 years and performed his first cosmetic breast augmentation procedure in 1998 when the NHS used to perform cosmetic surgery for eligible patients. Mr Shoaib works in full time aesthetic private practice, where he has a surgical and non-surgical practice based in London and Glasgow. Mr Shoaib has won several awards including Best Cosmetic Group UK, Best Cosmetic Clinic Scotland and Best Reception Team UK at the Aesthetics Awards. Qual: MB ChB, FRCSEd, DMI(RCSEd), MD, FRCSEd (Plast)

VIEW THE REFERENCES ONLINE! WWW.AESTHETICSJOURNAL.COM

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

Advertorial RELIFE

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RELIFE RESULTS: Top tips to business success Reinvigorate your business with RELIFE Definisse Before the craziness of all things Christmas descend upon us, it is good to take time out and reflect on what can only be described as a ‘challenging’ year. The pandemic brought with it new ways of working, as well as changes to the types of services offered to patients. Efficiencies gained from the use of tele-consultations and online consent forms may afford you more treatment time if adopted as standard moving into 2022. Annual business planning also affords the opportunity to review the success of services and treatments you offer, both in terms of patient satisfaction as well as the revenue they deliver. It might be a time when

you are open to looking at new suppliers and new treatments, or streamlining the back end to deliver increased profit margins. RELIFE Definisse, the aesthetics arm of one of Italy’s leading pharmaceutical companies, A. Menarini, is one of the only aesthetic ranges offering peels, filler, and threads. Perfect for today’s combination approach to meet the needs of patients. RELIFE’s ‘one stop shop’ provides lab-grade products matched with a gold-standard training programme to ensure consistent, quality results that patients return for again, and again. We asked RELIFE’s KOLs for their top business building tips on how to achieve the best results possible…

REfine your audience “Pinpointing my target market has enabled me to tailor services and offer specialised treatments for patients,” explains aesthetic practitioner and RELIFE brand ambassador, Dr Vincent Wong. He adds, “In parallel with growing the business as a whole, I have developed a specific expertise working with the LGBTQ+ community.” Dr Wong recently treated RuPaul’s Drag Race stars Bimini Bon-Boulash and Baga Chipz. He employed a range of procedures to feminise certain facial features including the use of RELIFE Definisse threads. He continues, “I use RELIFE threads to give the most reliable results in terms of holding the skin and underlying tissues in place, safely and securely.” Before

After

REestablish ‘Beauty of the Moment’ As we move closer towards the party season, we see a shift in the kind of treatments and procedures patients look for. “Glowing, healthy skin are common requests,” says aesthetic doctor and RELIFE ambassador Dr Simon Zokaie, “More and more patients look for revitalising facial treatments so that their skin looks its best, pre-Christmas.” He continues, “The UK winter always leads to dry and dull skin caused by more time indoors, the heating turned up, and vitamin D levels lowered. Patients want treatments to ‘wake up’ their skin and get rid of ‘tired-looking’ complexions. I recommend treatments like Definisse Hydrobooster, which replenishes lost moisture, and gives great results with no downtime – patients love how their skin looks and feels.”

RELIFE Beauty of the Moment Winter Webinar 4th November Discover the benefits of introducing RELIFE into your clinic with insights and presentations from Dr Vincent Wong, Dr Martyn King, Sharon King and Dr Puneet Gupta. Dr Wong will also be presenting an exclusive celebrity case study transformation. Bimini Bon Boulash before and after Definisse threads

Aesthetics | October 2021

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Advertorial RELIFE

Clinic Case Study: The HUNAR Clinic The Hunar Clinic, based in Gerrard’s Cross, was awarded this year’s Aesthetics Award for Best New Clinic UK & Ireland, sponsored by RELIFE. Providing patients with the latest top of the range treatments is key to the Hunar Clinic’s success. We talk to them about how and why they decided to start working with RELIFE Definisse and the difference it has started to make. Top tier training The first step in the RELIFE journey prior to even placing an order, is to sign up for one of their training courses. Learn all about the products, when and how to use them and get the best results. Tutored by some of the best in the business, training is held in small intimate groups. Designed to build confidence, delegates are invited to take part with live models. “RELIFE gave us hands-on training – the perfect mix of practical and theory,” says Dr Puneet Gupta, aesthetic practitioner and co-founder of Hunar Clinic. “We felt completely confident about using RELIFE knowing that we had access to our trainers if needed.” He continues, “The natural look we achieve with RELIFE fits in with our clinic’s overall ethos – a perfect addition to our portfolio.”

A 360º treatment approach With the RELIFE Definisse range of aesthetic products, you can be confident that your patients’ needs can be effectively met. “Mix and match is very much part of today’s approach for bespoke, natural looking rejuvenation solutions,” says Dr Gupta. He adds, “We find that the majority of our clients want subtle tweaks over time, rather than a dramatic change in one go. The fact that we know the Definisse aesthetic range is lab-grade and from the same pharmaceutical company is reassuring in itself,” Dr Gupta continues, “We are confident that the products work seamlessly together, and equally well on their own. Patient feedback has been very positive.” Colore: P. 296 C

The REassurance of continuous support With the spotlight firmly on training, RELIFE provides an exclusive online educational platform where once trained, customers can access a continuous programme of events and training modules. “The good thing about RELIFE is that their support doesn’t just end once you’ve undertaken the training and made your first order,” says Dr Gupta. “Working together feels like a journey – whether you have questions about the products, or want to boost your clinic’s marketing, RELIFE is there throughout.” Aesthetics | October 2021

This advertorial was written and supplied by RELIFE

For more information about RELIFE Definisse, the products and the training programme, visit www.relifecompany.co.uk or come and meet us at CCR, Stand D28 PP-RL-UK-0384, Date of preparation Sept 2021, GB21187

RELIFE at CCR 2021 14th – 15th October Stand D28

Visit us at stand D28 and meet with our special guest to discuss her incredible transformation using the DefinisseTM range of fillers, peels and threads from RELIFE. Or scan to keep up to date with the latest from Menarini

Filler SKUs CE0123 – CROMA-PHARMA GmbH, Industriezeile 6, 2100 Leobendorf, Austria

Hydrobooster CE0459 CROMA GmbH, Industriezeile 6, 2100 Leobendorf, Austria

Threads CE0373 Assut Europe SpA, Via G.Gregoraci, 12 00173 Roma, Italia

Peel Program CE Mastelli S.r.l., Via Bussana Vecchia 32, 18038 Sanremo (IM)

Intended for UK healthcare professionals only

The UK’s leading medical aesthetic event at ExCeL London

Illustration does not show all packs available in the range

The Definisse™ range from RELIFE.

REsurface, REstore, REshape.

My skin says how I feel Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or App Store. Adverse events should also be reported to A. Menarini Farmaceutica Internazionale SRL. Phone no. 0800 0851497 or email: medinformation@relifecompany.co.uk

relifecompany.co.uk PP-RL-UK-0370

GB21177

September 2021

HAS GROWN TO BECOME

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MOST DIVERSE RANGE

needs

OF FILLERS

1,2

TO ANSWER THE EVOLVING

OF YOU AND YOUR PATIENTS

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Adverse events should be reported. For the UK, Reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for Yellow Card in the Google Play or Apple App Store. For Ireland, Suspected adverse events can be reported via HPRA Pharmacovigilance, Website: www.hpra.ie; Adverse events should also be reported to Galderma (UK) Ltd, Email: Medinfo.uk@galderma.com Tel: +44 (0) 1923 208950 References: 1. Data on file (MA-33939). 2. Öhrlund A. Poster presented at AMWC 2019. 3. Carruthers JD et al. Plast Reconstr Surg 2008;121(Suppl 5):5S–30S. UKI-RES-2100115 DOP September 2021

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Case Study: Treating Lips in Skin of Colour Patients Aesthetic nurse Lucy Williams discusses her method for treating skin of colour lips The golden ratio is considered an important concept for treating the face in medical aesthetics, and in terms of lip treatments it refers to where the lower lip should be 1.6 times thicker than the upper lip.1 While this is true for the Caucasian face, it does not apply to all ethnic groups.1 Certain skin colours, in particular black skin patients, genetically have greater lip volume as they age. This is due to increased melanin in darker skinned patients, which helps protect the skin against ultraviolet radiation and cause the skin to be protected throughout the patient’s lifetime, shielding the skin against damage to the DNA2 and ultimately resulting in patients of racial origin having a greater lip fullness.3 Skin of colour is also less prone to solar elastosis, a degenerative condition of elastic tissue in the dermis due to prolonged sun exposure, which causes the skin to become thicker (also known as photoageing).3 It is normally found in patients with fair complexions, negatively affecting the production of collagen and elastin.2 Due to this, skin of colour patients rarely develop radial rhytids (fine lines and minor creases) in their lips and vermilion border, resulting in more volume within the lip regardless of ageing.4 Therefore, in the case of black or mixed-race patients, the ratio of their lips should typically be 1:1 rather than 1:1.6.1 As such, when treating skin of colour patients, practitioners should ensure that they are able to assess and treat the face differently. In terms of lip filler treatments for ageing skin of colour patients, they may seek to restore the youthful fullness of their lips. In this case it is more common that the injectable product is placed only in the upper lip, as the lower lip usually maintains its volume.5 It is also found that decreased lip volume and perioral lip lines are also more pronounced in Caucasian skin, likely due to a combination of muscle action and the deleterious effects of UV exposure on lighter skin.6 So, it may be more likely that perioral lines are less likely to be a concern for patients with darker skin.

Case study Consultation and assessment A 30-year-old skin of colour (mixed race white and black Caribbean) female patient presented to my clinic with concerns of a general lack of definition to the lips and a lack of volume in the

top lip, which she felt had worsened with age. A thorough understanding and assessment process will result in a better understanding of the aesthetics of the lips and consequently a more successful treatment plan and outcome. As such, I spent around 45 minutes undertaking a full consultation which included a full facial approach and gave the patient all the information about the treatment, so that fully informed consent could be given. It is also important to fully understand the patient, who they are, and their motivations for treatment to help manage patient expectations and give them a good treatment outcome. The patient had no relevant medical history and had never had any aesthetic treatments before. To add to this assessment, mental health, social and economic factors were also undertaken. My assessment determined that my patient was a previous smoker, exercised regularly, ate healthy and had no sun damage concerns. Undertaking a full medical consultation enables us to give an understanding of the patient’s reason for treatment and for us to develop a safe treatment plan. Lips are three dimensional and it’s important to assess the profile as well as the front view. There are three basic types of facial profile. A straight profile, also known as the straightjawed or orthognathic, is where the nose, lips and chin are almost inline; a convex profile, also known as the retrognathic profile, has a retruding chin, long nose and prominent mouth; and a concave profile, also known as the prognathic profile, is characterised by a bold lower jaw and chin.7 The angle of convexity of 8-16° indicates a straight profile, while an increased or decreased angle is an indication for convex or concave profile.8 As such, I identified that my patient had a

As the patient wanted natural looking lips with volume and definition, the correct product selection was key

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

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Before

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After

Figure 1: Patient before and after treatment using 1ml of Restylane Kysse

straight profile, which gave an indication of how much volume I could add to the upper and lower lips to keep the profile straight and the results natural. From the assessment I also noted that the patient had a slight natural asymmetry to her top lip in which her right top lip had more height and her bottom right top lip had slightly more volume than the left. It is important to point out asymmetries to patients so expectations can be managed, and they do not have unrealistic outcomes. There are limitations to dermal fillers especially when treating asymmetrical areas.10 Pre-treatment As the patient wanted natural looking lips with volume and definition, the correct product selection was key. I decided to use the Restylane OBT range, which contains soft gels with varied degrees of cross-linking and a high flexibility to provide natural looking effects.11 With my patient wanting volume and definition I decided that Restylane Kysse was the perfect choice to give my patient her desired outcome, as this filler is specifically formulated to enhance, define, or augment the lip body and border.11 Before any treatment is carried out, I always recommend that the patient has a coolingoff period to take in all of the information so they can make a fully informed decision. I recommend a cooling-off period of two weeks as recommended by the General Medical Council (GMC).12,13 Pre-treatment instructions were given including no alcohol, anti-inflammatory and antiplatelet agents for one week prior to treatment, unless medically necessary, to reduce the risk of vascular injury such as swelling and bruising post-treatment .14,15 Treatment Before any treatment, I always take pretreatment photographs to document the results. The patient’s makeup was then removed from the lower third of the face using Clinisept+ Prep & Procedure. I find

this a great method of cleansing the skin before any aesthetic treatment as it employs an oxidising method of action, which is not only more effective in removing microbial contamination but is also gentle on the skin. EMLA cream was then applied to the lip area, and we waited for approximately 15 minutes for the area to numb, after which I once again cleaned the lower third of the face with Clinisept+. The patient’s asymmetries were marked out with a white pencil and documented, and the patient was laid down to a flat 180-degree angle to begin the treatment. As the asymmetries were already identified, I corrected these asymmetries first before adding volume. In my experience it is much easier to fix asymmetries first and add definition with a needle, rather than a cannula. I used a 30 gauge needle to inject 0.1ml into the submucosal of the left side of the Cupid’s bow, using a tenting technique to adjust the asymmetry. I then added 0.1ml to the lower left side lip body to correct the asymmetry on the bottom lip. I sat the patient up to a 90-degree angle to check that the asymmetries were corrected, which they were, and once I was satisfied that this had been addressed the patient was laid back to add definition and restore lost volume. Again, I used a tenting technique for the top lip, starting at the Cupid’s bow continuing along to the oral commissures. The tenting technique provided definition to the lip border, and I then added a small amount of volume to the main body of the lip. To do this I used a linear threading technique to the three small tubercles on the upper lip and two on the lower lip, which gave the shape of the lips its individuality, something that should be preserved during augmentation. Following the treatment, the area was cleaned with Clinisept+ Aftercare and a lip ice pack was applied for approximately five minutes, which I find can help prevent erythema and oedema. Post-procedure photographs were also taken, and I documented in the patient’s notes how

much product had been injected and to what area of the lip. It is important to document the treatments performed for patient follow-up appointments to ensure continuity, and in case any complications arise such as skin necrosis. Results Immediately after the treatment there was minor swelling and no obvious bruising, and the patient was advised that this would rectify itself within 48 hours, with the lips taking up to two weeks to fully settle. It is vitally important that all patients are given relevant aftercare advice to reduce the risks of side effects and complications, for example no makeup should be applied to the area, no heat exposure, no exercise, no alcohol, and no smoking for 24 hours following the procedure.14 The patient was extremely happy with the results and by correcting the asymmetries, adding definition, and increasing volume, she was more confident in her appearance. She was advised that the results would last approximately up to 12 months,16,17 and then a follow-up appointment will be needed.

Treating all ethnicities effectively Ultimately as a medical aesthetic practitioner, I find it is important to consider the goals, anatomy, and ethnic background of each individual before performing lip augmentation. As always, a full facial and holistic approach should be undertaken prior to treatments, and whilst ethnicity plays an important part, a patient will not be treated based on this aspect alone. Lucy Williams is the founder and director of Aurielle Aesthetics, Wiltshire. She has more than 10 years’ experience as a nurse and more than three years’ experience as an aesthetic injector. Williams is registered with the ACE Group World and has extensive training and expertise within aesthetics, having recently completed the Lee Walker Aesthetics Academy. Qual: RGN, DIP Nursing

To learn more about Restylane dermal fillers, attend CCR on October 14-15. Register on p.20!

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

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there is no universally accepted definition of the ideal or attractive lower leg. Apart from aesthetic concerns, another presenting complaint is not being able to fit into kneehigh boots, as mentioned previously.

Patient selection

Treating the Calf with Botulinum Toxin Dr Varna Kugan explores the use of botulinum toxin to treat the lower leg and calf muscle A popular treatment in East Asia is the use of botulinum toxin A (BoNT-A) for the slimming and contouring of the lower leg, namely the calf muscles. It is a safe and effective non-surgical alternative treatment modality and this article will draw upon my experience in successful outcomes.

Treatment popularity In this demographic of patients, generally they tend to have short legs relative to their torsos and this coupled with thick calves further accentuates this physical disproportion.1,2 In the West, treatment with BoNT-A is not as popular, there is growing awareness, especially for those struggling to fit into knee-high boots.3 I believe that it would be beneficial for practitioners to be aware that BoNT-A can be used safely and effectively in calf contouring with satisfactory results. It is worth mentioning that this is a common treatment request in my practice where many of my patients are East Asian. In addition, all the patients I have performed this treatment on are women and I have not had any requests or concerns about calf bulkiness from men at this time.

Aesthetic ideals

There are many factors to consider before performing this treatment to ensure optimal patient satisfaction and outcomes. It is imperative to note a full medical and social history including exercise habits and physical activity. For example, an athlete or a patient who participates in regular activity which requires leg contraction, such as running, badminton, and cycling would not be a suitable candidate as there would not be a significant improvement.4-7 Similarly, patients with oedema of the lower legs or excess subcutaneous fat would also not be suitable.8 Practitioners can assess the calves to determine if bulges are caused by muscle or fat and asking the patient to stand on their tiptoes and palpating the lower leg. This can also help delineate areas of maximal bulging. The ideal patient is one with thin subcutaneous fat over the calf and bulky medial and or lateral gastrocnemius muscles.9

Anatomy The triceps surae muscle, or calf muscle, is defined as the gastrocnemius and soleus muscles (Figure 1). The gastrocnemius is comprised of two muscle bellies, a medial and lateral head, that originate from the medial and lateral condyles of the femur, respectively. These reconvene to insert into the achilles tendon and calcaneus. The soleus muscle originates from the posterior aspect of the tibia and fibula and inserts into the achilles tendon and calcaneus. However, the soleus lies deep to the gastrocnemius.

There are conflicting opinions on the aesthetic ideals of the lower leg in females. A plastic surgeon based in Casablanca named Dr Fahd Benslimane described the concept of a ‘perfect’ lower leg shape.4 He concluded that in the Western world, attractive legs are straight and in continuity with the thighs. In addition, the importance of the similarity of curve distribution and progression from knee to ankle.4 Lateral belly of In my experience, gastrocnemius some individuals will find muscular or well-defined calves attractive, whereas others will disagree, preferring slimmer Lateral belly of gastrocnemius and less bulky calves. A study published in the Aesthetic Plastic Surgery Journal Medial belly of gastrocnemius Soleus concluded that Asian women prefer small lower legs with a straight line in the medial aspect.4 It is important to note that Figure 1: Anatomy of the calf muscle

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

Peroneus longus

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BALANCE References 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

M-BEL-UKI-0938 Date of Preparation January 2021

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Mild hypertrophy

Moderate hypertrophy

Severe hypertrophy

Total dose per leg

100 U

150 U

200 U

Medial gastrocnemius

50 U

70 U

80 U

Lateral gastrocnemius

30 U

60 U

Peroneus longus

20 U

50 U

60 U

Figure 2: Table of the appropriate dosing of onabotulinum toxin A during the first session for calf contouring7

Both muscles are responsible for plantar flexion at the ankle joint and calf flexion at the knee joint. The deeper soleus muscle plays an important role in standing, supporting the legs, and preventing forward bowing.10,11 Another muscle, the peroneus longus, which is responsible for plantar flexion and eversion of the foot, runs laterally and superficially to the lateral head of the gastrocnemius. It originates from the posterior tibia and the posterolateral surface of the fibula and inserts into the cuneiform and first metatarsal bones.10,11 The peroneus longus and the lateral head of the gastrocnemius contribute to the most prominent part of the upper two thirds of the lateral lower leg. Whilst the most prominent part on the medial side is the lower two thirds of the medial head of gastrocnemius.10,11

Approaches for treatment Conventional surgical methods, such as myomectomy and neurectomy, have been associated with significant morbidities, including postoperative haemorrhage, haematoma, infection, irreversible nerve damage, and scarring.12 Liposuction has limited efficacy because the primary determinant of calf thickness is the size of the gastrocnemius muscle rather than the amount of subcutaneous fat.13 One non-surgical treatment option other than BoNT-A is radiofrequency-induced calf muscle volume reduction; however, there have been reported cases of fibrosis and disabling contractures including severe equinus deformity.14,15 The concept of the BoNT-A treatment for calf muscle contouring and slimming is similar to masseteric hypertrophy. The desired goal being the muscle debulking via muscle atrophy. Currently, there are no universally agreed upon guidelines or standardised protocols for the administration of BoNT-A in the correction of gastrocnemius hypertrophy. As such, the injection method varies depending on the practitioner and their experience. The literature on calf contouring with BoNT-A is limited, with proposed doses stated by

either anecdotal evidence or small case studies.10 Practitioners should be aware that BoNT-A treatment for aesthetic calf slimming and contouring is off-label, and this should be explained to the patient in the consultation. After taking a full medical and social history and performing a clinical assessment as described earlier, one should take pre-treatment photos from the back of the lower legs both during normal standing (relaxed) and on tiptoes (contracted). In addition, measurements of the most prominent circumference of the lower leg should be recorded both during the relaxed and contracted positions. There are many injection techniques described in the literature with varying doses, types of botulinum toxin, results, patient satisfaction and complications.10 I will present the injection technique described by Seoul-based dermatologist Dr Kyle Seo that I have used the most and have achieved excellent results with.11 Currently, there is no formal classification

The ideal patient is one with thin subcutaneous fat over the calf and bulky medial and or latera gastrocnemius muscles

system for the degree of muscle hypertrophy or leg shape for BoNT-A treatment. However, practitioners can broadly categorise patient cases into mild, moderate and severe hypertrophy (Figure 2). This will help guide appropriate dosing for each leg. The medial head of gastrocnemius on the medial side and lateral gastrocnemius and peroneus longus on the lateral side are major target muscles. To improve the medial

Figure 3: Injection points for the peroneus longus and the lateral gastrocnemius (left) and the injection points for the medial and lateral gastrocnemius (right).

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

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After

agreed upon guidelines for injection technique, pattern, dosing, or classification. However, I have outlined my personal preferences and I hope this article offers a starting point for further discussion on the application of BoNT-A for calf contouring and slimming. Dr Varna Kugan is a JCCP-registered aesthetic practitioner with more than five years of experience and a special interest in East Asian aesthetics based in Shanghai. He is the clinical director at PICO Clinics, with clinics in Europe and China. He is also the lead trainer and head of PICO Academy. Qual: MUDr (MD)

Figure 4: A 24-year-old female before and one month after BoNT-A for calf slimming using 100U of onabotulinum toxin A per side.

calf bulge, BoNT-A is injected into the medial head of gastrocnemius. In the case of ‘O-shaped’ legs, where the lateral head and peroneus longus are more prominent, it is advised to avoid treating the medial head to avoid exacerbating the shape.11 If overall volume reduction is the goal, then it is important to treat both heads of gastrocnemius and peroneus longus. Excessive muscle weakness can occur if more than 200 units per leg is used. Thus, Dr Seo recommends a two-step approach in which treatments are spaced two to three months apart to reduce the risk of muscle weakness.11

Treatment outcomes The desired goal during the first session would be to provide global calf contouring. Subsequently in the second session, the goal would be to reduce muscle volume and/or provide further contouring.11 The total dose per leg for the second session at two to three months would be lower than in the first session and this should be based on clinical assessment and the overall outcome from the first session. To ensure maintenance of results, it is advised to repeat the treatment on a sixmonth basis.16 However, this is not a hard and fast rule as there may be factors that influence the duration of efficacy, such as exercise and physical activities, that strengthen calf muscles. A reduction in calf size can be seen from one week to one month post-treatment. Approximately 50% of the initial muscle volume tends to return after six months and the full volume is restored by 12 months.11-16

Possible side effects From the publications to date, the most reported side effects were transient ecchymoses or cramps.9 In addition, there was a case of calf muscle fatigue when wearing high-heeled shoes during the first two weeks post treatment, which resolved within four weeks.8 The complications in Dr Seo’s patient cases were ecchymosis, temporary weakness and/or pain, mild tenderness for a few days and bruising.9 One study reported that with the authors’ 48-point injection technique, 66% of patients experienced cramps in both legs that worsened when walking, but this resolved within one to two months.7 No difficulties with gait or athletic activities have been reported. Another possible side effect is that atrophic gastrocnemius muscles could result in compensatory hypertrophy of the underlying soleus muscles.16 Regarding the long-term effects of toxin treatment to the calf muscles, there are only animal studies on rats where BoNT-A was injected into the gastrocnemius and soleus muscles. The findings showed that the viscoelastic properties of the achilles tendons were reduced five weeks after treatment.17 However, no similar studies have been conducted in humans yet.

A treatment to consider Calf contouring and slimming with BoNT-A can be a safe and effective alternative solution to surgery and it is especially popular with East Asian patients. Correct patient selection is important to achieve good aesthetic outcomes and thus patient satisfaction. There are no universally

REFERENCES 1. Sundaram H, Huang PH et al., ‘Aesthetic Applications of Botulinum Toxin A in Asians: An International Multidisciplinary, Pan-Asian Consensus’, Plast Reconstr Surg Glob Open, 4(12), (2016) <https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC5222633/> 2. Benedetto A, ‘Botulinum Toxins in Clinical Aesthetic Practice. Facial and Lower Limb Contouring’, Botulinum Toxins in Clinical Aesthetic Practice, (2011) pp.206-222. 3. The Mail Online, The Women Having Botox to Fit into Their Boots, <https://www.dailymail.co.uk/femail/article-2864709/Thewomen-having-Botox-fit-boots-promises-shave-inches-chunkycalves-doctors-warn-cripple-kill-you.html> 4. Benslimane F, ‘The Benslimane’s Artistic Model for Leg Beauty’, [online] Aesthetic Plastic Surgery Journal 36(4) (2021). 5. Tsai CC, Lin SD, et al., Aesthetic Analysis of the Ideal Female Leg, [online] Aesthetic Plastic Surgery Journal. (2000) 6. Lee JT, Wang CH, et al., Subtotal Resection of Gastrocnemius Muscles for Hypertrophic Muscular Calves in Asians, [online] Plast Reconstr Surg, 2006, 118(6) 7. Bogari M, Tan A, et al., Treatment of Gastrocnemius Muscle Hypertrophy with Botulinum Toxin Injection Follower by Magnetic Resonance Imaging Assessment and 3-Dimensional Evaluation, Aesthetic Surgery Journal, [online] (2017)16, 37 (10) pp.1146-1156 8. Han KH, Joo YH, et al., Botulinum Toxin A Treatment for Contouring the Lower Leg, Journal of Dermatology Treatment, [online] (2006) 17(4), pp. 250-254 9. Ashi W, Zhu L, et al., Classification of Hypertrophic Gastrocnemius Muscle and its Treatment with Botulinum Toxin, Aesthetic Plastic Surgery Journal, [online] (2019), 43(6) pp. 1588-1594 10. Cheng J, Chung HJ, Botulinum Toxin Injections for Leg Contouring in East Asians, Dermatologic Surgery Journal, [online] (2020) p.46 11. Kyle K, Botulinum Toxin for Asians, (Singapore: Springer, 2017) 12. Wang H, Xu X, et al., Safety and Efficacy of Selective Neurectomy of the Gastrocnemius Muscle for Calf Reduction in 300 Cases, Aesthetic Plastic Surgery Journal, [online] (2015) 39(5) pp.674-649 13. Kim IG, Hwang SH, et al., Endoscope-Assisted Calf Reduction in Orientals, Plastic and Reconstructive Surgery Journal, [online] (2000) 106(3), pp713-718 14. Hwang CH, Excessive Gastrocnemius Fibrosis Developed After Radiofrequency-Induced Cosmetic Volume Reduction, [online] (2011) 35(6) pp.1172-1175 15. Lim KS, Shim JS, et al., Severe Equinis Deformity After Radiofrequency-Induced Calf Muscle Reduction, Aesthetic Plastic Surgery Journal, [online] (2013) 37(4) pp.786-791 16. Lee HJ, Lee DW, et al., Botulinum Toxin For Aesthetic Contouring of Enlarged Medial Gastrocnemius Muscle, [online] (2004) 30(6) pp. 867-871 17. Khayyeri H, Blomgran P, et al., Achilles Tendon Compositional and Structural Properties Are Altered After Unloading by Botox, Science Reports Journal, [online] (2017) 7(1) p. 13067

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

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BELOTERO® balance & BELOTERO® revive Merz Innovation Partner Dr Chris Hutton from Array Aesthetics in Belfast shares his approach to treating a 42-year-old patient with difficult-totreat lateral cheek lines using a combination of BELOTERO® Revive and BELOTERO® Balance As a doctor, my background is in medicine, but, ironically, I was probably a much better student of the arts than I was in science at school. The visual arts have always really interested me, and as art is a huge part of aesthetic practice, it made sense for me. What I enjoy most is rejuvenation. Typically my patients are women who are are noticing with skin texture as they the lines the signs of ageing or are feeling like they themselves. She came in asking for look a little bit tired, and it’s getting filler, but my position was thatthem she down. Facial wasn’t reallyrejuvenation, a suitable particularly candidatevolume for replacement using dermal fillers, can make volumising in the classic sense. such a profound change to how someone looks and then, ergo, how they feel, which is I chose to do a spot treatment really what it’s all about.

using BELOTERO® Balance initially for combined with Thethe bulkstatic of mylines practice is really centred BELOTERO® Revive to treat the and I’ve around hyaluronic acid dermal fillers, 2 texture at the subsequent visits. The been using Merz portfolio really since I started about years ago. know them changes this 10 patient wasI experiencing well, and they are related the products we ageing use in our were generally to the training academy as well. process but more specifically to photodamage. She described a For me, there are advantages of combination ofgenuine fine lines, erythema, using BELOTERO®, the most important being hyperpigmentation, and the changes their low propensity to stimulate an immune in skin texture, which is really what response.1 BELOTERO® Revive is about2. Patient safety is paramount. When it comes

We did the first treatment in May to BELOTERO® Revive, I think that Merz2021. At this visit, BELOTERO® Aesthetics hasI used been very clever with it Balance to the tapped perioral region, because they’ve into the mindset of the patient the injector. needle There areusing injected withand a 30-gauge a superficial blanching technique4. BELOTERO® Balance is really nice for 56 these sort of static lines, but when you

many skin boosters on the market, but one of the frustrating things about them is how long it takes before patients see anything happening! None of these products are going to give anyone a structural change like fuller cheeks or a sharper jawline; it’s all about the skin. The great thing about BELOTERO® Revive is the fact that they’ve introduced 2 glycerol to the Glycerol is a use a little bitproduct. of topical anaesthetic to molecule that will absorb its weight in water in make it more comfortable. about 72 hours.3 patients needle start to see something IThis usemeans a 30-gauge and inject as happening quickly, usually within three days.

superficially as I can. The 30-gauge needle is what comes as standard with It’s a relatively new product. I’ve just started BELOTERO® Revive, and I just inject to use it, so I have been ringing all my itpatients generally, covering thetoareas up at three or fouralldays see what’s that we’re and worried aboutnumber in terms of happening, a significant of them texture. You use cannula are saying, “It’scan hardalso to put myafinger on it, to thread down thejust area. I prefer but I justup feeland like everything looks a bit plumper.” The glycerol gives you thatthe before to use a needle because that’s 5 the HA starts to kick in. Seeing more instant method used in the ‘Belove’ study .

Case Study A 42-year-old female patient presented to me complaining of fine, static lines and textural skin changes, mainly in her lower medial cheek/lateral perioral region. These ‘cat scratch’ lines which are lateral to the cheek and extend to the perioral region,

Before

results keeps patients interested.

You want to inject as superficial Theyou other thing like abouttoBELOTERO® as can. It’sI difficult get truly Revive is that you can spot treat. Where intradermal consistently with a someone’s got an issue, particularly needle, you’re going to realistically with a localised area of skin laxity, that’s be subdermal, but you want to be just starting to crepe, and it’s not really raising a little blebcan in fill terms of visual something that you or volumise. 2 feedback . It’s a straightforward Having something like BELOTERO® Revive treatment – a very up your sleeve to besimilar able to technique go and spotto superficial blanching, is ait very treat, is particularly usefulwhich because allows you to be a bit more flexible.2 well-recognised technique. In terms of outcome, a gradual Aesthetics | October 2021 improvement in fine lines, skin

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needle is what comes as standard with needle is what comes as standard with 2 BELOTERO® Revive, and I just inject I chose to do a spotRevive treatment BELOTERO® is about be subdermal, but you want to be . I chose to do a spot treatment BELOTERO® Revive, and I just inject using BELOTERO® Balance initially it generally, covering all the areas raising a little of visual using BELOTERO® Balance initially it generally, covering all the areasbleb in terms Advertorial for the static lines combined with that we’re worried about in terms of 2terms of forWe the static lines combined with that we’re worried about in @aestheticsgroup @aestheticsjournaluk Aesthetics aestheticsjournal.com Merz . It’s atostraightforwardAesthetics did the first in May 2021. BELOTERO® Revive to treatment treat the texture. You canfeedback also use a cannula BELOTERO® Revive to treat the texture. You can also use a cannula to Before 2 texture thread up and down the area. I prefer visits. 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There are genuine advantages of using BELOTERO , the most important being their low propensity to stimulate an immune response

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AESTHETICS EDUCATION. TAILORED TO YOU, POWERED BY ECADE Dr Chris Hutton completed his undergraduate medical training at Queen’s University Belfast. He has undertaken postgraduate education in aesthetic medicine course at the Queen Mary University of London. He is a Merz Innovation Partner and has been published in a European medical journal. Qual: MB, BCH, BAO (QUB), PGCert (AesMed Lon.) www.merz-aesthetics.co.uk/ecademy

AESTHETICS EDUCATION. TAILORED TAILORED TO TO YOU, YOU, POWERED POWERED BY BY ECADEMY. ECADEMY.

AESTHETICS EDUCATION. For more information on educational content go to www.merz-aesthetics.co

For more information on educational content go to For more information on educational content go to www.merz-aesthetics.co.uk/ecademy

Adverse events should be reported. Reporting forms and information for United Kingdom can be found at www.mhra.gov.uk/yellowcard. Reporting forms and infor found at https://www.hpra.ie/homepage/about-us/report-an-issue/mdiur. Adverse events should also be reported to Merz Pharma UK Ltd by email to UKdrugsafety@m

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 Adverse events should be reported. Reporting forms and information forAdverse United events Kingdom can also be found at www.mhra.gov.uk/yellowcard. forms and information for Ireland can be found at https://www.hpra.ie/homepage/about-us/report-an-issue/mdiur. should be reported to Merz Pharma UK Ltd by Reporting email to UKdrugsafety@merz.com or Republic on +44 (0)of333 200 4143. found at https://www.hpra.ie/homepage/about-us/report-an-issue/mdiur. Adverse events should also be reported to Merz Pharma UK Ltd by email to UKdrugsafety@merz.com or on +44 (0) 333and 200 4143. References: 1. Merz Aesthetics, (n.d) Merz Data on File (DOF) BEL-DOF-011_01 REF-0922 2. BELOTERO® Revive IFU 3. Fluhr 2008 - Glycerol the skin holistic ap

4. BELOTERO® Balance IFU 5. BELOVE1

References: 1. Merz Aesthetics, (n.d) Merz Data on File (DOF) BEL-DOF-011_01 REF-0922 2. BELOTERO® Revive IFU 3. Fluhr 2008 - Glycerol and the skin holistic approach to its origin and functions References: 1. Merz Aesthetics, (n.d) Merz Data on File (DOF) BEL-DOF-011_01 REF-0922 2. BELOTERO® Revive IFU 3. Fluhr 2008 - Glycerol and the skin holistic approach to its origin and functions 4. BELOTERO® Balance IFU 5. BELOVE1 4. BELOTERO® Balance IFU 5. BELOVE1

AESTHETICS EDUCATION. TAILORED TO YOU, POWERED BY ECADEMY.

For more information on educational content go to www.merz-aesthetics.co.uk/ecademy

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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 M-BEL-UKI-1231 Date of Preparation August 2021 https://www.hpra.ie/homepage/about-us/report-an-issue/mdiur. Adverse events should also be reported to Merz Pharma UK Ltd by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143.

M-BEL-UKI-1231 Date of Preparation August 2021 M-BEL-UKI-1231 Date of Preparation

August 2021

s: 1. Merz Aesthetics, (n.d) Merz Data on File (DOF) BEL-DOF-011_01 REF-0922 2. BELOTERO® Revive IFU 3. Fluhr 2008 - Glycerol and the skin holistic approach to its origin and functions RO® Balance IFU 5. BELOVE1

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intensity of hyperpigmentation, the severity of the nasal fat pad prolapse and the degree of rhytidosis (or myocutaneous laxity) of the eyelid as well the amount of fluid retention or oedema.7,8

Tear trough deformity Tear trough deformity may be classified as follows:12,13

Managing Dark Circles in SOC Dr Stephen Humble discusses the aetiology and management of dark circles in skin of colour patients In aesthetic medicine, dark circles under the eyes are a common concern across all ethnicities, but they may be particularly prominent in the setting of skin of colour due to higher concentrations of melanin.1 Regardless of the Fitzpatrick scale,2 before determining the best way to manage dark circles under the eyes, it is always useful to assess what the specific contributing factors are. Specifically, within the setting of skin of colour (SOC), the universal causes of dark circles must be considered, such as tear trough deformity; however, the approach to treatment may be modified appropriately. For instance, higher baseline concentrations of melanin may significantly accentuate underlying hollowness and hyperpigmentation can cause dark circles even in the absence of tear trough hollowing, especially in SOC.1,3-6

Anatomy Perhaps the first thing to consider in dark circles is the underlying anatomy around the eye, including the nasojugal fold.1 The orbicularis oculi muscle and the levator palpebrae superioris control the opening and closing of the eyelid.7 The tear trough is a triangular depression below the lower

eyelid and within the orbicularis oculi muscle that runs diagonally from the medial canthus to the mid-pupillary line.7,8 It is comprised of a superficial and deep plane and is supported inferiorly by the orbicularis retaining ligament.8,9 The anatomical predisposition to the development of tear trough deformity is not known to be significantly different between differing ethnicities.8,10 However, the overlying skin varies significantly with regards to its thickness and its melanin concentration, and this can magnify the prominence of the tear trough deformity disproportionately.1,4 The angular artery is the most important vascular structure to consider (although there are others) and it emerges below the orbicularis oculi muscle to travel along the inner canthus of the eye, it is accompanied by the angular vein.7,8,11 The potentially catastrophic risk of intravascular injection to vision must be minimised by careful technique, aspiration and arguably the blunt cannula technique.11 The infraorbital nerve emerges from the infraorbital foramen inferior to the orbital rim within the mid-pupillary line.7 Dark circles under the eye area may be evaluated more generally by assessing the depth of the tear trough deformity, the

• Class I: Volume loss limited medially to the tear trough. May have mild flattening extending to the central cheek area. No bulging orbital fat • Class II: Volume loss in the lateral orbital area and the medial orbit, may have moderate volume deficiency and flattening of the middle and upper cheek. Mild to moderate orbital fat bulging • Class III: Full depression circumferentially along the orbital rim, from medial to lateral. Severe orbital fat bulging Tear trough deformity may be treated effectively with hyaluronic acid (HA) filler particularly well in Class I patients and may be improved in Class II patients, however HA filler will not improve orbicularis oculi hypertrophy, pigmentation, myocutaneous laxity or oedema.7 Patient selection is of vital importance as the most severe cases may not respond well to treatment with HA fillers and more invasive surgical techniques are indicated such as blepharoplasty or fat grafting.5,8,12,14 There are two main approaches for the administration of HA filler to the tear trough area: performance is with either a needle or a cannula.7 There is no proven advantage of one technique over the other for any given skin type, but my personal preference is for the cannula technique due to its better safety profile and less risk of bruising, which may appear particularly dark in SOC patients.

Hyperpigmentation Hyperpigmentation may be more prevalent and more noticeable in patients with SOC due to a number of exogenous and endogenous factors.1,3-6 Naturally, darker skin tones Fitzpatrick2 IV-VI tend not to experience sunburn and as such, especially during childhood, may not have necessarily had a natural prompt to wear SPF.3 Many people with SOC have connections with hot countries and may have spent time living in or visiting regularly, thus increasing their cumulative exposure to UV light, which is one if the principle exogenous causes of hyperpigmentation.4,5,15

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The principle active treatment for infraorbital pigmentation in SOC is topical therapy containing tyrosinase inhibitors Common endogenous factors include atopic dermatitis or eczema, which may be associated with periorbital pruritis. Regular vigorous rubbing of itchy skin around the eyes is associated with microtrauma and inflammation, which in itself may exacerbate pigmentation.1,5,6 The presence of tear trough deformity and/or localised oedema may also combine well with periorbital pigmentation to generate particularly dark circles in SOC.5 There also appears to be an inherent genetic predisposition observed in familial groups which may be autosomal dominant in some cases.5,16,17 The aim of management is to first identify the causative factors and modify them wherever possible (e.g. avoiding sun exposure, using SPF 50 suncream1 and wearing good quality sunglasses) before determining the appropriate treatment plan. The principle active treatment for infraorbital pigmentation in SOC is topical therapy such as cosmeceutical agents containing tyrosinase inhibitors.1,5,15 Tyrosinase in the enzyme that converts dopa to the pigment melanin and thus is the main target in the treatment of hyperpigmentation.1,5,15 The most effective and well-known tyrosinase inhibitor in this setting is hydroquinone, but treatment typically requires at least three months’ duration due to the length of time the skin cycle takes to complete.5 It is a relatively potent treatment and one or two pea sized amounts may be sufficient for the entire face. Long term use of hydroquinone is contraindicated, and it has the potential to be carcinogenic in animal models with systemic ingestion; however, it is considered safe for topical use on the face in humans for limited periods of time.5 Use around the periorbital area is more contentious as it may be more irritant in the delicate under eye area, although there is a clinical precedent for its careful use in Asian skin.1,18 Other tyrosinase inhibitors include kojic acid, arbutin and azelaic acid, which are less potent than hydroquinone and may potentially be used over longer periods of time in patients that require ongoing treatment to prevent

pigmentation returning.5,15 It is of critical importance in the context of SOC for patients to be informed that these treatments may temporarily make the skin more susceptible to the development of new pigmentation during the active treatment phase. I tell my patients it is mandatory that scrupulous SPF 50 protection is used every day during treatment to prevent the development of hyperpigmentation and sun exposure should be minimised.1 This approach also applies to retinoids, which are often used as co-agents in the management of hyperpigmentation due to their ability to accelerate cell turnover within the skin cycle and thus accelerate the lightening effects of tyrosinase inhibition.1,6,15 It is worth noting that the while drugs such as hydroquinone can lighten hyperpigmentation, they do not usually make the skin lighter than the baseline skin tone.19 Antioxidants such as vitamin C, ferulic acid and phloretin are also very useful in the setting hyperpigmentation.6 UV rays penetrate through the layers of the skin and generate free radicals, which in turn can trigger melanogenesis and collagen degradation. Antioxidants scavenge the free radicals and may therefore treat and prevent the development of future pigmentation.5,6,20 Peptides are involved in protein regulation and synthesis as well as cell proliferation, angiogenesis and melanogenesis. Peptides can improve the appearance of dark circles under the eyes in numerous ways including the stimulation of collagen synthesis and modulation of neurotransmitter release.6

Other therapeutic options Lower lid blepharoplasty may involve excision of excess skin as well as fat excision and transposition.21-23 A transconjunctival or transcutaneous approach may be used to target the inferior orbital fat pads for their excision, repositioning or augmentation.22,23 This may even be combined with fat grafting for facial rejuvenation.24 Non-surgical options in the setting of SOC include: platelet-rich plasma (PRP), Er:YAG Laser, radiofrequency

devices, cautious superficial chemical peels, and topical agents.1,5,15,25-28 Hydroxyapatite has also been proposed as an alternative to HA fillers to treat tear trough deformity,29 although this is not widely popular due to its inflexibility and the perceived associated risks.30 It is worth noting that not all types of chemical peel or laser are suitable for people with SOC due to the increased risk of new-onset hyperpigmentation observed with darker skin tones. Therefore, it’s key that practitioners ensure they have undertaken the correct training/education so they are able to choose the right treatment.

Conclusion Dark circles may be significantly more prominent in the setting of SOC, and their treatment has similarities and differences in comparison to lighter skin tones. In addition to the individual anatomy of the patient, there are both endogenous and exogenous factors to consider carefully during the diagnostic process, including cumulative sun exposure and genetic predisposition. Appropriate clinical treatment should be individualised and based on the identified causative elements. Tear trough fillers may be appropriate for loss of volume of the bony orbit, while cosmeceuticals containing tyrosinase inhibitors, retinoids and antioxidants are mainstays of treating dark circles in SOC. Other more invasive options such as surgical blepharoplasty or fat transfer may be appropriate for the most severe cases, typically in the older demographic, but these approaches are perhaps left until after more conservative treatment has been trialled extensively due to the risk benefit profile. Dr Stephen Humble is a consultant and honorary senior lecturer in anaesthetics and pain medicine at Charing Cross Hospital, and also specialises in medical aesthetics. He qualified in Medicine at the University of Aberdeen in 2000 and holds several degrees including a Level 7 qualification in Aesthetic Medicine. Qual: MBChB, MSc, PhD

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Advertorial: Rejuvenating the Eye Area Dr Angelica Kavouni discusses using Thermage FLX® to treat the eye area As we age, the eyelid skin loses its elasticity and stretches, and the muscles directly underneath (orbicularis oculi) weaken. The septum which is an incredibly important structure to the eyelids unfortunately also weakens, either over time or due to a genetic predisposition. The orbital fat prolapses above and below the eyelids, causing sagging and eye bags under the eyes.1 Patients often find that the reduction of orbital fat that tends to happen with ageing causes the eyes to ‘sink in’, accentuating the lid laxity. In the upper lids, the disinsertion or attenuation of the muscle may cause ptosis. Age related descent of the brow (brow ptosis) often also contributes to the ptosis formation.2 Around the eyes, deepening of the lines of expression especially at the lateral lid margins – commonly known as crow’s feet – can be reduced cosmetically by botulinum toxin injections, however the skin laxity cannot be addressed. According to leading cosmetic surgeon Dr Angelica Kavouni, many of her patients ask her to treat eyes that seem to make them look ‘tired.’ She comments, “Patient demand for non-surgical wrinkle reduction treatment procedures has grown dramatically over the past decade as new treatments and technologies have been introduced.3 This is why non-invasive treatments which promote collagen like Thermage FLX® are becoming incredibly popular – especially around the eye area.”

What is Thermage FLX®? Thermage FLX® is a non-invasive radiofrequency-based skin tightening device that stimulates the production of new collagen4 to smooth and tighten the skin,5 explains Dr Kavouni. She says, “Thermage FLX® is different to anything else available in the marketplace as patients can expect visible results after a single treatment6 as opposed to a full course. With little to no downtime,5 patients can quickly return to their normal routine. Thermage FLX® works across the entire face, including forehead, eyes, nasolabial folds, jaw line, jowls and the area under the chin, as well as on the arms, buttocks, tummy and thighs.” After more than 18 years of expertise and innovation, Thermage® has become one of the most trusted skin tightening devices with 2.5 million Thermage® treatments performed in the world.* Thermage® has demonstrated a good safety profile over the years and high patient satisfaction levels with 94% of patients declaring the

Dr Kavouni explains, “The Thermage FLX® procedure involves sending radiofrequency energy waves to the skin’s deeper layers. The heat produced causes existing collagen to contract – which brings the tightening effect – and more importantly, stimulates the production and growth of new collagen over a period of four to six months.8” Its AccuREPTM technology autotunes each pulse of energy, which is customised to the skin, for targeted and effective tightening.5 The Comfort Pulse technology (CPT) of Thermage FLX® delivers interspersing cooling burst to keep the skin cool, coupled with the enhanced multi-directional vibration feature** for more a comfortable treatment experience.9

Thermage FLX® key features: • Quicker procedure: 25% faster treatments compared to the previous Thermage® CPT version11 • Automatic calibration: AccuREPTM Technology enables optimised energy delivery for consistent output • Improved patient comfort10: The multidirectional vibration helps aid in patient comfort** • Versatility of the system: One handpiece to treat the face, eyes and body without the need to interchange any handpieces • Treatment of multiple body areas in a one-hour session: Depending on the area to be treated, one treatment can take up from 30 to 90 minutes • Enhanced touchscreen navigation: The updated interface is userfriendly and modern for a better user experience REFERENCES *sales data ** The handpiece vibration function is not available when using the Eye Tip 0.25 1. Salvi SM, Akhtar S, Currie Z. Ageing changes in the eye. Postgrad Med J. 2006;82(971):581-587. doi:10.1136/pgmj.2005.040857. 2. Van den Bosch W A, Leenders I, Mulder P. Topographic anatomy of the eyelids, and the effects of sex and age. Br J Ophthalmol 199983347–352. [PMC free article] [PubMed] [Google Scholar]. 3. Shapiro SD, Eros Y, Abrahami Y, Leviav A. Evaluation of safety and efficacy of the TriPollar technology for treatment of wrinkles. Lasers Surg Med. 2012 Aug;44(6):453-8. doi: 10.1002/lsm.22044. Epub 2012 Jun 29. PMID: 22806630. 4. Shapiro SD, Eros Y, Abrahami Y, Leviav A. Evaluation of safety and efficacy of the TriPollar technology for treatment of wrinkles. Lasers Surg Med. 2012 Aug;44(6):453-8. doi: 10.1002/lsm.22044. Epub 2012 Jun 29. PMID: 22806630. 5. B. D Zelickson, et al. Histological and ultrastructural evaluation of the effects of a radiofrequencybased non-ablative dermal remodelling device: a pilot study. Arch Dermatol.2004 Feb;140(2):204-9. 6. E. Finzi, A. Spangler. Multipass vector (mpave) technique with nonablative radiofrequency to treat facial and neck laxity. Dermatol Surg. 2005 Aug;31(8 Pt 1):916-22. 7. R. Fitzpatrick et al. Multicenter study of noninvasive radiofrequency for periorbital tissue tightening. Lasers Surg Med. 2003;33(4):232-42. 8. J.S Dover, et al. Results of a survey of 5,700 patient monopolar radiofrequency facial skin tightening treatments: Assessment of a low-energy multi-pass technique leading to a clinical end point algorithm. Dermatol Surg 2007; Aug;33(8):900-7. 9. Thermage flx skin tigthening treatment of the year report. 10. Solta Medical, 2009. Report on Gazelle Clinical Study 09-100-GA-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. 11. Walter, W.,2017 Solta Medical Support for Thermage FLX™ product feature claims. Bothell. 9.J Cosmet Laser Surgery EndyMed Study April 2010 3. 12. _LSM_Bogle_Evaluation of Multiple Pass Low Fluence Algorithm for RF Tightening of Low.

This advertorial was written and supplied by Thermage FLX®

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Aesthetics | October 2021

Advertorial VIVACY UK

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NEW LIP FILLER STYLAGE® LIPS PLUS Dr Jasmin Taher discusses her experience with VIVACY’s latest lip filler Laboratoires VIVACY has developed a new lip filler called STYLAGE® Lips Plus, for a fuller and more glamorous result. This product was designed to ensure that despite producing more volume, the results provide a natural appearance in line with VIVACY’s values. This exciting addition to the portfolio can produce significantly more volume to the lip compared to its more subtle counterpart, STYLAGE® Special Lips. With the boom in social media use and particularly the use of filters, patients are regularly seeing how they would look with significantly bigger lips. I have found that this has led to a societal shift towards increased numbers of younger patients requesting more dramatic results from their treatments. STYLAGE® Lips Plus perfectly accommodates this, by providing results with enhanced volume that still maintains softness, complementing the properties of the lip tissue. This product was designed to ensure that despite producing more volume, the results provide a natural appearance in line with VIVACY’s values. Ideal patients for this product would tend to be a younger demographic desiring more glamorous results that are natural, yet noticeable. It is imperative that, as practitioners, we carefully assess the patient’s whole face and lips prior to treatment as some patients will not suit a more dramatic result, and some lip types do not have the capacity to increase volume rapidly. Patients best suited to this filler would have a spongier lip type of medium to larger size, that has the capacity for more volume without looking stretched or overfilled. Patients with very thin or mature lips and tighter tissues would be best treated with STYLAGE® Special Lips for more subtle increase in volume. This is to ensure a natural result with lower risk of migration. Containing 20mg/g HA, STYLAGE® Lips Plus has a higher concentration of hyaluronic 64

Case Study

Before

The 29-year-old female patient presented for lip filler treatment, with no previous record of any aesthetic treatment or relevant medical history. The patient stated that she felt that her lips looked dehydrated and lacked volume. She After requested a ‘plumper look that is still natural.’ On assessing her lips, I could see that she presented with medium sized lips of a spongier lip type. The multiple lines and grooves indicated a capacity for increased volume that looked natural. It was clear that her lips were the perfect candidate for Patient before and after treatment the new STYLAGE® Lips Plus. After a thorough with STYLAGE® Lips Plus consultation and consent process, I treated this patient with 1ml of STYLAGE® Lips Plus using the 30g needle provided in the box. In order to achieve this result, I used multiple vertical threads all placed sub-vermillion to reduce the likelihood of filler expansion outside of the vermillion border. The result was a defined, soft and glamorous lip which, despite being swollen still looks natural. Once the swelling subsides and the filler integrates, this will look plump yet natural.

acid than STYLAGE® Special Lips (18.5mg/g). This makes the product extremely adept at producing more volume with 1ml. In my own experience with the new product, I found that the lips instantly appeared more volumised, yet still felt soft to the touch. I also found that the inclusion of the antioxidant Mannitol ensured that post-operative swelling was substantially less than I expected. The product has been specifically designed to be compatible with superficial injections, integrating beautifully, and producing a result that moves harmoniously with the musculature of the lip. In addition, this integration reduces the risk of lump formation. I found that whilst working with STYLAGE® Lips Plus the product would evenly spread throughout the lip tissue producing a result that would look and feel smooth and soft. Aesthetics | October 2021

Conclusion Overall, my experience with STYLAGE® Lips Plus was extremely positive. I found it to be a versatile product that produces a soft and volumised result, perfect for patients seeking a more glamorous look. The product can be used with various injection techniques for a superior result that integrates into the lip tissue seamlessly. In a society where patients are becoming increasingly aesthetically driven, we must be able to offer a variety of products to tailor their treatment to match their realistic goals. Dr Jasmin Taher is a Level 7 trained aesthetic practitioner, who runs a clinic in Fulham, London. She is a brand ambassador and trainer for VIVACY UK.

FIND OUT MORE @vivacylab.uk *Medical Devices Class III, regulated health products bearing the CE marking (CE 0344). Only to be administered by appropriately trained healthcare professionals who are qualified or accredited in accordance with national law.

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A summary of the latest clinical studies Title: Study of the 0.1% Tretinoin Cream Vs Fractional Microneedling Radiofrequency Combination with Fractional CO2 Laser for the Treatment of Striae Alba in Indonesian Patients Authors: Listiawan M, et al. Published: Journal of Cosmetic and Laser Therapy, September 2021 Keywords: Laser, Radiofrequency, Striae Alba Abstract: Striae distensae (SD) is linear scar tissue in the dermis that arises from the stretching of the skin. There are two types of SD, striae rubrae and striae albae (SA) which is marked with a line hypopigmentation that cause a psychological problem, especially in the high skin types. The standard therapy is a 0.1% tretinoin cream, which takes a long time to reach the collagen, so needs invasive measures to reach these targets. This study compares 0.1% tretinoin cream with combination therapy of fractional microneedle radiofrequency (FMR) and fractional CO2 laser for SA. The number of subjects was 11 patients in each group with Fitzpatrick skin types IV or V. Biopsies were taken before and after therapy. The clinical changes in SA lesions in this study were represented by measurements of the length and width. The percentage of collagen in the area is the amount of collagen fibres with Masson’s trichrome staining. The clinical changes of lesions in the combination therapy decreased. The percentage change in collagen area in the combination therapy group had a higher increase. The side effect experienced by all combination group subjects was post inflammatory hyperpigmentation, and two subjects in 0.1% tretinoin cream group experienced irritation. Title: Superficial Lip Injections Utilising Cohesive Polydensified Matrix Hyaluronic Acid-Based Soft Tissue Fillers Authors: Goldie K, et al. Published: Journal of Drugs in Dermatology, September 2021 Keywords: Dermal filler, Injectables, Lip Improvement Abstract: A combination of optimal injection technique and dermal filler choice is key for improving lip architecture with natural and long-lasting results. Eligible patients underwent lip contouring and volumisation using a superficial direct tissue action technique. All injections were performed with CPM-HA lip fillers using a 30G needle and retrograde microthreading. Injected volume was 0.8-1.2 mL. High-resolution ultrasound imaging (US), 3D surface scanning, and Global Aesthetic Improvement Scale (GAIS) assessments were performed before, and one, three and six months post-injection to define the anatomy, positioning, longevity and patient satisfaction. 16 patients were injected. US measurements revealed an increased orbicularis oris muscle distance up to one-month post-injection, after which measurements returned to baseline values. This observation correlated with complete product integration into the surrounding tissue visualized by US at three months. An increased dry mucosa thickness remained at six months, and GAIS scores revealed 70% of patients continued to experience visible lip improvements. 3D analyses revealed increased total lip surface area at three months with increased Cupid’s bow distance, philtral height, and anterior upper lip projection. Superficial injection of CPM-HA fillers offers an effective and safe tool for improving lip architecture and volume.

Title: Association Between Exposure to Ambient Air Pollution and Occurrence of Inflammatory Acne in the Adult Population Authors: Haddad C, et al. Published: BMC Public Health, September 2021 Keywords: Acne, Pollution Abstracts: Acne vulgaris is one of the most prevalent skin diseases responsible for dermatological consultations. Outdoor air pollution is an external factor discussed to trigger inflammation of the skin. This study aimed to find a link between the exposure to ambient air pollution and inflammatory acne occurrence in the Lebanese adult population. A cross-sectional study was conducted, using an online questionnaire to collect the data from different Lebanese regions. The survey covered pollution exposure questions as well as several factors known to have a role on acne. 372 participants were included, aged 18 to 55. The results of a logistic regression taking the presence/absence of acne as the dependent variable, showed that female sex, younger age, using hydrating cream, working near a power plant vs not, having a severe NO2 exposure compared to none, a higher number of family members with acne or history of acne were significantly associated with higher odds of having acne, whereas having dry skin compared to normal was significantly associated with lower odds of having acne. The occurrence of inflammatory acne in Lebanese adults was found to be associated with exposure to high levels of NO2 and employment near a power plant known to emit CO2, CO, SO2, NO2 and PM. Our findings can serve as a first step towards implementing awareness of a skin care routine suitable for highly polluted areas. Title: Infraeyebrow Blepharoplasty Using Dynamic Suspension Technique Between Dermis-Fascia Flap and Frontalis in Upper Eyelid Lifting and Eyebrow Augmentation Authors: Cao Z, et al. Published: Journal of Craniofacial Surgery, September 2021 Keywords: Blepharoplasty, Eyebrow, Technique Abstract: Upper eyelid laxity affects facial aesthetics, and the eyebrow arch in the East Asian population is low. The authors developed infraeyebrow blepharoplasty using a dynamic suspension technique between the dermis-fascia flap and frontalis for upper eyelid lifting and eyebrow augmentation. A study was performed on 43 female patients with upper eyelid laxity from August 2015 to October 2019. The epidermis and superficial dermis of the infraeyebrow was removed from the surgical marking area with the deep dermis and fascia preserved. The eyebrow skin flap was separated from the frontalis surface, which exposed the area around the eyebrow arch. The preserved dermis-fascia flap was folded and suspended to frontalis in the superior margin of eyebrow arch. Follow-up was 25 months. All incisions healed well and were almost invisible. The eyebrow area improved with upper eyelid skin lift and eyebrow augmentation; 40 cases were “very satisfied” with their appearance. Three cases were “not very satisfied,” including one case with numbness in surgical area. Two cases had slight bilateral asymmetry of the upper eyelids. The dynamic suspension technique is worthy of clinical application because it can correct upper eyelid laxity, augment the low eyebrow arch, and obtain an invisible scar by reducing the incision tension.

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

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Advertising vs. PR PR and communications consultant Julia Kendrick goes back to marketing 101 and outlines how and when to use these powerful tools for your clinic With a booming UK aesthetics market, and an industry coming out of lockdown, there has never been a more exciting time for practitioners to create and grow a thriving brand presence. However, this highly competitive specialty brings the inevitable challenge of standing out from the crowd and being heard above the ‘noise’. PR and advertising are two key tools in your marketing arsenal, but how and when should you use them? In this article, I will outline what differentiates these two methods and provide insights as to how they can be delivered effectively, helping you grow brand awareness, secure and maintain revenue, and connect effectively with new and existing customers.

Spot the difference… The main difference between advertising and PR is that in the former, you have complete control over the brand messages, tone, and how or when content appears. Adverting is a paid channel – so you spend the money to secure the space or visibility directly. For the latter, you can shape and influence how your brand is communicated, but don’t have direct control on the outputs – this is down to third parties such as journalists, influencers, your patients, and the broader public. Although often you might hire a consultant to help, PR is earnt, not paid – it focuses on securing credibility and trust by influencing and informing others to talk on your behalf, hence why it is often more convincing for consumers (but more challenging to implement!).

PR vs. advertising Contrary to the title of this article, the biggest mistake you can make is assuming it should be PR VERSUS advertising – putting your marketing tools in an ‘either/or’ scenario. The most successful way to build a strong personal or clinic brand is to employ a combination of these tools over time – in my experience neither one in isolation will truly deliver the right results for your business. These are complementary strategies and should be tailored and combined to your individual business needs, challenges and current status. In addition, many clinics may not have the budget for a combined PR and advertising approach – so think carefully about your business objectives, available time, resources and budget when deciding which route to use and when. Whilst many consider PR to be mainly focused on media coverage, this is not always the case, particularly within the world of aesthetics. The ultimate aim of PR should be to increase trust and understanding of your business amongst target audiences and the broader public. Advertising can be a useful strategy for more short-term, targeted boosts to help attract new customers and establish/drive recognition within a rapid timeframe - often as an adjunct to broader PR and marketing activities.

Selling vs. convincing PR and advertising both aim to influence your audience to make a certain decision – they just approach this differently. According to

Advertising

Paid or unpaid?

Paid

Earnt

Key strength

Builds exposure

Builds trust and credibility

Audience mindset

Audience is sceptical

Media or third parties give validation

Guarantees?

Guaranteed placement

No guarantee, must persuade

Control

Complete creative/content control

Media/third parties’ control

Style

Ads are mostly visual

PR uses language, experiences

Speed

Can be implemented quickly

Takes time to build and generate results

Bottom lines

“Buy me, I’m great!” What you say about yourself

“Buy them, they’re great!” What others say about you

Table 1: The key differences between marketing and PR

a 2014 Nielsen study1 commissioned by inPowered on the role of content in the consumer decision-making process, PR was found to be almost 90% more effective than advertising. An advert may contain all your brand messages verbatim, but there can be a lack of ‘independent verification’ to push consumers through the indecision barrier. We know that an advert will say their product is the best, but do we instantly believe it? Sometimes yes, but we often look for other sources of validation and opinion before we make a purchase decision – especially for higher price items. This is where PR can come in – unpaid media coverage and people talking about your brand can increase the reasons to believe your sell. We all know the power of a personal recommendation; PR uses other people to do the talking for you – relaying their personal experiences of you or your clinic to the media, their followers, or friends.

Using advertising tools Print advertising remains the most expensive platform, and even with many publications switching to a digital format, purchasing space is still a cost premium. As a highly visual format, you may need to budget for creative imagery costs. Once developed, adverts can be used repeatedly for as long as your budget allows – the more repeats, the more visible your brand becomes. Online advertising has grown rapidly in the last few years and can be a highly targeted and effective option for clinic marketing – including social media ads, pay-per-click (Google ads) and display or banner ads. For an idea of costs, look on target publication websites for a media pack. Costs will be based on advert size and duration, and you may be able to secure a discount by booking repeated slots. Usually, you will be expected to provide your own artwork, which you can commission out to a freelance graphic designer or company, but certain publications may offer a design service for an additional cost. Advertorials are an alternative option – these blend advertising and editorial, with a mix of visual and text content so there is more opportunity to deliver your messages, versus a visual ad format. Advertorials are still charged as ‘paid space’ and usually you are responsible for the content, but this form of paid placement usually gets more support from the publication in terms of design and layout. Here are my top tips for creating a good quality advertorial:

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

Redefining the science and aesthetic of facial anatomy

Where innovation leads

Introducing the new CE marked, quality, intelligent HA dermal filler, designed for practitioners that want to lead not follow. KYSENSE® Is the latest tool using advanced technology for advanced aesthetic artistic precision, projection and ultimate patient satisfaction. KYSENSE® has been developed by scientists in collaboration with doctors with decades of experience in the HA dermal filler market and who contribute to peer reviewed publications in HA dermal filler technology and in facial aesthetics. The KYSENSE® manufacturing process HA-Protect, removes destructive oxygen species from the crosslinking stage, meaning the long HA chains are intrinsically more protected and preserved leading to advantageous rheological properties for a more natural look and feel to the tissue.

KYSENSE® with its unique rheological properties and an ergonomic syringe and ultra-sharp TSK HCP needle, KYSENSE® allows for a more comfortable treatment experience without the need for lidocaine. I love using Kysense® because of its natural results. My patients love the minimal swelling and are amazed they cannot even feel the products in the lips like other fillers they have tried. Caterina Alvarez Independent Nurse Practitioner

...precision, projection and ultimate patient satisfaction.

Find out more by booking onto one of our free webinars. Email: caroline@circaskin.co.uk

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My top five tips for successful advertising 1. Get targeted: To deliver return of investment, you MUST reach your target customers. Find out where your customers get their information or spend time online. Consider, what do they read or listen to? Which social networks do they use? Then focus your advertising spend in those specific places; scatter-gun tactics are money down the drain! 2. Differentiate yourself: Create strong, clearly defined messages which truly set you apart from competitors. Try to include the customer’s perspective – why they need you, or what problem only you can solve. If you can’t explain succinctly who you are and why you’re different, customers will redirect to competitors. 3. Be multi-channel: Consumers need multiple ‘touchpoints’ with your brand to build trust and tip them from consideration into action. Plan advertising across a range of channels (such as print, online and social media) and formats (web, mobile) to maximise success. 4. Be consistent: This is a marathon, not a sprint, so ensure you budget for sustained visibility, not one-hit bursts. Maintenance is key to avoid dropping visibility. 5. Monitor the results: How many people clicked your ad or opened your email? How many took action? Became customers? Which ad formats were the most or least successful, and why? Track your results and get tangible feedback – this is vital to shaping your future strategy.

Common PR tactics include clinic or product launch events, press campaigns and relationship-building. As an example, if your goal is to secure media coverage, you or your PR provider will ‘pitch’ your story to a journalist to get your ‘offering’ (be that a product, service or business) written about as an unpaid piece. The journalist and publication have control over if it’s published, when and how they write the story. Generally, press only write about something once – therefore you need to consistently come up with fresh approaches and ‘new news’ to get more coverage. This creative thinking, and the strategy of how to best ‘pitch’ you to press in a way that meets the media agenda is a key element of PR agency support. Critically, what you are buying when you bring in a PR specialist is not only their time and capabilities, but also their media contacts and relationships honed over years.

Ultimately… • Research other advertorials in the publication to get an idea of their style and tone • Consider your aims – what are you hoping to achieve from the piece? • What’s the main focus of the advertorial? Are there key facts you need to include? • What’s the ‘call to action’ for readers? How will they get in touch with you? QR codes and social media handles are useful. • Can you provide an exclusive reader offer? Social media advertising With most social platforms, you can now create highly targeted advertising campaigns which identify users based on specific preferences, demographics, and location. This means it is much more likely to drill down to those people interested in, or looking for, your services within a reasonable search radius. This tool allows you to ‘split test’ a campaign – trying out which messages or images deliver the best engagement or action from your target audiences. The purpose of your adverts can be clearly defined – for example increase brand awareness, to increase followers, to click-through to your website or take an action – like booking an appointment. Social advertising allows for clear budget allocations which will be reduced according to either user engagement or a set period of time elapsing – meaning you won’t run up mountainous costs! With certain platforms

like Facebook and Instagram – you can ‘boost’ posts for instant visibility. Otherwise, most platforms have a dedicated advertising services which takes you through step by step how to create an advert and run a campaign.

Using PR tools One of my favourite mantras is: ‘PR is what people say about you when you’re not in the room’. It is a multi-faceted strategy which helps you create and ‘own’ your brand space against competitors, educating audiences to increase understanding and awareness with a view to driving demand/sales. The underlying goal is to establish and nurture a reputation, creating trust and influencing perceptions to change decision-making behaviour. PR often requires specialist support to be delivered effectively and consistently. It can be viewed as ‘intangible’ or difficult to justify in terms of budget, but this is a common misconception. Whilst advertising provides a direct cost to exposure ratio, PR can bring lasting rewards if you have well-planned investment over time. PR is about building and maintaining your reputation and therefore has a broader remit in terms of exposure, word of mouth and brand trust. A successful PR strategy is a longer process with sustained investment, but ultimately it will help you achieve those key pillars of educating, engaging and influencing customers for longterm business benefit.

Building a trusted, engaging and visible brand reputation is a vital strategy to drive your commercial success. In the hyper-competitive world of aesthetics, your reputation and profile are key drivers of both new and repeat business, and by investing in a consistent marketing strategy with a blend of PR and advertising, you can give yourself the best chance of survival and success. The tools and techniques in this article give a clear outline for getting started – but if you need further guidance on how to take things to the next level, an experienced specialist communications agency can provide much needed strategic support. Julia Kendrick is an awardwinning communications and business strategy consultant, with a 17-year career spanning beauty, medical aesthetics and healthcare. Founding Kendrick PR in 2015, she is a seasoned industry speaker, author and trainer, and creator of the E.L.I.T.E Reputation Programme, the industry’s first online PR and marketing aesthetics training programme. REFERENCE 1. Nielsen, Content Marketing is 88 Percent Less Effective than Public Relations, 2014, https://www.linkedin.com/ pulse/20140325101743-36910198-content-marketing-is-88percent-less-effective-than-public-relations/

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

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Making Tax Digital Chartered accountant Jonathan Bardolph advises on the changes to taxation and how this may affect your business For aesthetic practitioners in business (whether it be as a sole trader, partnership, or limited company) you will soon be moving away from calculating tax annually to a quarterly submission and payment system. Currently, individuals complete an annual tax return and pay Her Majesty’s Revenue and Customs (HMRC) through payments every January and July. Payments on account are based on the previous year’s income and business profits. This results in a balancing payment (or refund if the profits are subsequently lower) the following January. The UK government is introducing Making Tax Digital (MTD) for income tax (and later corporation tax) which will change the way tax is administered.

Whilst the changes are due in 2023, with the effective dates being dependent on the type of entity you trade as, it is important to organise your aesthetic practice now so when MTD is effective, your practice is compliant and ready on time. Whilst this may be an added layer of administration alongside running a business, there are some useful benefits in complying with MTD early.

Outlining MTD The majority of aesthetic practices are either sole trades, partnerships or limited companies. A self-employed individual must maintain accounting records to enable an annual self-assessment tax return to be

Whether your business is affected by VAT, income tax (and NI) or corporation tax, MTD will become a mandatary requirement over the next few years

prepared (or partnership return if trading as a partnership) in case HMRC decide to raise an enquiry.1 The types of records that need to be maintained are predominantly, but not limited to, business income and expenses.2 Many practitioners keep manual records and populate these onto a spreadsheet before sending them to an accountant to enable a tax return to be prepared. Whilst this is acceptable for the purposes of preparing a tax return, it is not going to be sufficient when MTD becomes effective, as the government has introduced this to help businesses and individuals keep up to date with their affairs. MTD for self-employed individuals is effective for accounting periods starting on or after April 6, 2023, for annual business incomes above £10,000. These rules also apply to property income for landlords.3 MTD means that digital accounting records need to be maintained on MTD compatible software and submissions will be made quarterly to HMRC.4 A final tax return declaration will be done at the end of the year for various claims and reliefs.5 For many VAT-registered businesses, MTD is already in operation for submitting VAT returns and has been since April 2019,3 but this is only in relation to VAT (in other words, it does not include corporation tax or income tax currently).

VAT and MTD It is interesting to note that where a practitioner has been trading under the VAT registration threshold (taxable annual turnover of less than £85,000)6 previously, but becomes liable to register for VAT, they must in addition, comply with MTD for VAT purposes. The rolling taxable turnover test (which is the basis on whether a business must mandatorily register for VAT) should be monitored continuously by practitioners to ensure that either the business registers for VAT on time or does not need to register if the 12-month taxable turnover is not breached.6 Where insufficient records are maintained, or the bookkeeping is not reviewed, late VAT registration penalties can result.9 For businesses trading as limited companies, the government will introduce MTD for corporation tax no earlier than 2026.3 However, there is a good argument to ensure your aesthetic practice uses MTD compatible software much earlier to enable tax planning and cash flow management.

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

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MTD means that digital accounting records need to be maintained on MTD compatible software and submissions will be made quarterly to HMRC

could improve the efficiency and potential profitability of your practice and enable tax planning to be done at the time rather than retrospectively, which should be avoided as it can be illegal! There is an MTD pilot available for individuals wishing to take part early before it becomes mandatory.4 There will be an MTD pilot for companies released in due course, however, you should get advice from your accountant before signing up to ensure that you meet the eligibility requirements and that you have appropriate software. HMRC have a list of MTD compatible software which is updated from time to time as new software becomes available.5

Be prepared! A practical example for a first-year sole trader I will outline a scenario which may be relevant to some practitioners. Let’s cast our minds back to the 2019-20 tax year (before the COVID-19 pandemic). For personal tax returns, where a business owner has a March 31 2020 year end (and let’s assume that this is the first year of trade), the income tax, class two and class four national insurance would be due by January 31, 2021, which is 10 months after the end of the accounting period.8 This would also include the first payment on account for the 2020-21 tax year. If a practitioner waited until January 2021 to prepare and submit the tax return to HMRC,10 the tax liability based on 2019-20 may come as a surprise if inadequate records were maintained and/or no funds were retained for tax. Also, during this point in time, it is possible that had there been funds set aside for tax, these could have been used throughout the year (for general living expenses during the pandemic). Therefore, the practitioner may be unable to pay the tax on time which can result in interest and late payment penalties. This can cause stress for the business owner who would likely have seen a reduction in income during the 2020-21 year as a result of COVID-19 restrictions, but still having to finance the tax liability relating to 2019-20 in January 2021. Here is the point. If the practitioner was using MTD compatible software (and if MTD was in operation that year), then the tax liabilities would be known much sooner as the submissions were done quarterly throughout the year. This would enable

the practitioner to plan finances better as the year elapses. With MTD you pay the tax as you go through the year rather than calculating it retrospectively.

Technology and bookkeeping As technology is advancing, it is easier to record income and expenses using mobile phone apps which have Application Programming Interface (API) integration with accounting software. For example, if a practitioner uses Xero, then HubDoc (optical character recognition software) taking pictures of invoices and storing them within the Xero accounting system, this enables the practitioner to spend less time entering data allowing extra time to be spent on other clinic commitments. It is important to mention that if you have bookkeeping software (which you can research or ask your accountant about) which records income and expense transactions, additional checks need to be carried out (such as bank reconciliations) to ensure that the information being produced is accurate. An example is where a bank feed (which mirrors the transactions in the bank account) needs to be refreshed every 90 days (due to open banking regulations). This is to ensure that there are no gaps and duplicated transactions. Checks must be done on both the profit and loss account as well as the balance sheet, but your accountant or bookkeeper can assist you with this. For a practitioner to have a bookkeeping system which has reconciled bank accounts, digital copies of sales invoices and expense receipts enables the practitioner to interrogate the software. This

Whether your business is affected by VAT, income tax (and NI) or corporation tax, MTD will become a mandatary requirement over the next few years and in some cases, this is already upon us (if a business is VAT registered). There is the need to move away from manual record keeping to MTD compliant software which not only complies with MTD requirements as they develop, but also provides information to the practitioner, which is relevant, updated, and accurate. Jonathan Bardolph qualified as a chartered certified accountant in 2007. He runs Accountably Ltd, an accountancy practice in the south of England which assists clients with personal tax, corporation tax, VAT, sole trade, partnership and limited company accounts including tax planning matters. REFERENCES 1. GOV.UK, Business Records if you’re self-employed, (2020) <https://www.gov.uk/self-employed-records> 2. GOV.UK, What Records to Keep, (2020) <https://www.gov.uk/ self-employed-records/what-records-to-keep> 3. GOV.UK, Overview of Making Tax Digital, (2020) <https://www. gov.uk/government/publications/making-tax-digital/overview-ofmaking-tax-digital> 4. GOV.UK, Sign up your business for Making Tax Digital for Income Tax, (2020) <https://www.gov.uk/guidance/sign-up-yourbusiness-for-making-tax-digital-for-income-tax> 5. GOV.UK, Find software that’s compatible with Making Tax Digital for Income Tax, (2019) <https://www.gov.uk/guidance/ find-software-thats-compatible-with-making-tax-digital-forincome-tax> 6. GOV.UK, VAT Registration, <https://www.gov.uk/vat-registration/ calculate-turnover> 7. GOV.UK, Making Tax Digital: Corporation Tax, (2020) <https:// assets.publishing.service.gov.uk/government/uploads/system/ uploads/attachment_data/file/934638/Making_Tax_Digital_-_ Corporation_Tax.pdf> 8. GOV.UK, Self assessment tax returns, <https://www.gov.uk/selfassessment-tax-returns/deadlines> 9. GOV.UK, Late VAT Registration penalty (VAT Notice 700/41), (2012) <https://www.gov.uk/guidance/late-registration-penaltyfor-vat-notice-70041> 10. GOV.UK, Self Assessment deadline: less than a month to go, (2021) <https://www.gov.uk/government/news/self-assessmentdeadline-less-than-a-month-to-go>

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

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appear for the right searches, and the right kinds of potential patients, you need to actually ‘manage’ it. To do this, you need a website (and App) called Google My Business.

What is Google My Business?

Using Google My Business Business consultant Rick O’Neill discusses how Google My Business can help generate clinic enquiries Most aesthetic business owners recognise that appearing on the first page of Google search results for key search terms can have a significant impact on traffic and enquiries. In fact, according to software company Moz, the first page of Google captures 71% of search traffic clicks and has been reported to be as high as 92% in recent years.1 Second-page results are far from a close second, coming in at below 6% of all website clicks.1 But, local search is the name of the game when it comes to attracting potential patients within a close radius of your business location, and I believe that the most critical element of local search is a Google Business Profile. So, what is it, how do you manage it, and how can you optimise it for best results?

Local searches I’m sure that you have all heard of the term search engine optimisation (SEO). It’s a big topic, and not one you can cover in comprehensive detail without putting on a week-long workshop. But there is one specific element of SEO that matters more than any other for an aesthetic clinic, particularly one with a fixed location, and that is what’s commonly referred to as a local search, or a ‘near me’ search. This is when someone types into Google, for example, ‘skincare clinic near me’ or ‘skincare clinic’ with location/GPS enabled on their device. According to software company HubSpot, this kind of search grew by more than 900% between 2013 and 2017.2 In 2020 as many as 46% of all Google searches were local and more than 50% of ‘near me’ searches result in a physical store visit.3 This clearly represents a significant opportunity to owners of aesthetic clinics to find new patients and scale their business, but where do you start in order to capitalise on this type of web traffic? To help manage and grow your clinic’s online presence, having a Google Business Profile is integral because without it you are highly unlikely to appear in local search results, which as we have established, is where a significant proportion of your potential patients are seeking clinics. This refers to your business’ ‘listing’ on Google, which is a profile all about your clinic that can appear either to the right of the search results (usually if someone searches for your business by its name) or within Google Maps (if people are searching for similar businesses to yours in their area). Sometimes Google will create a Google Business Profile for your business automatically if it finds information about it via your website or other sources, but if not, you will need to create one yourself. A Google Business Profile contains information such as your business name, location, opening hours, website address and much, much, more as I’ll cover later. However, simply having a Google Business Profile is only the start. In order to optimise your profile to

A Google My Business (GMB) account is the only means by which you can claim ownership of your Business Profile, verify it, attain management rights to it, and unlock additional free features to increase your visibility on Google, and ensure that the details presented on your profile are correct and current (sometimes these are auto-generated by Google and can contain errors or out of date information). You can find GMB online, and they also have an excellent mobile application called My Business which I would highly recommend to help you keep on top of your Google Business Profile optimisation and updates (including responding to reviews, which as you will read below, is very important). There are four essential steps to getting started and optimising your GMB profile. So, let’s break each of these down into some simple actions you can take today to have a significant impact on your results from Google search. 1. Creating an account Firstly, you should log into the Google account you want to use to manage your business from. This will be linked to your Gmail email address, and if you don’t already have one you will need to create one. Once logged in, head to business. google.com and click ‘manage’ at the top right. Then, search for your business and click ‘manage now’, or if you can’t find it click ‘add your business to Google’. Follow the steps and populate your information. 2. Verifying your business In the process of populating your GMB profile, Google will ask you to verify it. This is a vital step, as the verification mark means you get the full range of options for managing your profile and optimising it, and more potential patients will find you as a result. 3. Optimising your GMB Once you’ve got full access to your GMB profile, and it’s been verified with Google, the real work starts! Optimising your GMB profile is an important and ongoing task. It makes the difference between having a GMB profile that only shows when people

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

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search your business by name, and having a GMB that appears when people search by treatment or condition – which is where the additional traffic comes from to help you scale your business. At my agency, we’ve been optimising GMB profiles for several years and have kept a careful eye on the elements that make the biggest difference to where your profile appears in the local results. Our internal check list now contains more than 80 ways to optimise a GMB for the best possible position in the search results. Here are the 14 most important ones (assuming you’ve already claimed/created and verified as above): • Complete every section of your GMB account in as much detail as you possibly can. Include key terms such as the types of consultations and treatments you offer • Be meticulous with contact information. Google ‘connects’ all the instances of your business name and address on the internet, and if they all match, you are ranked higher in search results • Select primary and secondary categories for your business type, so it’s clear to Google when to present your business as a result to a potential patient. You can select one primary category (the most weight in the Google algorithm) and 10 secondary categories • Mark off applicable attributes. For example, things like accessibility and payment options so that both Google and your potential patients can see that your business offers a comprehensive service • Write a complete ‘from the business’ description. Again, include important key phrases relating to the services you provide in order to help your GMB appear in results when potential patients search for these key phrases (e.g dermal fillers Brighton) • Publish Google posts weekly (these are like social posts, but appear on your GMB and are seen by potential patients on Google searching for your business or similar ones near to them) • Upload new (high quality) photos of your clinic, your marketing, and your team. It’s been revealed that 60% of consumers give more consideration to local results that include good quality images5 • Answer/add questions. For example, you could add questions and answers that you are commonly asked, such as the treatments you offer. In addition, patients

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can pose questions on your GMB profile, which you can respond to via the App or the GMB website Collect and respond to reviews – this is a big one because the number of positive reviews and how quickly you respond to them makes a significant difference to when and how high up your profile appears for searches Add a list of your treatments and services. This will help Google present you as a result for more searches, but also show your potential patients the services you offer. This makes it more likely they would choose to click through to your website, over a profile that has no information Set up messaging. The GMB App offers a way to do this in real time, so you can answer questions and convert someone from browsing to an enquiry Maintain your Business Profile. Add posts to your GMB profile every two weeks. These posts can be new treatment details, educational content, or offers. In our trials at my agency, we’ve shown that GMB posts have an impact on your profiles position in local results for up to two weeks Connect your social media profiles, like Facebook and Instagram, as Google considers active social media presence a strong indicator that your business is active and credible and so it is more likely to rank your profile higher Connect your appointment booking link to your GMB profile making it convenient for potential patients to make an enquiry quickly and easily

4. Getting the App! The GMB app gives you an important tool for boosting your local search presence and engaging patients online. It helps you reach out to new patients. Plus, the intuitive interface makes it simple to immediately update your business information. The App also allows you to communicate with your patients, for example after a customer leaves a review, you have a chance to respond to it (and when you do this, it adds to your rank with Google, as responding to reviews is a known signal that your business is active and credible).

Typed: Skincare clinic near me Voice: What are some good skincare clinics in my local area? According to early 2019 survey data from Perficient Digital, voice is now the number two choice for mobile search, after the mobile browser.7 Your GMB listing is an important part of local SEO and voice search. Because voice searches are often used to find out important details about your business, such as contact number, address, and opening hours, Google must have accurate information on these details. Your website and structured data (which is the meta data and title tags used in your website’s code8), go a long way in making sure Google has the right information about your business, but Google (or Alexa/Siri) wants to be accurate, and the way it does this is by looking at your GMB listing. This will give Google all the information it needs to understand what your business does, who it’s for, when it opens, where it is, and much more. This is the exact information voice searches are asking for, so it’s a quick way to get accurate results to people’s questions.

Get started! Verifying and optimising your GMB profile can have a significant impact on your Google presence and therefore the traffic and enquiries coming into your aesthetic clinic. Now is the time to take this action and benefit from the results. So, what are you waiting for? Rick O’Neill is a digital consultant to the medical aesthetics, cosmetic surgery and pharma sectors. With more than 20 years’ experience in digital marketing, O’Neill is the founder and owner of the award-winning digital agency Look Touch & Feel (LTF) and founding partner of The Aesthetic Entrepreneurs.

VIEW THE REFERENCES ONLINE! WWW.AESTHETICSJOURNAL.COM

Don’t forget about voice search! The way we type queries into Google is quite different from the way we talk to our voice assistants (Siri, Alexa). For example, if you’re looking for a local skincare clinic, your searches might look a little like this:

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

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In The Life Of Dr Dev Patel

The clinic owner and Merz Innovation Partner talks about his new skincare range and how he balances his work/life schedule patient results was when I started to use Merz’s dermal filler Radiesse® in 2013, which at first I used cautiously, but became more confident with time. Its ability to stimulate collagen and elastin production means that long after the filler has gone, my patient is still looking better post-treatment.

A healthy morning… On Mondays and Thursdays, I wake up at 6.15am and arrive at the gym for 7am to exercise under the watchful eye of my personal trainer, who I have been with for more than 10 years. On other weekday mornings I’m a bit lazier and spend an extra 30 minutes in bed. I do 20 minutes of Surya Namaskar (sun salutes) and yoga breathing exercises, which my mother as a long-time yoga practitioner, has always encouraged me to do. I also make sure I never miss breakfast! Typically, I have spiced Indian-style scrambled eggs and a slice of toast. I’m a big chilli fan, so by the time breakfast is over I would have eaten oneto-two green chillies. Luckily, my clinic Perfect Skin Solutions located in Portsmouth, is only a few minutes away from my house. Ideally, I would cycle to work but as my bike was recently stolen, I have been using my car! On arrival, I eyeball the clinic inside and out as I want to maintain a flawless presentation — a piece of debris on the floor or a wonky sign — the details matter. A brief hello to my team and I’m into a full clinic with my first patient.

Working with my team… At the clinic, I always work alongside an aesthetic therapist. We have six therapists currently who are on rota to be my assistant when conducting aesthetic treatments. I can give more focused attention to my patients, while my assistant conducts all the routine paperwork. During all treatments, the therapist offers a second pair of hands to help reduce bruising risk and improve the comfort level of the patient. My assistant and I will work in near silence during treatments as I prefer to have my patients drift into a calm state, and therefore we communicate largely through non-verbal communication, which takes around three months to perfect! Half of my day consists of administering injectables, and then the other half involves a mix of scar treatments to non-surgical blepharoplasties. I make sure that I never miss lunch. I have 45 minutes set aside but inevitably, with all the messages and questions from team members, it usually ends up being 10-15 minutes. My father (also a doctor) made me 76

Most memorable day…

promise to always take lunch and have at least 15 minutes away from my desk, which I always abide by.

Incorporating other work commitments into my schedule… At the start of the third lockdown, I decided that I needed to make some changes to my working schedule for my mental health. I dropped my clinical sessions on Thursdays and made it an ‘admin’ day. Half of my day is focused on my new bioceutical skincare line CellDerma, which launched in my clinic in December 2020. It has exceeded my expectations regarding the clinical outcomes we are seeing, particularly with our GF5 serum, which has reduced healing time after ablative procedures and the number of calls we get from patients concerned with their recovery. Another work commitment I love outside of seeing patients is working with Merz Aesthetics. The deep ethics of the company is something I admire. Becoming a Merz Innovation Partner was an amazing achievement! Merz have drop-in morning workshops every month for one of their injectable products, so practitioners who are thinking of adopting the product or using it can have their questions answered. Practitioners have 15 minutes with two Innovation Partners, along with someone medical from the Merz team for them to ask product specific questions. A big game-changer for me in getting good Aesthetics | October 2021

In my medical career, my time in the Royal Navy was very special. You could give me any month and year and I could tell you an interesting anecdote and where I was in the world. When I left the Navy and became a GP, I was told that ‘one day would blend into the next’ and I did find this. However, within aesthetics, each year is memorable! There has been an acceleration and development of my knowledge and ability so there have been many milestones. If I had to pick one memorable moment it would have to be winning The Intraline Award for Best Clinic South England at the Aesthetics Awards. Gaining recognition of peers in such a tough arena was emotional.

Favourite treatment to perform…

Dermal fillers! Although there are long-term benefits and improvements for the patient, there is an immediacy to it. Check out the Magic Mirror Moments series on my social media!

Career if you weren’t in aesthetics…

I’d be a lawyer – I like to argue a case. Or something else in the military, maybe a pilot! I aspire to get my pilot’s licence in the future.

Any hobbies…

I have just joined a local rowing club. I also enjoy spending time with family, seeing friends and walking the dog.

This article is sponsored by Merz Aesthetics

M-MA-UKI-1609 Date of Preparation: September 2021

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“I want to continue to educate myself and inspire others in all I do” Dr Ifeoma Ejikeme recalls her specialist training in aesthetics and her win at the Aesthetics Awards Growing up in London with a strong family medical background, Dr Ifeoma Ejikeme has been surrounded by medicine from a young age. Her father and three of her five siblings all work in medicine, so it has always been a strong influence in her life. Graduating from Bristol University in 2007 studying general medical training, Dr Ejikeme recalls how she always had a passion for head and neck surgery and believed this was the medical route she should go down. Travelling to New York to attend Columbia University in 2009 to conduct a postdoctorate fellowship specifically in rhinology, she explains, “On a placement in Texas, I spent time with a world-renowned rhinologist. On my first day, I went into his office dressed in scrubs as I believed I would be working in ear and nose surgery. Instead, I witnessed him administering botulinum toxin to a patient, doing a chemical peel treatment and a non-surgical rhinoplasty.” During this time, Dr Ejikeme was shocked at the use of aesthetic procedures as it was a new venture which she had not considered before. She recalls, “At the time, it completely blew my mind! I couldn’t get my head around what he was doing – he was using a filler to correct a nasal deformity and the results were immediate! Nowadays, it seems so normal to me, but at the time, it was incredible.” Being able to quickly understand aesthetics through her medical background was how Dr Ejikeme fell in love with the specialty. She adds, “During the rest of my fellowship with him, I witnessed both aesthetic and surgical results. It hit me that what I wanted to do was to be able to enhance facial features the same way he was doing.” After finishing her fellowship, Dr Ejikeme switched to general medicine, completed her internal medical residency, and undertook a Master’s in Aesthetic Medicine at Queen Mary University in 2013. She recollects, “When I finished my Master’s, I was awarded the highest

distinction of the year and was invited to join a faculty at the university. I’ve been there ever since, and I absolutely love it! Interestingly, I continued to have a passion for noses and did my dissertation on ‘Aesthetic Indications of the Nose’.” Within her training, Dr Ejikeme completed her Certificate of Eligibility for Specialist Registration (CESR), a pathway for training in Medicine, and joined the specialist register as a medical consultant. “You need to have done a certain amount of outpatient clinic appointments, and a certain amount of monitored procedures. One aspect I felt I needed to complete before starting my own practice was to conduct 10,000 cases,” she explains. Instead of jumping straight into owning a practice and completing treatments, Dr Ejikeme wanted to shadow other professionals and assist in procedures. “I had my certification in aesthetics; I could do it myself, but I wanted to watch how others did the treatments. I was monitored and then had others watch me do it for weeks. I started independent practice and worked with many big clinic chains to ensure I was the best I could be and eventually gained my 10,000 cases!” Starting her own clinic Adonia Medical Clinic in London during 2017 was a challenge. “Picking the location was one of the hardest decisions I faced. I knew I wanted a local practice in London with lots of space, but it took me almost four years to find the perfect spot. I decided on Central London as I wanted a beautiful clinic in a private location. When I saw the double fronted three story building, I fell in love,” she adds. Whilst visiting other clinics during this time as a patient, Dr Ejikeme felt that as a woman of colour, practitioners did not fully understand her concerns, which is an aspect she wanted to implement into her own clinic. In 2020, Dr Ejikeme became a founding

member of the Black Aesthetics Advisory Board (BAAB) with four fellow aesthetic professionals. She recalls, “The BAAB was created after the atrocious murder of George Floyd. The BAAB aimed to bridge the gap with brands to understand how to better serve black customers and patients.” Along with her commitments to the BAAB, she is a member of the American Board of Internal Medicine (ABIM) in the US and the Royal College of Physicians in the UK. She is also a speaker at many conferences including CCR and BCAM, whilst being a KOL for brands including CeraVe, Shisheido, Aquagold and Ultraformer. Thinking back over her career in aesthetics, Dr Ejikeme notes that her biggest achievement was winning Best Clinic London at the 2019 and 2021 Aesthetics Awards. “I remember when I first started in aesthetics, not attending the Awards because I thought only the most prestigious people went. I would recommend everyone to enter as you never know, you might win too! I’m still wrapping my head around it. I always wanted my own practice and having that recognition is incredible,” she explains. In the future, she notes, “I want to continue to educate myself and inspire others in all I do.”

My favourite treatment is… Microdroplet dermal fillers! I like to use the minimal amount possible to give the maximum result. Combined with chemical peels, this works so well.

Any hobbies… I’m a movie junkie! I love anything fantasy such as Game of Thrones.

Best piece of career advice… Be your own cheerleader! Back yourself and believe in yourself.

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

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Other areas for improvement when it comes to aesthetic training is facial assessment, which is currently focused on that of the Caucasian face. Therefore, when advising and conducting restorative work we usually base our knowledge on that example. Can we apply this knowledge to people of different ethnicities? People of colour age differently, have different facial characteristics, so we need to understand the structure and functional difference of black and brown skin, in order to treat appropriately.

The solution

The Last Word  Nurse prescriber Khatra Paterson points out the limitations in training when it comes to skin of colour, and provides suggested areas for improvements My nursing career started in 1988 at the School of Nursing at Royal Liverpool Hospital. I was the only black person in my year group of more than 100 students. Over the intervening years, the proportion of nurses from the Black, Asian and Minority Ethnic (BAME) community has grown to one in five, which more closely matches the community we serve.1 However, there is still an evident lack of knowledge when it comes to treating darker skin types, particularly in the aesthetic field.

A gap we need to fill   During my initial training as a nurse, skin colour and the effect it can have on diagnosis and treatment was never mentioned. This omission has continued in most of my subsequent training as a midwife, health visitor and for the last 10 years in my role as an aesthetic nurse. For example, I was taught that a person presenting with a myocardial infarction would display a number of physical symptoms, including changes to skin appearance, but these skin colour changes were described with a white person in mind. For a person of colour, the majority of these symptoms would be the same, however the way they presented could be dramatically different. For example, whilst a person with white skin may well go either pale grey or blue in appearance, what would the appearance to a person of colour skin look like? For Fitzpatrick V and VI the skin will not look blue but will likely be ashen.2 In addition, colour changes in darker skin tones are not as apparent as in white skin for those that are ill or in shock. The lack of information and training on skin colour also extended to descriptions on how skin disorders present. This gap in my knowledge began to take on added relevance as I moved into the aesthetics field. My initial aesthetic training was conducted by a well-recognised and established UK training company, but throughout my time with them there was no mention of how we were to recognise and diagnose complications in people of colour. As I practise in a part of the country where the proportion of BAME patients significantly exceed the national average; I was keen to gain a greater insight. When I asked trainers how a vascular occlusion due to dermal filler would present in a person of colour, they were unable to give clear guidance or provide evidence. As we know, vascular occlusion, if untreated, can lead to skin necrosis and tissue death so early identification is crucial to avoid long-term damage of skin. I appreciate that for certain treatments, uptake is lower from BAME patients. Therefore, there will be fewer examples of complications from which we can all learn. However, this should not stop us from striving to improve. There needs to be a better understanding how adverse reactions appear in darker skin tones to prevent mismanagement or a delay in management.

Gaps in our knowledge and experience will significantly increase the chances of problems occurring. Knowledge gaps can be filled through specific training on skin and ethnic background variations; how skin of colour responds to treatments, facial structure differences and appropriate treatment options, potential complications and how to avoid them. Practitioners need to actively seek this information and training out, and if they find it is unavailable, encourage training providers and companies to focus on this. They should also share their case studies and help educate others based on their own experiences. As practitioners, we also need to seek out and promote images that showcase a wider variety of what represents the aesthetic ideal, acknowledging that what defines beauty and youth will vary across skin colours and ethnicity.

Get to know diverse skin colours and ethnic face variations We live in a diverse society and this needs to be reflected in our training and training material. As we improve our knowledge, not only will we be able to treat our existing patients with skin of colour better and achieve better outcomes, but we will be able to broaden the appeal of our treatments to include the whole of our diverse society. Khatra Paterson is a nurse prescriber with more than 32 years’ experience within the medical field. Paterson has specialised in aesthetics for more than 10 years and owns and is the director of KP Aesthetics clinic in Hale, Cheshire. Qual: BSc, BA REFERENCES 1. NHS, CNO Black and Minority Ethnic (BME) Leadership, <https:// www.england.nhs.uk/nursingmidwifery/delivering-the-nhs-ltp/ cno-black-and-minority-%20%20ethnic-bme-leadership/> 2. My American Nurse, Color awareness: A must for patient assessment, 2011.

Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021

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