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VOLUME 8/ISSUE 10 - SEPTEMBER 2021

UKI-RES-2100104 DOP August 2021

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Understanding LED Therapy CPD Aesthetic nurse Emma Coleman explores LED therapy for skin conditions

Training in Aesthetics

Aesthetic trainers explain the options available to further your career

Chemical Peel Complications

Dr Xavier Goodarzian outlines the common complications caused by chemical peels

10/08/2021 17:20

Hosting Students

Dr Uzma Qureshi discusses the benefits of hosting medical students at your clinic


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Contents • September 2021 06 News

The latest product and industry news

17 News Special: Industry Responses to APPG Report

Aesthetics investigates how the specialty has reacted to the APPG report

20 CCR Announces Stellar Line-Up

The exciting agenda for CCR on October 14-15

23 Writing a Winning Aesthetics Awards Entry

Acting Editor Shannon Kilgariff provides tips for writing an Awards application

CLINICAL PRACTICE 25 Special Feature: Training in Aesthetic Medicine

Aesthetic trainers explain the options available to develop your career

28 The Spherical Revolution

Revanesse shakes up the UK dermal filler market

31 CPD: Understanding LED for Skin Health

Aesthetic nurse Emma Coleman explores LED therapy on skin conditions

News Special: Industry Responses to APPG Report Page 17

37 Celebrating 25 Years of Restylane

Galderma celebrates Restylane’s anniversary

41 Understanding Chemical Peel Complications

Dr Xavier Goodarzian outlines complications caused by chemical peels

44 Case Study: The Merz Approach with BELOTERO Revive

Nurse prescriber Julie Redmond shares why she is excited about this new product and presents a case study

47 Understanding Gynaecomastia

Mr Alex Karidis outlines the causes and treatments of gynaecomastia

51 Introducing EMSCULPT NEO

A new approach to address body concerns in a single treatment

53 Case Study: COVID-19 Vaccine Reaction

The management of a complication following the COVID-19 vaccine

58 Considering Radiofrequency for the Younger Demographic

Dr Kirsty Lau presents her advice for treating patients in their twenties

59 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 61 Hosting Undergraduate Medical Students

Dr Uzma Qureshi explores the benefits of undergraduate placements

64 Preventing Burnout

Business consultant Stuart Rose shares advice on production capability

67 Installing Standards into Your Clinic

Business consultant Taruna Chauhan outlines the benefits of implementing Care Quality Commission standards

70 Assessing Your Clinic’s Risk

Accreditation and safety leader Thomas S. Terranova discusses emergency preparedness plans

72 In Profile: Dr Chris Hutton

Dr Chris Hutton explores the importance of education within aesthetics

73 In the Life Of Sharon Bennett

The BACN chair gives an insight into her working schedule

74 The Last Word: Bloggers and Influencers

Dr Arreni Somasegaran debates injectable freebies for bloggers

NEXT MONTH IN FOCUS: DIVERSITY • Injecting the Calf with Toxin • Treating Black Lips

Special Feature: Training in Aesthetic Medicine Page 25

Clinical Contributors Emma Coleman is a dermatology and advanced aesthetic nurse practitioner. She trained in aesthetics in London in 2015 and gained a distinction in Clinical Dermatology Diploma. She is a clinical director at the four Emma Coleman Skin clinics. Dr Xavier Goodarzian is the medical director and co-owner of the national award-winning Xavier G. Clinic. He is a lecturer and trainer at conferences throughout the UK and abroad and the past lead trainer for Innomed Training. Mr Alex Karidis has more than 25 years of experience in plastic surgery and has run his own practice in St John’s Wood, London for 17 years. He has expanded his offering with the Karidis Medispa in Beauty Bazaar, Harvey Nichols. Dr Victoria Manning is an aesthetic practitioner and GP, with more than 20 years’ clinical experience and is the co-founder of River Aesthetics. She is a global threads trainer and is also an aesthetics industry media contributor, writer and speaker. Dr Charlotte Woodward is an aesthetic practitioner and GP with more than 25 years’ experience. She is the co-founder of River Aesthetics. She was one of the first in the UK to offer non-surgical breast lifting using PDO threads.


Reduce inflammation and redness Speed post-procedure recovery Increase patient comfort levels Reduce patient downtime Enhance results “Being able to treat inflammatory skin conditions, revitalise tired and ageing skin, as well as to deliver results for pain management and wound healing has broadened both my in-clinic and at-home treatment offering. Most importantly, my Celluma devices have taken our patients’ results and satisfaction to the next level.” Miss Sherina Balaratnam MBBS, MRCS, MSc (UCL) Surgeon and Cosmetic Doctor Medical Director, S-Thetics Clinic Beaconsfield, Buckinghamshire (UK)

CERTIFIED LIGHT THERAPY TRAINING BY WYNYARD AESTHETICS ACADEMY Classes: 20 September 2021 Contact: helen@WynyardAestheticsAcademy.com www.international.celluma.com

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Editor’s letter “It is our view that dermal fillers are a crisis waiting to happen.” Does anyone remember this? It was a powerful statement written in the Review of the Regulation of Cosmetic Interventions, published seven years ago. Although Professor Sir Bruce Keogh and Shannon Kilgariff colleagues outlined the issues prevalent within Acting Editor & the aesthetics specialty, it’s safe to say that not Content Manager much has been done. The release of the new @shannonkilgariff report by the All-Party Parliamentary Group on Beauty, Aesthetics and Wellbeing (APPG) again shines a light on how the lack of regulation is risking patient safety. Whether it will convince the Government to take stronger action, I am personally eager to find out! In the meantime, have a read of our News Special, where we speak to key industry stakeholders and associations about their views on the report (p.17). We’d also love to hear your thoughts on the topic – tag us on social media after reading the article! This month we focus on professional development, so we have some really great business themed topics. Have a read of our

Special Feature on aesthetic training (p.25) and check out the In Practice section! Speaking of which, we have a whole In Practice agenda happening at CCR at ExCeL in London on October 14-15! There will be topics ranging from diversity and personal wellbeing to marketing, consultations and patient safety. There’s something new for everyone to learn, bring back to your clinic and better your practice! I have been working with lots of inspirational practitioners and industry experts on this agenda, so I am personally very excited to share it with you. For more information about CCR, and to register for free, turn to p.20. Remember, Aesthetics Awards entry opens this month on September 30! You will have a whole month to enter, but start having a think about your entries now and read my top tips for success on p.23. Get in touch if you have any questions – contact@aestheticsjournal.com. As always, we would love to hear from you about your thoughts on this issue and what you would like to read about next. Get in touch via email: editorial@aestheticsjournal.com or tag us on Instagram @aestheticsjournaluk.

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

#Qualification Jude Dunican @judedunicanaesthetic Proud to announce that I have achieved my master’s degree in Aesthetic Medicine with a distinction award #education

#BeyondBeauty Dr Ingrid Wilson @dringridwilson It was a pleasure and honour to be able to contribute a non-surgical perspective on male hair loss. Congratulations to the team for such an informative magazine!

#Television Dr Elizabeth Hawkes @dr_elizabethhawkes Incredible to get the opportunity to talk eyes and eye health live in the studio today. Thank you @gbnewsonline for having me

#International S-Thetics Clinic @sthetics_clinic Enjoyed filming a range of webinars for iS Clinical USA's Global Education platform today!

#Scars Mr Ioannis Goutos @ioannisgoutos Pleasure to be filming with crew @thebadskinclinic and @phoenixhospitalgroup this weekend #skin

JCCP reveals new training framework The Joint Council for Cosmetic Practitioners (JCCP) has announced a new educational and training framework in collaboration with the Cosmetic Practice Standards Authority (CPSA). The JCCP has now completed an exercise with CPSA colleagues and the British Association of Dermatologists (BAD) to review the alignment between the GMC Plastic Surgery and Dermatology Specialist Register membership requirements. The exercise looked into the knowledge and practice competencies against the CPSA standards and the JCCP framework. As a result, the JCCP has announced that full equivalence and alignment has been approved between the specialist register for Plastic Surgery and the specialist register for Dermatology with regard to Level 7 aesthetic practice. Any current member of the GMC Plastic Surgery or Dermatology specialist registers will be able to join the JCCP practitioner register as a full member without any requirement for further educational attainment or attendance at a fast-track assessment centre. Practitioners who hold such registration status should contact the JCCP register team to confirm their live membership of one of these two specialist registers to either revise their current registration category, or to request membership of the JCCP. Chair of the JCCP Professor David Sines commented, “Following a thorough review of the GMC specialist register curricula regarding theoretical knowledge and practice competence has been affirmed to assure us that members of either of these two registers demonstrate equivalence and full compliance with the JCCP and CPSA’s Level 7. We are delighted to announce this decision.” Botulinum toxin

Juvaplus to launch robotic syringe in the UK Swiss medical technology company Juvaplus will be launching a new robotic syringe for the use of botulinum toxin injections to the UK. The Juvapen Expert is CE marked and the company worked with the Swiss Federal Institute of Technology (EPFL) for the development of its technology. Due to its internal mechanisms, the device produces a constant homogenous flow, enabling the toxin to distribute evenly across the designated area, reducing pain, discomfort, and visible swelling, commented Juvaplus. Sales and marketing manager at Juvaplus, Edouard Legrand, said, “We are enormously proud to introduce the Juvapen Expert to the UK. We believe that this technology is a game changer for the aesthetic and therapeutic industry. Practitioners can provide more accurate and therefore aesthetically pleasing results for their patients by using this device.” The device will be launching in September and unveiled at the Aesthetic and Anti-Ageing Medicine World Congress (AMWC) in Monaco.

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


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Anniversary

Galderma celebrates 25 years of Restylane Pharmaceutical company Galderma is celebrating 25 years of the hyaluronic acid filler Restylane this year. The filler was the first non-animal HA filler to receive European approval in 1992, and in 2003 it was the first to secure approval by the Food and Drug Administration (FDA). The range has been used in more than 50 million aesthetic treatments worldwide and continues to be used today. Read more about the anniversary on p.37. Galderma will also be the Headline Sponsor of CCR on October 14 and 15 – register for free on p.20.

Vital Statistics In a survey of 1,500 marketers, 48% use hashtags and 46% use live videos as tactics in their social media marketing (Hubspot, 2021)

43% of 160 people felt uninformed about the risks or side effects when undergoing cosmetic treatments

Conference

Dr Arthur Swift to speak at CCR World renowned plastic surgeon Dr Arthur Swift will be a keynote speaker for Canadian dermal filler manufacturer Prollenium as it launches Revanesse to the UK at CCR on October 14 and 15. Dr Swift will be presenting a symposium on ‘Lips and Tweaks with Revanesse’ on October 14 and another on ‘OMGEE Curve: Mastering of the Midface with Revanesse’ on October 15. Taking place on the afternoon of the 15th in the Gallery with three sittings will be ‘An Audience with Arthur’, involving an informal Q&A session. Headline Sponsor Galderma will be also be exhibiting along with hundreds of other well-known companies and brands. Key speakers coming to CCR include: Miss Priya Chadha, Miss Lara Watson, Mr Ash Labib, Dr Nestor Demosthenous, Dr Sophie Shotter, and more! Achievement

IBSA Derma wins award for beauty standards campaign Pharmaceutical company IBSA Derma has won the Press, Outdoor and Promotion Key Award 2021 in the ‘Media Relations and Brand Storytelling’ category. The company won the award with its ‘Me as a Masterpiece’ campaign, detailing that beauty does not belong to preconceived standards. The exhibition presented images without traces of modifications or filters, with the goal to show the four protagonists feeling themselves in their beauty, explains IBSA Derma. The campaign was assessed on the originality of the idea, the effectiveness onto the target market, and the achievement of the objectives. The campaign staged at the National Museum of Science and Technology Leonardo da Vinci in Milian. Marketing and communication manager of the Dermoaesthetics Division at IBSA Italia, Maria Bisogni, commented, “We are very proud of this project and the important recognition received. The goal has been to put women and their essence at the core, with the hope of sparking a desire to rediscover and enhance one's uniqueness.”

(Mental Health Foundation, 2021)

In a survey of 1,000 men and women aged 18 and over, 55% would be interested in an app or website to see how aesthetic procedures would affect their face (AEDIT, 2021)

60% of 1,300 acne sufferers experience truncal acne as well as facial acne (Galderma, 2021)

An average Facebook user clicks on 12 ads per month with women clicking on more ads than men (Status Brew, 2021)

In a survey of 1,212 people, 91% either ‘agreed’ or ‘strongly agreed’ that people are undergoing cosmetic treatments when they are too young (Cosmetic Surgery Solicitors, 2021)

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


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Events Diary 3rd September 2021 International Association for Prevention of Complications in Aesthetic Medicine (IAPCAM) symposium iapcam.co.uk

4 -5 September 2021 th

th

13th 5CC Virtual World Congress www.5-cc.com/en/2021/home/

10th-11th September 2021 British College of Aesthetic Medicine (BCAM) second virtual conference bcamconference.co.uk

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

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Distribution

Clinisoothe+ Skin Purifier launches into clinics Skincare product Clinisoothe+ Skin Purifier is now available from aesthetic distributors. The product was launched to consumers in the UK during 2020 but due to demand, Clinisoothe+ will become available to clinics, explains the company. The product is used for aftercare post-procedure and suitable for all skin types. Clinisoothe+ explains that the product is free from all toxins including alcohol, parabens, sulphates, preservatives, colourants and fragrance. According to the company, the product is a hypochlorous solution which protects the skin from pollutants and impurities, preventing breakouts and promoting rapid recovery. It is available in two sizes, 100ml and 250ml. Ross Walker, director of Clinisoothe+’s manufacturer Clinical Health Technologies, said, “Following the launch of Clinisoothe+ Skin Purifier, we were delighted that it quickly garnered hundreds of reviews and became another awardwinning product. However, we received a deluge of requests for it to be available to aesthetic clinics and their patients as an effective product to help address skin conditions daily. Therefore, we are excited to make it available through all major aesthetic distributors.” Hair

14 & 15 October, ExCeL www.ccrlondon.com

MHRA

Top-Q dermal filler sold with false CE mark The Medicines and Healthcare products Regulatory Agency (MHRA) has revealed that models of Top-Q dermal filler are being sold with a falsely applied CE mark. The MHRA has warned practitioners that the hyaluronic acid filler has not been obtained with regulatory oversight for products claiming a medical purpose. These devices have been manufactured to unknown standards and their safety as medical devices cannot be verified, explains the MHRA. The MHRA advises users providing treatment to not use any Top-Q dermal fillers in their possession, to not buy any Top-Q dermal fillers, report any suspected or adverse events involving these devices through their local incident reporting system and/or national reporting authority as appropriate, and to contact the MHRA team about concerns regarding any devices they have purchased or intend to purchase.

Pharma Hermetic unveils new hair recovery programme Cosmetic and pharmaceutical manufacturer Pharma Hermetic has launched the Hair Recovery Programme SP55. According to the company, the programme has been developed to support stem cells in the hair follicle using peptide SP55 which includes 55 amino acids to enhance the growth of hair and activate dormant follicles to rebalance the scalp. The dihydrotestosterone (DHT) blocking ingredients inhibit the formation of the 5a-reductase to reduce inflammation and provide a better supply of key ingredients for healthy cellular growth, explains Pharma Hermetic. The programme is for in-clinic use and to retail for home-use. George Brankov, medical director at Medaesthetics, commented, “The Pharma Hermetic range is taking the hair restoration industry by storm. There are some amazing success stories with these natural hair restoration products which is very exciting.” Mental health

Harley Academy to create psychology framework Training provider Harley Academy is partnering with the Centre for Appearance Research (CAR) to assess the framework of psychological assessment. Consultant clinical psychologist at CAR Alex Clarke and co-director of CAR professor Nichola Rumsey will assess the feasibility of an evidence-based framework for psychological assessment and follow-up in practice. The collaboration aims to generate the data necessary to improve understanding of the psychological benefits and risks of cosmetic procedures, definitive assessment tools, recommendations for patient management, and training for practitioners. Founder of Harley Academy Dr Tristan Mehta commented, “Our partnership will address the lack of data surrounding long-term psychological consequences of non-surgical cosmetic interventions. We are in need of a validated consultation tool which allows us to predict psychological outcomes from our treatments and protect patients.”

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


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Celebration

Aesthetics Awards entry opens this month On September 30, entry for the prestigious Aesthetics Awards 2022 opens. With 26 categories and a chance to become a finalist at our dazzling ceremony, there is plenty of time for you to perfect your entry. Have a read of acting editor Shannon Kilgariff’s tips for writing a winning Aesthetics Awards entry on p.23. Kilgariff commented, “We are so excited for the Aesthetics Awards to return with a bang! Due to the pandemic, we hosted a successful virtual ceremony in May, but we are delighted to welcome back the awards in-person and to celebrate the successes of the industry over the past year.” Entry will close on October 30 and the Aesthetics Awards ceremony will take place on March 12, 2022, at the Royal Lancaster Hotel in London following the second day of the Aesthetics Conference and Exhibition. Partnership

Revision Skincare now available at GetHarley Skincare brand Revision Skincare has partnered with skincare platform GetHarley. The range uses peptides to combat visible signs of ageing and formulates all of its products with prebiotic technology to help the skin’s microbiome, explains Revision Skincare. Founder and director of AestheticSource, Revision Skincare’s exclusive distributor, Lorna Bowes said, “GetHarley offers a virtual premium service for both the practitioner and consumer providing benefits such as automatic replenishment alerts and buying and managing stock on behalf of the practitioners, meaning there is no purchase requirement for the practitioner. This service has been a huge success for our AestheticSource customers. We look forward to welcoming more happy customers in the future!” Treatment

LABthetics launches new chemical peels The Salicylic acid 10% peel is aimed at treating acne, reducing pore size, and helping acne scarring. The peel is combined with a salicylic cleanser to use at home as a preparation product. The Jessner peel is a blend of glycolic, lactic and kojic acids to remove the superficial layers of the skin, dry out active acne, reduce wrinkles, and scarring and improve the appearance of sun damaged skin. The peel is combined with an at-home brightening barrier cream to focus on the active ingredients in the peel. Emma Caine, founder of LABthetics, commented, “The launch of our new peels is an exciting addition to our portfolio as we approach the chemical peel season. The peels have been formulated to achieve results and not trigger the inflammatory cascade causing post-inflammatory hyperpigmentation associated with skin peels. We have some more exciting products launching later this autumn.”

Auditing

Your Brand's Images Photographer Hannah McClune’s monthly tips on how to strengthen your business through branding

How well are your current images performing?

If you are not feeling confident that the images you are sharing are the right ones – or that the images are not doing their best possible job at attracting patients – then maybe you need to review what you share. Great quality images will make you look polished and professional, while poor-quality images... well the opposite. Take some time to check if the images you are sharing strengthen your brand and the way your business is seen. It starts with identifying your brand values and dream patients:

1. Your brand clarity: What values do you

want your business to stand for? 2. Your dream patient: Who is it you want to sell to and be booked by? Once you know these two main factors you can start to check your photos against each other. Compare what it is you post on social media platforms, have on your website, and also anything offline to be sure they match the values you want to reflect and also will be appealing to your ideal customers.

For more branding advice

Would you like a free copy of Visible by Hannah’s 10 page audit workbook? It guides you through your brand clarity, your dream client and ultimately, the comprehensive checks you need to complete for every place you share images. The guide is available for all readers. Email Hannah for your copy at hello@visiblebyhannah.com

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 10 - September 2021


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

AUGUST ROUND-UP The BACN worked directly with Galderma throughout August looking in-depth at the original biostimulator, Sculptra. It was great to see so many members interact throughout the month, with the full In Conversation With video series between Mel Recchia and Sharron Brown available on the BACN IGTV page and Facebook, and the InFocus webinar recording available within the members' area of the website.

COMING UP IN SEPTEMBER The BACN is so excited to be partnering with Allergan Aesthetics for the whole of September, focusing on all things lips. BACN Management Committee Member Mel Recchia will be speaking with an Allergan Aesthetics KOL for our In Conversation With video series, and the InFocus webinar will be looking at ‘Lips: An Introduction to Shape’. The webinar will be led by an expert panel featuring Alison Telfer, Rosey Drewitt-Staples, Rachel Wainwright, and Kealy McBride. Allergan will also be offering a 15-minute takeover for the Peer Review with a lip guide tool for all members. The Peer Review will be led by BACN Regional Leader for London Constance Campion and BACN Management Committee Member Clare Amrani. • In Conversation With – Tuesday September 21 • InFocus Webinar – Tuesday September 28 • Peer Review – Thursday September 30

MEMBERSHIP SURVEY Every year, the BACN sends a detailed survey of questions relating to aesthetic practice in nursing to all BACN members. The information gathered from the survey helps to develop membership services and offers to be amended and tailored to responses, and also maps changing trends. Throughout September, the BACN will be promoting the survey to members and encouraging as many responses as possible, with a focus on prescribing, complications, and how COVID-19 has affected business practice. All BACN members have received information with how to complete the survey, with the closing date October 8. For more details, please contact Gareth Lewis at glewis@bacn.org.uk. This column is written and supported by the BACN

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Microneedling

Ivanmed to launch Dermapen 4 Aesthetic and medical supplier Ivanmed is launching the microneedling device Dermapen 4 at an event in London this month. At the launch, Dermapen trainer Dr Andrew Christie will introduce the device, explain the new features and how these will transform microneedling treatments. Dr Christie will also present the MG meso-glide collection and how to incorporate this into the Dermapen 4 treatments. The new features of the Dermapen 4 include a digital scar treatment setting, 3mm depth and anti-contamination management. It is also CE marked, adds Ivanmed. Simon Ringer, sales director at Ivanmed, commented, “We are delighted to announce the launch of the Dermapen 4 in London this September. We are excited for practitioners to elevate their treatments and offer enhanced results when treating medical conditions.” The launch will take place at The Doubletree Tower of London Hotel on September 11 and 12. Statistics

Rise in aesthetic procedures by domestic abuse victims Data released by The Safety in Beauty Campaign has revealed that enquiries relating to domestic abuse has fuelled a demand for aesthetic procedures. The organisation received 347 enquiries from February 2020 until May 2021. 98% of enquiries were from women between the ages of 27-49 seeking corrective or restorative treatment as a result of direct physical abuse. Facial injuries were reported in 92% of cases and 81% of the enquiries, one or more of the injuries were physically visible to the external world. Founder of The Safety in Beauty Campaign, Antonia Mariconda, commented, “Historically our organisation deals with around 2030 enquiries a year from victims of domestic abuse seeking free or charitable help in restoring and repairing injuries. We focus on helping enquirers that are victims of sub-standard or botched beauty and aesthetic procedures, it was surprising to see a demand in an area we are not predominant in.” Mariconda contacted nurse prescriber and aesthetic educator Clare Spalding, who has been supporting and helping victims for more than 20 years. Mariconda is working with the Domestic Abuse Charity and Spalding to formulate two training courses via The Safety in Beauty Centre of Excellence, due to launch in 2022. Skincare

PCA Skin introduces new mist Cosmeceutical company PCA Skin UK has added the Daily Defence Mist to its portfolio. The new mist aims to protect the skin from daily exposure to environmental stressors such as blue light and other pollutants, whilst offering a boost in hydration to the complexion, explains PCA Skin. The product contains taraxacum officinale (dandelion) extract, an antioxidant which reduces inflammation and oxidation in the skin to combat dullness and improve radiance; aloe barbadensis leaf juice which softens and soothes the skin; and marrubium vulgare extract which aims to neutralise free radicals and strengthen the skin’s barrier and improve surface texture, adds PCA Skin. The product is available through PCA Skin distributor Church Pharmacy.

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021

W


WINDSOR Join the Cutera team alongside a panel of world-leading aesthetic experts for a day of learning and luxury at CUCF Windsor 2021.

PANEL OF SPEAKERS

Held from the beautiful, historic town of Windsor, Cutera University Clinical Forum will be the ultimate aesthetics educational and networking experience, comprising an unrivalled CPD-accredited agenda. CUCF will focus, as always, on

DR ANNA HEMMING

DR DAVID ECCELSTON

DR NESTOR DEMOSTHENOUS

DR JULIA SEVI

DR TATIANA LAPA

DR TAPAN PATEL

the most trending discussion points from within the industry, with a focus on device-led treatments, including live talks and product demonstrations, together with open panel discussions and a champagne networking event. 27th September 2021 09:30 - 17:00 Castle Hotel Windsor 18 High Street, Windsor SL4 1LJ

REGISTER TODAY!

cutera.co/windsor21 FOLLOW @cutera_uk FOR THE LATEST ANNOUNCEMENTS ON THIS EVENT!

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Hydration

mesoestetic launches new moisturising range Pharmaceutical company mesoestetic has released a new moisturising solutions range. According to the company, the new range is formulated with highly effective active ingredients to prevent dehydration and provide protective action through antioxidant and antipollution ingredients. Ha densimatrix is an intensive concentrate which is suitable for all skin types. The product combines hyaluronic acid in several molecular structures for penetration at different levels, explains mesoestetic. The product also includes anti-hyaluronidase complex that aims to block the action of external aggressors and antiageing pro complex to promote the synthesis of collagen and elastin. The hydra-vital light is a gel cream suitable for combination and oily skin. The product contains hyaluronic acid for hydration, urban d-tox, an antioxidant and anti-pollution active ingredient, and polysaccharide to stimulate recovery of the barrier function, states mesoestetic. The company outlines that the hydra-vital factor k is a nourishing cream for normal and dry skin, containing amino acids, urea, allantoin and lactic acid. The product also has vitamin E which has an antioxidant effect to protect the skin against free radicals and skin ageing. The hydra-vital mask is a moisturising mask for dry and dehydrated skin. The mask, which contains hyaluronic acid and viola tricolour extract, for immediate hydration. Argon oil and panthenol helps the skin to recover from lipids essential for its comfort and balance, producing an anti-redness action to the skin. Event

BCAM to host second virtual conference The British College of Aesthetic Medicine (BCAM) is holding its Virtual Annual Conference on September 10-11. The event will focus on the future of aesthetic medicine post COVID-19 with presentations, panel discussions and wellbeing sessions. Lecture topics include transgender considerations in modern day aesthetic treatments, rejuvenation using radiofrequency in combination with skincare, and innovations in eye rejuvenation. Speakers at the event include aesthetic practitioners Dr Nina Bal, Dr Victoria Manning, Dr Sophie Shotter, Dr Vincent Wong, Dr Charlotte Woodward, consultant ophthalmologist and oculoplastic surgeon Miss Elizabeth Hawkes, founder of ACE Group World and aesthetic practitioner Dr Martyn King, and founder of the International Association for Prevention of Complications in Aesthetic Medicine Dr Beatriz Molina. BCAM president Dr Uliana Gout said, “We are so thrilled to be launching the second BCAM virtual conference after leading the way last year with our first virtual event. Having a record-breaking number of delegates register last year, we are excited to continue this journey for 2021. We have embraced the virtual arena and connectivity with members and colleagues is crucial to BCAM, especially during COVID-19. We are excited that BCAM is leading the way in aesthetic medicine.”

MY CC R HIGHLIGHTS Dr Tapan Patel explains what he is looking forward to in October The entire medical aesthetics community finally reunites on October 14 & 15 at ExCeL, London, to get back to business! CCR has always provided a central hub for the surgical and non-surgical specialties and this year is very special as it will be the first large scale event to be opening its doors. The exciting two-day event will unwrap the latest news and innovations in aesthetics through live demonstrations and thought-provoking and skill-enhancing content delivered by foremost industry experts. I’m proud to be returning to CCR this year to deliver an anatomy and cadaver masterclass during which I will be demonstrating a range of educational techniques. I’m excited to share my experiences with my peers and talk about how I administer treatment to achieve beautiful, natural-looking results. It’s just £120 and open to registered healthcare professionals – you can sign up at www.ccrlondon.com. There’s so much on offer at CCR this year so here’s what else I’m looking forward to: • 150+ leading aesthetic brands with the latest products, techniques, and innovations • 7 CPD conferences covering all the latest topics with 80 CPD points available • Injectable Symposiums from leading brands Galderma, Allergan, Prollenium and Relife • ISAPS Symposium UK, plus a Surgical Conference covering body, breast and eyes • ACE Group World half day complications conference • An audience with esteemed educator and innovator Dr Arthur Swift • In Practice advice covering everything from mental health to social media platforms CCR is truly the event to find out about all the pioneering and cutting-edge research, launches and advancements in the aesthetics market and I hope to see you all there! Make sure you’re there on October 14 & 15 for the unmissable aesthetics event of the year. Find out more and register now at

c c r lo n d o n . c om

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


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Eyes

AestheticSource unveils new overnight cream Distributor AestheticSource has launched the skinbetter science EyeMax AlphaRet Overnight cream. According to the company, the new cream features AlphaRet technology, which includes a combination of a retinoid and alpha hydroxy acid to reduce the appearance of lines and wrinkles around the eye area. The cream also aims to treat dryness, puffiness, and reduce darkness in the skin around the eyes. In a dermatologist-led clinical trial, 26 participants of varying skin tones used the cream nightly over a period of 12 weeks. 94% saw an improvement in the appearance of under-eye dryness at 12 weeks, and 42% saw an overall improvement in under-eye puffiness. The trial was not clinically tested on the eyelids. CEO of AestheticSource Lorna Bowes commented, “We are delighted to launch this effective overnight eye treatment, featuring the AlphaRet technology from skinbetter science.” UV

Heliocare to launch sun protection products Skincare company Heliocare is adding three new SPF products to its portfolio. According to the company, the Heliocare 360 Pigment Solution Fluid helps prevent and correct hyperpigmentation caused by sun damage. The product contains niacinamide to inhibit the transfer of melanin while ellagic acid reduces melanin synthesis. The Heliocare 360 Age Active helps to prevent and correct the visible signs of ageing such as fine lines, explains the company. Ingredients include hyaluronic acid to firm and hydrate, serine to stimulate production of natural skin hydrators, and trehalose to hydrate and protect against oxidative stress. The product features a soft-focus complex to diffuse light and tint to even skin tone. LED

4T Medical introduces Cube Light to the UK Aesthetic product supplier 4T Medical has launched the Cube Light LED device. According to the company, the device aims to stimulate the skin’s natural rejuvenation and repair processes without discomfort. The device has six wavelengths of light to treat a range of skin concerns including acne, sun damage, redness and rosacea, hair loss as well as reducing fine lines and wrinkles, explains 4T Medical. Each of the wavelengths penetrates the skin at different depths. Managing director at 4T Medical Julien Tordjmann commented, “The LED Cube Light allows for multiple treatment opportunities. It offers the choice of six different wavelengths to be used either individually or in combination for a bespoke light therapy. It can be used on the face, body or scalp with the special Scalp Diode setting for hair loss.”

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Baljit Parmar, Aesthetic Business Unit Head of Galderma UK Why is September 2021 a special month for Galderma? This September sees us celebrate the 25th anniversary of Restylane – a huge milestone in the fast-paced world of aesthetics. Restylane paved the way for a generation of aesthetic injectables, as the first non-animal-based HA filler to be approved by the US FDA for cosmetic injection in 2003. How big of an impact has Restylane had in the filler market? In the constantly evolving world of aesthetics, it’s unusual to find a company which mixes heritage, business longevity and innovation. Since 1996, Restylane has continued to grow and evolve in response to a demanding market – keeping pace with competitors and bringing trusted innovation to practitioners. Today, the Restylane range has been used in over 50 million aesthetic treatments worldwide. We are proud of our heritage and are committed to developing new injectable treatment technologies which best support our customers and patients. What will be the next evolution in the injectables market? Our vision is to actively bring new aesthetic solutions to the market, whilst continuing to drive excellence within our existing portfolio. We see our role as a partnership with practitioners – not only focusing on new products, but continuing to push for excellence with proven, trusted and heritage brands that deliver optimum results. How will Galderma be celebrating during this anniversary month? We are excited to join our international colleagues at the AMWC congress, where we will unveil a new addition to our dermal filler portfolio – more information will be coming to the UK in early 2022. In addition, we have some exciting commercial offers and rewards this month to thank our customers for 25 years of loyalty. Adverse events should be reported. For the UK, reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store. For Ireland, suspected adverse events can be reported via the HPRA Pharmacovigilance www.hpra.ie Adverse events should also be reported to Galderma (UK) Ltd. E-mail: medinfo.uk@galderma.com Tel: +44 1923 208 950

This column is written and supported by

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Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


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Recruitment

Aesthetic Technology expands team British manufacturer Aesthetic Technology Ltd has expanded its UK sales and client support team. The new additions to the team include business manager for the south Kate Harris, who has previously worked in the device sector for companies such as Cutera, Lynton Lasers and InMode. Emma Cobb, business manager for the Midlands has previous experience in the UK and International spa sector. Louise Brown and Stephanie Warrington will be joining the internal sales and client support team, whilst Andrea Taylor joins the senior Aesthetic Technology team as compliance and commercial director from the British Standards Institution. Director of Aesthetic Technology Ltd Louise Taylor, commented, “This is an exciting and busy time for Aesthetic Technology in the UK and overseas. Investing in the expansion of the team is important to ensure we continue to provide the best sales and support to our clients.” Education

SkinCeuticals to hold virtual training events Professional skincare and antioxidant company SkinCeuticals will hold the first of three medical training events on September 6. The first event, named the Aesthetic Injectables and Skin Health, will review the indications and limitations of commonly used injectables in aesthetic medicine, outline the benefits of integrating medical-grade skincare with injectables, and discuss key features in developing an individual approach within the safe treatment parameters. The event will be led by aesthetic practitioner and trainer Dr Ana Mansouri. A second training event will take place on October 4, discussing aesthetic injectables and consultation skills and a third event on November 8 will outline aesthetic injectables and results maintenance. The first event will take place at 1pm and 7pm GMT on Microsoft Teams. Virtual

New video game for dermatologists launches Medical video game creator Level Ex has launched a new game aimed at educating dermatologists. According to the company, Top Derm covers multiple topics with original dermatology imagery and will provide the opportunity to earn educational credits. Some of the features include specialty content crafted by dermatologists combined with elements of interactive play. These challenges will cover a wide variety of topics such as skin cancer; adult, cosmetic, surgical dermatology and paediatric dermatology; the ability to support colleagues, submit content and leave feedback; and computer-generated images to help dermatologists recognise any skin disorder regardless of skin tone, explains Level Ex. Dr Peter Lio, dermatologist and clinical assistant professor of dermatology and paediatrics at Northwestern University, Illinois, stated, “The use of gaming for medical education is something I have been passionate about for quite some time. Top Derm is a unique resource leveraging technological advancements to help train and reinforce identification of a wide range of disorders and diseases on different skin tones and in different lighting conditions.” The company plans to implement multiplayer challenges and social features to create in-game discussions between dermatologists. Top Derm is available for free in the App Store and Google Play.

News in Brief VIVACY launches survey on aesthetics Aesthetic product manufacturer Laboratories VIVACY UK has launched a survey to explore the impact of COVID-19 on the aesthetic industry. VIVACY explains that the common term ‘Zoom Boom’ has caused patients to search for ‘tweakments’ after months of self-reflection on video calls. As a result, VIVACY wants to explore what impact this has had on the aesthetics industry as well as reveal the changes in patient demands for treatments. You can complete the survey by visiting the VIVACY Instagram page and following the link in their bio. Lynton launches two workshops Laser and IPL manufacturer Lynton has unveiled two new customer workshops. Lynton explains that the workshops will focus on helping Lynton customers to improve their clinics from both a business and marketing viewpoint. Each workshop will include discussions and live demonstrations with the radiofrequency microneedling Focus Dual device, the body contouring machine ONDA Coolwaves by DEKA and microneedling EPN Pen. The first workshop will take place on September 20 at Cloud 23 in Manchester, and the second will be on October 11 at Radisson Blu Edwardian in London. AlumierMD recruits new clinical educator Skincare brand AlumierMD has appointed Melissa Brown as its new clinical educator. Brown will be working in southern clinics providing technical and clinical training and support. Brown commented, “I wanted to work for AlumierMD as I loved that they care for the environment. With clean products that have cosmetic acceptability, the results speak for themselves! I love to educate clinics on medical-grade skincare due to the overall business success value it brings.” APTOS thread training dates announced Aesthetic distributor Novus Medical has announced new training dates for APTOS thread lifting. According to the company, the APTOS training courses have been carefully designed to consist of both the theoretical and practical methods involving different facial zones. Each course will be mostly focused on needle and thread methods but will also focus on specific APTOS thread lifting techniques and the most suitable combination therapies available. The training will take place on: September 8 and 29, October 6 and 20, November 3 and 7 and December 15, at Welbeck Street in London.

Reproduced from Aesthetics | Volume 8/Issue 10 - September 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.

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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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Industry Responses to APPG Report

from consultations to delivery and post-treatment management, and so believe that this should not be disputed, but rather enforced as an absolute.

Standards and qualifications

As outlined in the report, the current regulatory framework in the UK places no restrictions on who may perform aesthetic non-surgical cosmetic Aesthetics investigates how the specialty has treatments in the private sector.1 The APPG suggest reacted to the report on cosmetic treatments that the Government must set national minimum standards for the training that all practitioners The All-Party Parliamentary Group on Beauty, Aesthetics and must be required to undertake to provide aesthetic non-surgical Wellbeing (APPGBAW) recently published its final report into cosmetic treatments (e.g. Level 7 qualifications), a notion that is botulinum toxin, dermal fillers and other aesthetic non-surgical supported by industry associations. JCCP Training and Education cosmetic treatments.1 committee member and founder of training provider Harley Academy, The year-long inquiry was commissioned to investigate how Dr Tristan Mehta, welcomed this suggestion, commenting, “Being standards for undertaking and advertising cosmetic treatments and Level 7 qualified shows you have been trained to be a safe and the relating regulatory and legislative structures, should be improved ethical injector, and that you have received master’s level training to support the aesthetics industry and protect public safety. This from experts in the field. It shows you have studied not just injecting report follows the 2013 Review of the Regulation of Cosmetic techniques but also anatomy, facial ageing, skin ageing, preventing, Interventions led by Professor Sir Bruce Keogh, which concluded and managing complications… the list goes on.” that ‘dermal fillers are a crisis waiting to happen’.2 Carina Fagan, chief academic officer of qualification awarding The APPG made a total of 17 recommendations, which were based organisation VTCT, also supported this recommendation, stating, on evidence given in public inquiry sessions and submissions from “VTCT fully supports this report. The proposed recommendations stakeholders including associations, training providers, practitioners, reflect our position of raising standards and encompassing the needs aesthetic industry operators, health regulatory bodies and patients of our industries. It is in the best interest of both consumers and themselves.1 Over the last few weeks, industry groups and practitioners to ensure that the industry is safe for all thorough robust associations have responded to the report, outlining their opinions, training and qualifications.” and providing further suggestions. Below, Aesthetics summarises the While the report discussed mandatory qualifications for aesthetic recommendations of the APPG investigation, and reports how the practitioners, it also looked into implementing the same for nonspecialty reacted. medics, noting that the current qualification standards hold a barrier to their progression. In particular, it states that those seeking a Legal definitions vocational route from aesthetics at Level 4/5 should be able to The industry currently lacks a clear definition on what constitutes an access advanced aesthetics at Level 7 courses for injectables and aesthetic treatment, making the data available to the government fillers. The APPG has also recommended that there should be a CPD patchy due to the incorrect grouping of aesthetics with other framework for both medics and non-medics, suggesting that there is industries, such as physical wellbeing activities, retail, or hospitality. a need for the beauty industry and the medical professions to work As such, the APPG has recommended that the Government should together to seek solutions that raise standards and protect the safety define in law what constitutes a ‘medical-related’ service and and wellbeing of consumers. what is an elective aesthetic non-surgical cosmetic treatment; as In addition, point five of the report recommends that there be well as advising them to collect annual data on types of aesthetic on-site medical oversight for non-medical practitioners when treatments, numbers of practitioners, premises, training courses and administering injectables. complications. This has received support from the Joint Council for Cosmetic Practitioners (JCCP), which outlined its own definitions The suggestion of allowing non-medics to access Level 7 of what constitutes a ‘medical’, ‘medically-related’ or ‘cosmetic’ qualifications has resulted in backlash from major industry associations procedure earlier this year, following the confusion highlighted during such as BACN, BCAM and the JCCP; which are all in agreement the COVID-19 lockdowns.3 that that the process of care required and understanding the risks associated with underlying medical conditions can only be Professor David Sines, chair of the JCCP, comments, “The JCCP appropriately achieved by having a medical or nursing qualification believes that the Government is correct in calling for a legal definition and cannot be taught in any vocational course. Professor Sines of medical/cosmetic treatments since we believe that this will provide commented, “It is increasingly apparent that at this time, high-risk the opportunity for safer regulation in the aesthetics industry. This will procedures like the injection of toxins and the insertion of dermal fillers ensure that an accurate and appropriate assessment is undertaken should only be administered by healthcare professionals who have of an individual who is presenting reasons for seeking treatment, and the necessary skills, qualifications and competence in these areas.” that treatment is provided by suitably qualified practitioners wherever a medical/clinical or medically-related reason for applying that Regulation and enforcement treatment is determined.” As it stands, local authorities in England can adopt powers to register Despite its potential benefits, the BACN stated in its response that practitioners and premises providing a limited number of special aesthetic procedures, regardless of need or outcome, are medical procedures under the local Government, however they do not have

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


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The non-medic response Maxine Hopley, CEO of Cosmetic Couture, a training academy that trains non-medics, has responded positively to almost all recommendations outlined in the report, except the suggestion to make dermal fillers prescription-only. She says, “It’s obvious there needs to be changes – we need a national qualification that's open to all and it’s great that this report highlights that both medics and non-medics should be treated equally in the industry and be given equal access to a new qualification at Level 4 and then to Level 7. But, making fillers a prescription only is a step too far and I don’t support that.”

the powers to cover at-home or mobile treatments. In addition, even when the powers are available, local authorities do not have adequate funding to complete the proper enforcement role.1 Therefore, the APPG recommends that the Government introduces a national licensing scheme to govern the oversight of advanced aesthetic nonsurgical cosmetic treatments such as botulinum toxin, dermal fillers, and threads. The group has also suggested that dermal fillers be classified as a prescription-only and, in line with recommendation five, be performed under the oversight of a prescriber who has gained the accredited qualifications to prescribe, supervise and provide remedial medicines if necessary. Dr Mehta sees this as a step in the right direction, commenting, “Through calling for fillers to become prescription-only and mandatory medical oversight for such treatments, the risk of permanent complications can be significantly reduced – the treatment for many complications with injectables need a medical prescriber.” Dr John Elder, who leads BCAM’s Aesthetic Medicine Regulatory and Advisory Group (AMRAG) agreed, noting, “With dermal fillers, the failure to recognise that something is going wrong and be able to initiate appropriate treatment – usually requiring prescription drugs – is a serious issue. Fillers should be prescription-only, and regulation is required to limit who can administer them, which will significantly reduce the risk to the public.” Dr Martyn King, chair of the Aesthetic Complication Group (ACE) Group World and vice chair of the JCCP, also voiced his support for this particular proposition, stating, “Currently, dermal filler is classified as a medical device, which basically means that anybody can buy it. If this type of product was made prescription-only it would be a huge step to better regulation, ensuring only quality products are used and that practitioners have the medical background and training needed if complications should occur.”

Ethics and mental health The report outlines that at present there is no regulation to mandate psychological screening of patients, and there is also no incentive for practitioners to safeguard their customers’ mental health. As such, the APPG states that the Government must work with the aesthetics industry on the development of psychological pre-screening tests to cover a range of broader psychological vulnerabilities; education for spotting these vulnerabilities must be included in national minimum standards for training; and that the recent legal ban on under-18s receiving treatments4 must be extended to PDO cogs and threads. The BACN welcomed this recommendation, with chair Sharon

Bennett commenting, “The government would be well placed to work with the specialty and develop pre-screening tests that can be performed by a medical professional (doctor, nurse, dentist). The need to identify, manage and refer those vulnerable and with psychological conditions is essential as part of our duty of care to patients. A screening tool will help give (medical) practitioners the tools to assess sensibly and sufficiently.”

Insurance Currently there is no legal requirement for non-registered healthcare professions to be insured to perform aesthetic treatments.1 The report recommends that the Government should require all practitioners to hold adequate and robust insurance cover; as well as ensuring that practitioners hold regulated qualifications for the aesthetic nonsurgical cosmetic treatments they provide, alongside appropriate industry-approved CPD training in order to qualify for this insurance. On these recommendations, Professor Sines notes that the JCCP extends its full support and agreement, stating that there needs to be a minimum threshold of indemnity for medical insurance to help with those who have a complaint or reason to raise a concern following receipt of the treatment.

Social media and advertising For this section of the investigation, the APPGBAW partnered with the APPG on Social Media. Research highlighted that social media has driven the societal pressures leading people to seek aesthetic non-surgical cosmetic treatments.1 As such, the group recommended that social media platforms take more responsibility for curbing and censoring misleading advertisements and for the mental health impacts of promoting aesthetic non-surgical cosmetic treatments. They advised that advertising restrictions should be placed on dermal fillers and PDO cogs and threads in the same way they are imposed on botulinum toxin as prescription-only. Bennett says the BACN agrees that there should be more regulation in this area. She comments, “We are not saying a blanket 'no advertising', but advertising dermal fillers should have a strict set of criteria to prevent misinformation, doctored photos, targeting the vulnerable with cheap offers, and poorly or untrained people promoting the procedures.”

The future of aesthetics… While not agreeing with every point mentioned in the APPG report, all associations have noted that the recommendations made can be viewed as a step in the right direction for regulating the aesthetic specialty. Professor Sines concludes, “The next steps should be to ensure that there is a parliamentary debate on the recommendations presented in the APPG report and to ensure that the Minister responsible for aesthetics at Westminster (Nadine Dorries) to provide a full written response with an action plan to ensure that the recommendations made and set out within the APPG report are acted upon without compromise.” REFERENCES 1. All-Party Parliamentary Group on Beauty, Aesthetics and Wellbeing, Inquiry into advanced aesthetic non-surgical cosmetic treatments, 2021 2. Bruce Keough, Review of the Regulation of Cosmetic Interventions, 2013, <https://www.gov.uk/ government/publications/review-of-the-regulation-of-cosmetic-interventions> 3. Holly Carver, Defining a Medical Procedure, Aesthetics journal, 2021, <https://aestheticsjournal.com/ feature/news-special?authed> 4. Chloé Gronow, MPs Support Children & Aesthetic Procedures Regulation, Aesthetics journal, 2020, <https://aestheticsjournal.com/feature/mps-support-children-aesthetic-procedures-regulation>

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


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Dr Qian Xu Clinical Lead Ai Beauty Clinic Dr Raj Acquilla Global Key Opinion Leader

REGISTER NOW!

14 + 15 October 2021 | ExCeL London

www.ccrlondon.com Use invitation code 1131

CCR Announces Stellar Line-up Headline sponsor

CCR will be making its debut at ExCeL London Khanna to discuss radiofrequency whilst Dr Daniel CCR_Ad2021_A4_RegisterSpeakerV4.indd 1 on October 14 and 15. Set to welcome over 3,500 Cassuto will discuss Balanced Facial Healing. Dr Nestor attendees, 150 brands, and more than 120 speakers, Demosthenous will discuss non-surgical biosculpting, CCR remains the only platform in the UK that unites the consultant ophthalmologist and oculoplastic surgeon, surgical and non-surgical communities. The two-day Mr Daniel Ezra will discuss the topical subject of event will focus on the latest trends, developments and hyaluronidase for filler reversals and Dr Sophie Shotter innovations in aesthetics through live demonstrations focuses on how to avoid unfavourable outcomes from and thought-provoking content delivered by leading toxins. Additional top UK practitioners to watch out for industry experts. CCR will deliver two full days of include Dr Marwa Ali, Dr Raul Cetto, Dr Raj Thethi, Dr education, all of which is CPD certified covering Nicola Zerbinati and Dr Abhinay Settipalli all with their everything from the latest in non-surgical innovations, to own expert approaches to the non-surgical agenda. surgical procedures across the body, breast and eyes, business guidance and insight from practitioners with The Surgical Arena successful brands and businesses, to symposiums from The Surgical Arena will deliver a packed programme of some of the industry’s leading brands. content focusing on cutting edge, innovative surgical procedures tailored to body, breast and eyes. The Non-Surgical Arena New for 2021, the ISAPS Symposium UK will take place The Non-Surgical Arena will host a packed agenda each morning in the Arena and feature global leaders in bringing the non-surgical agenda to life. Highlights include a 25-year celebration of Restylane with facial aesthetics trainers Miss Priya Chadha and “CCR 2021 will comprise of an enormously Miss Lara Watson and a focus on Sculptra delivered diverse programme of speakers and topics by Dr Munir Somji from Headline Sponsor Galderma. New for 2021, The ACE Group World, will be delivering which have been curated specifically to a half-day complications programme. Dr Beatriz Molina, inform, fascinate, motivate and inspire founder of IAPCAM discusses complications related to audiences. We can’t wait to once again lips with a focus on vascular occlusions whilst renowned trainer, ENT surgeon, and famous for his non-surgical welcome back our delegates to enjoy this rhinoplasty, Mr Ash Labib, speaks about complications programme, which sets us apart from other arising from treating the nose with a specific focus on hyaluronidase. Additional speakers include nurse expos and places us firmly at the forefront of prescriber Liz Bardolph, Dr David Eccleston, Dr Xavier the industry” Goodarzian, Dr Steve Tristram, Dr Martyn King, nurse Courtney Baldwin, Event Manager, CCR prescriber Helena Collier, Mrs Sabrina Shah-Desai and Dr Harryono Judodihardjo. The Non-Surgical Arena also features Professor Bob

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


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aesthetic plastic surgery reviewing contemporary techniques in body contouring. The faculty of speakers include Mr Mark Soldin, Dr Nina Schwaiger, Dr Pouria Moradi, Dr Kourosh Tavakoli, Dr Sheila Nazarian, Dr Christopher Khorsandi and Mr Dan Marsh. The Surgical agenda continues each afternoon with a focus on breast (October 14) and eyes (October 15). Highlights include consultant plastic surgeon, Mr Reza Nassab, who will be discussing Breast Augmentation: Aligning Patient Expectations and Reality. Consultant ophthalmic and oculoplastic surgeon Miss Elizabeth Hawkes will speak on the topic of Upper Eyelid Blepharoplasty and The Importance of the Skin Crease. Pioneering Expert in periorbital surgery Mrs Sabrina Shah-Desai will discuss Treatments for Severe Festoons, consultant plastic and reconstructive surgeon Mr Sotirios Foutsizoglou will discuss Functional and Aesthetic Complications following Lower Eyelid Blepharoplasty, and also speaking will be reconstructive aesthetic surgeon Mr Ernesto Azzopardi.

In Practice Theatre The In Practice Theatre will deliver a programme of highly informative discussions and ensure clinic owners and managers are better equipped to make their practices and clinics a great success. Hosting a discussion about patient relations, Dr Ifeoma Ejikeme will lead conversations with Dr Tahera Bhojani-Lynch and Dr Amiee Vyas about inclusivity from racial and gender perspectives. Dr Mayoni Gooneratne will chair wellness and psychological-focused discussions with Dr Bhavjit Kaur and Professor Brian Franks which will touch upon red flags, aesthetic wellness treatments and taking care of your own mental health and wellbeing. Danny Large will chair an interesting discussion about expanding treatment offerings, incorporating the expertise of Vanessa Bird, Dr Ingrid Wilson and pharmaceutical brand SkinCeuticals, who will discuss how to integrate skincare into your patient journey. Other presentations cover marketing and PR, patient safety and complications and career development, with highly respected speakers including aesthetic nurse Emma Coleman, Professor David Sines and Dr Anna Hemming.

Some of the speakers you can look forward to seeing

Dr Tapan Patel

Miss Priya Chadha

Dr Nestor Demosthenous

Dr Qian Xu

Dr Raj Thethi

Dr Sophie Shotter

Miss Lara Watson

Mrs Sabrina Shah-Desai

Dr Abs Settipalli

Miss Elizabeth Hawkes

Mr Ash Labib

Dr Ifeoma Ejikeme

Symposium & Live Demonstration Stage Two packed days of content delivered by the world’s biggest brands and their KOLs takes place on the Symposium & Live Demonstration Stage. Highlights include the Allergan Lunchtime Takeovers with Miss Sherina Balaratnam and Dr Rashpal Singh, esteemed educator and innovator, Dr Arthur Swift who will deliver a Prollenium Symposium, and there will be additional Symposiums from Relife, Vivacy and Lumenis.

Gallery Room Additional events on the conference programme take place in the Gallery Room and include a half-day workshop, Getting Started in Aesthetics in partnership with Harley Academy featuring Dr Tristan Mehta and Dr Emily MacGregor (October 14) plus a one-day Anatomy and Cadaver video Masterclass delivered by industry guru Dr Tapan Patel (October 15).

Scan the QR code to register! ccrlondon.com All information correct at time of print

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


A Natural Look is an Exact Science.

Patients today want a filler that naturally integrates into their tissue, so that they can retain their identity and express their emotions with confidence1. With BELOTERO®’s portfolio of fillers, it’s possible to tailor a personal treatment protocol for every patient, so they can feel empowered with natural-looking results2.

merz-aesthetics.co.uk/belotero

References: 1. BELOTERO® Lips Quantitative Market Research. 2. Sundaram H.et al. PRS Journal. Aug;136:149-163. Merz Pharma UK Ltd. Ground Floor Suite B, Breakspear Park, Breakspear Way, Hemel Hempstead, Hertfordshire HP2 4TZ MERZ AESTHETICS® is a registered trademark of Merz Pharma GmbH & Co. KGaA. www.merz-aesthetics.co.uk M-BEL-UKI-0744 Date of Preparation June 2020

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


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Aesthetics Awards Entry Writing

Writing a Winning Aesthetics Awards Entry Acting Editor Shannon Kilgariff provides her top tips for writing a successful Aesthetics Awards application Known as the ‘Oscars of Aesthetics’ the Aesthetics Awards are a celebration like no other in our field. It’s not only a spectacular opportunity to get dressed up and network with 800 peers in the field of aesthetic medicine, but it’s also a way to celebrate a year of hard-earned achievements. Being recognised as a Finalist, or even receiving Commended, Highly Commended or Winning accolades at the Aesthetics Awards not only cements your trust and credibility status, but it can completely revolutionise your PR and marketing efforts. However, with hundreds of entries each year, not everyone can be recognised as a Finalist. Luckily, there are things you can do which can dramatically increase your chances of impressing the judges! 1. Think ahead Before you jump headfirst into drafting your brilliantly written entry, take a moment to plan. Spend time going through each category and create a shortlist of the ones you are eligible to enter, with a note of those you have the best chance of winning. Although it’s great to enter all eligible categories, if you’re strapped for time, it’s better to just enter a couple and really nail the application, rather than spreading yourself too thinly. Being successful is about quality, not quantity! 2. Gather your evidence Those who can actually prove their claims by providing evidence have a far better chance of becoming a Finalist. It’s great to say your patients are all satisfied with their treatments, but if you can’t show this then it’s just a blanket statement. Gather as much evidence as you can to provide meaningful numbers – think patient satisfaction surveys,

percentage increases for growing patient numbers and revenue, and the number of new treatments. Year-on-year data and how this has progressed over time always impresses the judges! 3. Read the question This seems obvious but it’s a common mistake many entrants make. Sometimes it’s easy to get carried away when your creative juices are flowing, but always remember to check to ensure you have answered the actual question. Also make sure it’s written in a clear way so the judge can easily understand and acknowledge that you have answered it well. Make sure to re-read your questions over to check it’s the best you can provide! 4. Think like a judge Remember the Aesthetics Awards judges are experts in the aesthetics field, but they are also people and don’t want to spend hours reading something dull, waffly, or poorly worded. So, summarise your points powerfully and concisely, but with detail where necessary. Try using bullet points to allow the judges to see your key points in an easy-to-digest format – they also help you stick to your word count!

5. Get a second opinion It’s best practice to proof-read social media posts and marketing content before it’s released, so why should your Awards entry be any different? Get a second, third, and fourth opinion on your entry (or as many as you can!). Ask someone else who knows the business inside and out, as well as a respected family member or friend for an objective view. Get them to check simple things like spelling and grammar (judges hate reading errors) as well as if anything vital might be missing. Submit your entries and see you at the celebration! The dazzling ceremony will take place at the Royal Lancaster Hotel in London after the second day of the Aesthetics Conference and Exhibition. Gather your team, put March 11-12 in your diary and spend the day learning, and the evening celebrating. Good luck to all entrants!

K EY DATE S

ENTRIES OPEN SEPTEMBER 30

ENTRIES CLOSE OCTOBER 30

FINALISTS ANNOUNCED & VOTING OPENS JANUARY 2022 Aesthetics | September 2021

WINNERS ANNOUNCED AT THE AESTHETICS AWARDS CEREMONY AFTER ACE ON MARCH 12, 2022 23


EXPAND YOUR POSSIBILITIES The innovative and multi-award winning Teosyal RHA range has been intentionally developed to respect the fourth dimension of facial aesthetics - dynamic movement. Thanks to the unique combination of both stretch and dynamic strength capabilities, the collection has been designed to be resilient enough to adapt to facial movements, promoting natural outcomes both at rest and in motion.

TEOSYAL® RHA DYNAMIC AESTHETICS


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commitment to a long-term career in aesthetics. There are no short cuts, and you should choose to get as much knowledge and experience as possible,” he continues. Miss Chadha agrees that it is imperative when starting out in aesthetic medicine that you look at the entire career progression as a whole. “It’s a huge investment of time and money – it’s a subspecialty that takes years, even decades to master,” she explains. If you are unsure whether the commitment required to pursue a career in aesthetics is for you, Mr Adrian Richards, medical director of training academy Cosmetic Courses, suggests doing a few one and two-day courses to introduce yourself to the world of aesthetics. “Aesthetics is a difficult subspecialty,” reiterates Mr Richards, adding, “We only train registered doctors, nurses, and dentists who have already undergone significant training in their fields, but aesthetics isn’t for everyone, so why not try a one or two-day course in injectables and see how you like it?” Depending on the course structure, pre-course Aesthetic trainers explain the different training theory and modules, e-learning, assessments options available to further develop your career and practical content, the traditional ‘Foundation Training Course’ could be a good place to start, Looking for the right training options can be a minefield within the suggests Miss Chadha, “But it’s only a start! A significant course will aesthetics specialty. With no law on minimum training requirements to not be just one day. The practical day will be sandwiched before and practice within aesthetic medicine, it can be hard to choose the right after with theory and online learning to cover the basics in aesthetic training route. While some providers will give you a brief overview, medicine,” she says. For example, an introduction to the industry, others are much more in-depth and will put you in a strong position facial anatomy, dermatology, consultations, consent, aftercare, when starting out as an aesthetic practitioner, or further your already complications, and business tips. “On completion of an appropriate flourishing career, with patient safety at the forefront. foundation course with all of the relevant modules, assessments As detailed on p.17, the recent report published by the All-Party and accreditations, practitioners can get the necessary insurance Parliamentary Group on Beauty, Aesthetics and Wellbeing (APPG), required to start as an injector,” says Miss Chadha. Although there highlighted the essential need for high-quality aesthetic training, as are benefits to short-term training courses, most trainers believe well as training standards and qualifications.1 they are not enough as a standalone qualification to enter the field. Advanced level nurse practitioner Aine Larkin, academic and Dr Mehta believes practitioners should always be striving to achieve clinical director at MAP-IQ training centre, welcomes the report and their Level 7. “If you complete a few different foundation courses and acknowledges the need for more comprehensive and compulsory realise that you are committed to a safe and successful career in training within the sector. “The vulnerable public need to be protected, aesthetics, then a Level 7 Diploma (sometimes called Certificate) in and this area must be recognised as a specialty only to be carried out Injectables for Aesthetic Medicine could be a great next step.” by medical practitioners who have regulated qualifications and training According to Dr Mehta, Harley Academy were the first to launch in their area of practice,” she says. the postgraduate qualification regulated by Ofqual (The Office of Miss Priyanka Chadha, joint CEO and founder of Acquisition Qualifications and Examinations Regulation) in June 2016. Other Aesthetics and recent winner of the CCR Award for Independent training academies have since developed their own Level 7 Diploma, Training Provider of the Year at the Aesthetics Awards, states, “There’s some with and some without JCCP approval. “It’s best practice to so much evidence of all the negatives that have resulted from a lack of look for JCCP approval as they own the original Health and Education regulation and training within the industry, and it feels like not enough England (HEE) guidelines,” he adds, “Typically to gain entry to a Level is being done. It’s taking risks with the public's health and more needs 7 qualification you will need to have an undergraduate degree in to be done to improve training and education within the industry.” a relevant subject, and most courses are only available to nurses, While there are still no legal requirements to train and practice in the doctors and dentists.” UK, Aesthetics spoke to some of the UK’s leading aesthetic trainers to deliver an overview of the best training options available to ensure Each Level 7 qualification will be different, but will typically be made patient safety. up of various modules, online study, mentoring, practical exercises, and a final examination. Topics often covered include safe use of Where to start needles and cannulas, business advice, in-depth knowledge of skin “Don’t get into aesthetics at all if what you’re looking for is a quick and facial ageing, anatomy and the psychological driving forces, route to a bigger salary,” says Dr Tristan Mehta, aesthetic practitioner complication management, and issues for patients considering and founder of Harley Academy. “It takes a strong mindset and cosmetic treatments. A Level 7 Diploma can take between six and 36

Training in Aesthetic Medicine

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


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Although there are benefits to short-term training courses, most trainers believe they are not enough as a standalone qualification to enter the field months depending on a number of factors. “In a severely unregulated industry with consumers who are becoming better informed, a Level 7 can offer a difference between you and less qualified practitioners in an increasingly competitive industry,” argues Miss Chadha. Larkin also encourages new practitioners to undertake the Level 7 Diploma. “There is currently no other UK qualification at the correct academic level to evidence learner competence in both knowledge and skills. Competence must be validated through an approved process to enable new clinical aesthetic practitioners to start practising in a completely new autonomous clinical specialty,” says Larkin.

The next steps CPD courses “Following an Ofqual and JCCP regulated Level 7 qualification where the basic modality underpinning knowledge, and skill are taught and assessed, I believe this is where a good continuing professional development (CPD) course comes in,” says nurse Larkin, adding, “CPD courses are there to build on and advance the knowledge and skills of clinical aesthetic practitioners to ensure they remain updated with the scientific evidence base to inform their practice.” The JCCP states that registered practitioners should demonstrate evidence of CPD achievements as required by their professional statutory regulatory body.2 It also specifies that a minimum of 50 hours of CPD must be demonstrated annually by all clinicians on its register, of which a core element is aesthetic-related. Cadaver training In a 2017 study of 168 aesthetic practitioners in Singapore undergoing a two-day cadaver training course, the results indicated that all four groups showed an improvement in their facial anatomy knowledge based on the comparison of pre-course and post-course test results.3 Mr Richards believes that to fully understand the vascular make-up of the human face, cadaver training is essential. “It’s a way to conduct three-dimensional observation and dissection of human anatomy and an opportunity to see the different layers and structures of the face to enable practitioners to optimise the correct placement of our dermal filler products,” he says, adding, “This essential knowledge not only makes for more effective filler treatments, but also reduces the risk of complications including vascular occlusions.” Arguably, it makes sense to undertake prior training courses, such as multiple foundation courses before you enrol on to a cadaver course, as they can be expensive and require a background in aesthetics

to get the most out of it, says Miss Chadha. “In terms of the future of aesthetic training, I strongly believe that cadaver courses should become an essential training opportunity,” she views. Master’s degree According to Mr Richards an academic master’s degree is similar to a Level 7 and can be a good choice for furthering your academic career, although it can be less practical and more academic, he adds. The university of Manchester, for example, offers a part-time MSc in aesthetics, which incorporates online learning, group work, and written assignments, two five-day residential sessions and a final dissertation over the course of 36 months.4 Larkin explains that MAP-IQ is currently working with regulators and awarding bodies to develop a progression route for those who have successfully achieved a postgraduate Level 7 Diploma to do their MSc in clinical aesthetic injectables. “A Master’s degree can indeed increase your knowledge, personal and professional skills and perhaps even boost your confidence and consequently your employability, such as a move into the regulated education or training sector,” says Larkin, adding, “A Master’s can also help in securing you further funding for your PhD, which you might want to do as a research project in a specific medical topic.” Becoming a trainer Miss Chadha recommends that experienced practitioners wanting to further their knowledge and improve their practice become teachers themselves. “At Acquisition Aesthetics, we choose our trainers very carefully,” she says, adding, “It can be a great opportunity for seasoned practitioners to pool their expertise, and it can also highlight gaps in your own knowledge. I genuinely believe that becoming a teacher is the best type of training, as you learn from other practitioners and are pushed to always be at the top of your game.” To become an aesthetics trainer, says Dr Tristan Mehta, academies will want to see that you have undertaken as much training as possible, so you have something to offer their students. You can read a previouslypublished article on becoming an aesthetic trainer by Dr Paul Charlson and Dr Vikram Swaminthan for more guidance.5

The future of aesthetic training It is uncertain whether the new APPG report will help to drive muchneeded industry regulation, but it has certainly highlighted the need for excellent training and education for a safe specialty. Larkin concludes, “It’s my view that if practitioners continue to selftitle themselves as aesthetic practitioners without ever evidencing underpinning knowledge and skill competence through a regulated post-graduate qualification, they are continuing to mislead and confuse the public in their search for an appropriately-qualified aesthetic practitioner.” She adds, “I would like to see the Level 7 Diploma become a compulsory benchmark in order for someone to call themselves a practitioner.” REFERENCES 1. All Party Parliamentary Group on Beauty, Aesthetics and Wellbeing, Inquiry into advanced aesthetic non-surgical cosmetic treatments, 2021 <https://baw-appg.com/> 2. Joint Council for Cosmetic Practitioners, Standards to Enter the JCCP Education and Training Providers Register, 2018. <https://www.jccp.org.uk/ckfinder/userfiles/files/Education%20and%20 Training%20JCCP%20Standards%20for%20ET%20providers%20V14%20September%202018.pdf> 3. Kumar N, Rahman E, Effectiveness of Teaching Facial Anatomy Through Cadaver Dissection on Aesthetic Physicians Knowledge, [online] 2017 <https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC5522661/> 4. Manchester University, MSc Skin Ageing and Aesthetic Medicine <https://www.manchester.ac.uk/ study/masters/courses/list/09805/msc-skin-ageing-and-aesthetic-medicine/ 2021> 5. Charlson P, Swaminathan V, Becoming an Aesthetic Trainer, Aesthetics Journal, 2020 <https:// aestheticsjournal.com/feature/becoming-an-aesthetic-trainer>

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


Advertorial Prollenium

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filler has spherical particles and is prized for its smooth, beautiful results that perform throughout the lifecycle in the skin. Safety Smooth Spheres provide a favourable safety profile. They are biocompatible due to their shape and low levels of modification, reducing irritation, pain and swelling.3,4 Spheres also typically have a smaller surface area. Inflammatory reactions are more pronounced for irregular shapes particles or those with more surface area.3 In one clinical study, the incidence of swelling was 51% higher with the comparator.2 REVANESSE® undergoes a purification process that removes floating BDDE and impurities resulting in a clean product and reduced irritation. It's tried and tested with more than three million syringes used worldwide. It also has reduced inflammation and immune response.

The Spherical Revolution REVANESSE® shakes up the UK dermal filler market You may have heard the rumours, there’s a new HA filler in town, and it’s already making waves. Brought to the market by Canadian powerhouse Prollenium, REVANESSE® is an FDA-approved hyaluronic acid dermal filler that is causing a stir. In fact, it’s boldly taking its seat at the table alongside the big boys of the pharmaceutical world by flying in aesthetics heavyweight Dr Arthur Swift to be the keynote speaker for its official launch at CCR this October. The brand is also making the bold decision to have a nurse-led injector faculty with trailblazing nurse prescriber Sharon Bennett at the helm. With such big names behind it, it’s no wonder tongues are already wagging about REVANESSE®. But isn’t it just another hyaluronic acid (HA) filler?

Not just another HA filler We all know that HA fillers are nothing new. They have been a staple of the global 28

aesthetics market since the early days, and the industry has been inundated with products, some of which have come and gone overnight, some of which have stayed the course. So, what’s so different about REVANESSE®, and why does Prollenium think it’s got what it takes to stand side by side with the HA goliaths? Canadian-made and FDA-approved REVANESSE® has already become a big player in the US and Canada, where REVANESSE® has revolutionised the aesthetics market with its unique formula, commitment to high-quality ingredients, and innovative manufacturing technique.1 The main selling points of this groundbreaking filler are focused on safety, performance and service. The company believes, first and foremost, that you should never have to compromise patient safety for performance. They strive for better, never settle, and encourage their injectors to do the same. The state-of-the-art dermal Aesthetics | September 2021

Performance Smooth spheres, less inflammation,2,3 more volume.5 A multi-centre, double blind clinical study found REVANESSE® used 10% less mean volume to augment both lips than the comparator.5 REVANESSE® also comes in a 1.2ml syringe, so goes even further still, that’s more fill for your ml. More is more, and going the extra mile for your patient creates loyal and loud brand advocates. REVANESSE® combines a high concentration of high molecular weight HA with low levels of BDDE at specific temperatures. It’s then wet milled and sieved to produce, not only spherical particles, but also a uniformly cross-linked gel that degrades in the skin at a uniform rate. Each product is designed meticulously for the indication and injection depth. Unique to REVANESSE®, specific amounts of non-crosslinked HA are added to hydrate the different gels creating different rheological combinations. Service Prollenium is a fast-evolving business with the goal of providing the best aesthetic product and service in the world. Rising through the ranks in 80 countries, Prollenium embodies values of innovation, commitment to ethics and transparency, passion and family, seeing its customers as part of its extended family. The company prides itself on the level of support it provides its customers. It is feedback-driven and invests in education, in-clinic support, and ongoing R&D to ensure it is always providing the best products.


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Advertorial Prollenium

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Meet the products REVANESSE® is the only cross-linked HA dermal fillers that are made in North America. Prollenium’s manufacturing facility is located just north of Toronto and is among a select few dermal filler

companies to receive FDA approval within the US. The REVANESSE® range includes four products with different sphere sizes to address multiple indications.

• REVANESSE® KISSTM: (25mg/ml cross-linked HA) with a low lift capacity and small particle size to enhance the vermillion lip and submucosal tissue. To be injected into the superficial to the mid dermis. Key indications: Lips and perioral lines.

• REVANESSE® CONTOURTM: (25mg/ml cross-linked HA) with a moderate/high lift capacity to lift and volumise in the deep dermis-tosubcutaneous layers. Key indications: Cheeks, chin, jawline and temples.

• REVANESSE® ULTRATM: (25mg/ml cross-linked HA) with a moderate lift capacity to fill and lift in the mid-to-deep dermis. Key indications: Lips, nasolabial folds, marionette, and temples.

REVANESSE® is for injectors with flair, injectors who see injecting as an art form and live to sculpt mid-face masterpieces and craft sumptuous kissable lips. The end goal? Naturallooking and long-lasting results. REVANESSE® is focused

• REVANESSE® SHAPETM: (25mg/ml cross-linked HA) with a very high lift capacity to volumise and give projection in the supra-periosteum. Key indications: Cheeks, chin and jawline.

on natural results, providing the perfect balance between smoothness and volume. The spherical particle shape of the filler is also developed to be accepted by the body and break down slowly over time.

Led by nurses

The UK is seen as a mature market in aesthetics. Unregulated practitioners are rising and with that injector and product complications too. Prollenium UK are proud to be advised by British nurses who always have their finger on the pulse and understand the market in granular detail. They want to inspire practitioners to never compromise between safety and performance. The nurse advisory group will help support Prollenium to empower British nurses to unleash their true injectable potential and join the #injectorsoftherevolution. It will be the first dermal filler brand to use an entirely nurse-led advisory group. “REVANESSE® is certainly making an impact and a welcome addition to my portfolio”, says aesthetic nurse practitioner and director of Harrogate Aesthetics, Sharon Bennett, an early adopter of the product. “Safety and performance are key for me. The fact that REVANESSE® has received FDA approval in the US gives me reassurance that it is a safe and reliable product.” She adds, “In clinic, I have been delighted with the results, as have my patients. The uniqueness of the spherical particles makes for a smooth, comfortable injection with low inflammation. I’m loving SHAPETM for defined cheekbones and ULTRATM for the lips. Plus, there is a generous 1.2ml in each syringe.”

Aesthetics | September 2021

For more information and to register for Dr Arthur Swift’s sessions at CCR and for all REVANESSE® product enquiries please contact: revanesseuk@gmail.com Follow us on Facebook – @ProlleniumUK. REVANESSE® is currently available to buy from Healthxchange. REVANESSE® is a registered trademark of Prollenium Medical Technologies Inc. REFERENCES 1. BDDE Cross-linked Hyaluronan Dermal Fillers Comparison of Commercial Products Update Report RD045, 2014. Prollenium Medical Technologies Inc. 2. A Multicenter, Double-Blind, Randomized, Split-Face Study of the Safety and Efficacy of a Novel Hyaluronic Acid Gel for the Correction of Nasolabial Folds. J Drugs Dermatol. 2018; 17(1): 66-73 3. Biocompatibility of Microparticles into Soft Tissue Fillers. Semin Cutan Med Surg. 2004; 23(4): 214-217. 4. Edsman K, Nord LI, Ohrlund A, et al. Gel properties of hyaluronic acid dermal fillers. Dermatol Surg. 2012;38:1170–1179 5. FDA Premarket Approval (PMA) Database (P040024/S072). Approval Order Statement for Restylane® Silk™, 2014. *Restylane Silk is a NASHA technology filler indicated for the lips available in the USA. Restylane® is a registered trademark of Nestlé Skin Health SA.

29


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Understanding LED for Skin Health Aesthetic nurse Emma Coleman explores the benefits of LED therapy for specific skin conditions

over 950 nm

650-950 nm

600-650 nm

LED emits narrow-band, non-coherent light with more than 95% of the light – or photons – at a precise wavelength, allowing for specific chromophore targeting.1,15 Its narrow-band nature makes LED a safer option compared to laser and IPL therapies, and it is suitable for all ages from infants to centenarians, although protective eye wear must always be worn by the recipient.15 The spectrum of light in advanced LED devices ranges from purple through to red (Figure 1)17 with each colour representing a different wavelength. Selecting the correct wavelength for individual patient needs is imperative in attaining treatment success and avoiding adverse reactions.15,16 It is reported that commercially available LED units include wavelengths in the red, yellow, blue, and near infrared portions of the spectrum,1 although some incorporate green light too. As Figure 1 and Figure 2 highlight, penetration and absorption increase proportionately to wavelength; the purple to orange spectrum of light possesses wavelengths capable of reaching to the deep dermis, whilst red LED light will be absorbed as far as the hypodermis.17,18

Blue 450-495 nm The efficacy of B-LED has been investigated in a number of studies, with promising results suggesting that even at lower wavelengths, blue light may prolong cell life and promote normal wound healing through wound size reduction and keratin expression.12,23 Whilst its efficacy in reducing facial acne lesions has been widely researched (discussed later)9,24,25 one recent study has provided conflicting evidence that exposure to B-LED at a wavelength of 415 nm can trigger an inflammatory response in acne sufferers,16 emphasising the importance of employing a quality device and selecting appropriate wavelength.

570-600 nm

Explaining LED therapy

Green 495-570 nm In vitro and animal studies have provided evidence that green LED (G-LED) application (516 nm) to skin promotes proliferation and migration of endothelial cells and demonstrates angiogenesis enhancement in wound healing, which proved to be superior to red LED in other trials.21,22 Generally, clinical trials associated with this wavelength are highly limited, and further human studies are required to validate its use.

495-570 nm

LED was invented in 1962 and consists of reflective surfaces upon which specialised electrical circuits – called semiconductor switches – are placed, each emitting a narrow spectrum of light.1 It is the composition of these switches which determines the colour and wavelength of light produced.1 Human interest in LED light originated with the National Aeronautics and Space Administration (NASA), which conducted plant growth experiments in space, providing evidence of the superiority of LED over fluorescent light in promoting photosynthesis.2,3 A 2015 study showed that cymbidium orchids exposed to a combination of both red and blue LED light displayed positive leaf growth and increased chlorophyll.4 Although botanical evidence remains controversial, a Florida Space Centre study in 2001 testified that spinach, radish, and lettuce grew better with fluorescent versus LED light exposure.5 This trial has led to a plethora of recent animal and human skin studies, with positive results highlighted in the treatment of certain dermatological and cosmetic issues.6-14

Red 650-950 nm For general skin rejuvenation, the literature suggests R-LED should be selected to ensure maximal absorption of light at a cellular level and with a recommended wavelength of 830 nm.15,19 Several studies have provided evidence that R-LED has the ability to promote healing and prevent scarring through fibroblast and keratin modulation.20,7

450-495 nm

Introducing LED therapy

therapy to enhance successful outcomes, which are discussed below. There is also much variation in the way LED is measured in different trials, with parameters including wavelength, power density, and dose being used, making it difficult to compare results accurately.

380-450 nm

Light emitting diode (LED) therapy has been gaining momentum in the aesthetics field. This article explores the theories behind its mechanisms in aesthetic and dermatology treatments and provides a review of the clinical literature of the efficacy of this mode of light in treating specific skin issues.

Summary of different wavelengths From reading the literature, it appears that the most widely researched wavelength in the fields of aesthetics and dermatology is red LED (R-LED), with blue LED (B-LED) the second most trialled medium. Many clinical trials employ other treatments or topicals alongside LED

Figure 1: LED light therapy wavelengths and absorption depth

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


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Yellow 570-600 nm Certain trials have provided evidence that this wavelength has anti-inflammatory, anti-wrinkle, and healing acceleration properties, stimulating collagen and reducing signs of photoageing.26,27 However, recent skin rejuvenation studies with yellow LED (Y-LED) are sparse; one single-subject trial demonstrated effective keloid scar degradation with a combination of Y-LED and hypocrellin B therapy.28 There is a planned future study, currently delayed due to COVID-19, which will analyse the effects of Y-LED on periocular rhytids.29 The exact mechanism of the effects exerted by LED light on plants and humans is controversial; visible light such as LED was believed to target cytochrome C oxidase, an enzyme involved in adenosine triphosphate production in cell mitochondria, providing energy for cells.39 Whilst other trials have provided evidence that it is the mitochondrial interfacial water layers (IWL) which are targeted, particularly by R-LED, appearing to alter the IWL viscosity and density.39,40,41

Rejuvenation Rhytids Although phototherapy has been marketed as an effective tool in reducing wrinkles, clinical trials in this area are minimal.29,13 One chemical study using amphotericin B, gentamicin and fetal bovine serum where cell growth was determined by measuring the absorbance of MTT in living cells, analysed the effect of B-LED skin exposure at a depth of 450 nm on cell turnover and survival. The results showed that B-LED irradiation exerted a cytoprotective effect through promotion of keratin and collagen type VI secretion and increased live cell population in treated areas of the skin in patients with psoriasis.12 This suggests that skin damaged due to pollution, UVA and UVB exposure or lifestyle factors may benefit from B-LED therapy at this level. Another US human trial (n=31) investigated the effects of combined LED light treatment at the orange to red end of the spectrum (633 nm and 830 nm) on periorbital rhytids. Each subject received nine light therapy treatments using a combination of 633 nm and 830 nm wavelengths and were evaluated at weeks nine and 12 using profilometry, clinical photography and satisfaction questionnaires. 52% of subjects showed a 25-50% improvement in photoageing scores by week 12; 81% of subjects reported a significant improvement in periorbital wrinkles on completion of follow-up.13 Due to the small-scale size and lack of control in this study, further research is required to evaluate the precise effect and exact mechanisms of this wavelength of LED light on facial rhytids.29

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The large-scale studies of Robert Weiss et al.27,28 exposed 900 subjects to pulsed Y-LED (590 nm) alone, or in combination with a rejuvenating thermal treatment, over a two-year period. Following self-assessment, 90% of subjects reported softer skin and a reduction in fine lines and wrinkles, ranging from significant to subtle. However, a similar, albeit small-scale study (n=36), refutes these findings, stating that individual physician assessment of the subjects following once weekly Y-LED therapy over eight weeks, failed to detect any physical facial changes.30 Hyperpigmentation and melasma Melasma is a resistant, sun or hormone-induced facial hyperpigmentation often seen across the mid-face. Hyperpigmentation occurs on the face and more rarely melasma can occur on the extremities, likely linked to UV light or drug activation.31 Both types of pigmentation are more common in women than men and can cause psychological distress.32 Treatment is difficult and focuses on therapies which reduce skin hyperpigmentation resulting from triggered hyperactive melanocytes.31 The pathogenesis of melanoma is not clearly understood, but growth factors and certain cell-signalling pathways may be involved.32 In 2012, an in vitro South Korean study analysed the effects of various LED wavelengths on melanogenesis rate. The aim was to prevent skin discolouration at its root cause, by identifying the optimum wavelength of light which would intercept the activities of tyrosinase, TRP-1, TRP-2, and MITF protein expression.33 All cultures were repeatedly irradiated with LED at 415, 530, 630, 660, 830, 850, and 940 nm. The melanin cell cultures were then analysed, and it was found that LED wavelengths at the higher end of the spectrum – 830, 850 and 940 nm – had performed most effectively in preventing the synthesis and activity of tyrosinase in primary cultured human melanocytes, without causing any cytotoxicity. Conversely, a wavelength of 415 nm exerted a cytotoxic effect on the cells.33 These results indicate that R-LED is potentially effective in treating skin conditions involving melanin over-production, although large-scale human trials would clarify these findings. A small pilot study enlisted seven female patients with bilateral dermal melasma, who had previously received unsuccessful treatment with hydroquinone and/or chemical peels. This trial adopted two-stage therapy, involving split-face microdermabrasion followed by exposure to pulsed R-LED at a depth of 940 nm to one side of the face, and standalone microdermabrasion on the other side. This was repeated once weekly over a single eight-week period. Results were evaluated at week 12 using the MASI Score (Melasma Area and Severity Index),

BLUE

YELLOW

RED

IR

COMBINED

Wavelength (nm)

400-170

570-590

630-700

800-1200

Variable

Depth of LED light penetration

>1mm

0.5-2mm

2-3mm

5-10mm

Variable

Deepest target

Epidermis

Papillary dermis

Adnexa

Adnexa and reticular dermis

Variable

Studied therapeutic uses

• Acne • Combination • Therapy

• Photoaging • Post laser and IPL recovery • Wound healing • Radiation dermatitis

• Post-surgical recovery • Post-laser recovery • Skin rejuvenation • Photodynamic therapy • Photodynamic therapy with injection of sensitiser • Sunburn protection • Mucositis

• Wound healing • Ulcers • Photo rejuvenation • Combination therapy

Figure 2: Parameters of different wavelengths of LED light and their clinical applications18

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021

• Acne • Photo rejuvenation • Post-procedure recovery • Reduction in skin melanin


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Aesthetics

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and Melanin Index. The results provided evidence that a combination of both microdermabrasion and R-LED therapy reduces melanin index by 25% at week 12 versus a reduction of approximately 3% in the control area.46 However, there are a number of drawbacks which negate the study’s results, including subject number and a failure to evaluate results after the 12-week period. Although, as a pilot it creates a strong foundation for further investigation.32 Elasticity From investigating the literature, it appears that trials analysing the effects of LED as a standalone treatment on skin elasticity specifically are limited. A split-face pilot trial (n=24) provided evidence that an at-home LED device implemented over an eight-week period significantly improved skin elasticity compared to control (P<.05).34 Several trials have investigated the effects of clinical LED device application, used in combination with topical 5-aminolevulinic acid (ALA), on photoageing and skin elasticity.14,35,36 One small trial (n=2) combined application of topical with LED therapy, with outcomes suggesting an improvement in elasticity and reduction in photoageing, although there was no control group.14 More recently, ALA 5% and LED light applications to sun-damaged neck skin in humans showed an increase in thickness and elasticity compared to IPL therapy.35 A 2020 study was able to provide evidence of significant facial complexion improvement (p<0.05), in six subjects, combining topical ALA with hyaluronic acid and R-LED therapy over a 12-week period. Results were analysed by dermatologists using the Global Aesthetic Improvement Scale36,47

Wound healing and scarring Chronic wounds which do not heal not only take an emotional and physical toll on patients, but also pose an issue for public health.37 Wound healing has four phases: inflammation, destruction, proliferation, and maturation.38 Certain trials have shown that LED light therapy may aid and accelerate the passage of a wound through all of these stages.7,8,23,37 Scarring is a natural consequence of wound healing, ranging from moderate to hypertrophic and keloid formations which can have significant aesthetic and functional consequences for patients.8

An analysis of studies One study compared the effects of R-LED and near-infrared LED light (NIR) on full-thickness skin graft healing in 30 rats. The results showed that R-LED significantly enhanced the skin graft score in relation to the NIR group and increased transforming growth factor beta (TGF-β) protein expression and density of collagen fibres, compared with the NIR and control groups. These results suggest that R-LED has the ability to modulate the expression of proteins related to tissue repair.7 A Finnish split-face human study (n=30) applied R-LED light to one side of the face of subjects following facelift surgery, tri-weekly over a threeweek period. The subjects were divided randomly into three groups of 10, each group assigned a controlled R-LED dose, as follows: low:160J/ cm2; medium: 320J/cm2; high: 480J/cm2. Subjects were followed up at one, three and six to 12 months post-surgery. The results provided evidence that those treated with 320J/cm2 (medium) dose R-LED had the most positive wound healing outcomes, including lower wound induration (hardness), lower levels of collagen – a favourable outcome in wound healing – and an overall scar improvement of 57.9% at six months’ post-operatively.8 This study uses measurements of dosing rather than wavelength to describe light treatment, making it difficult to

compare findings with other similar studies. Another study observed the effects of R-LED and B-LED on wound healing in rats, exposing the excisions to 10 minutes of either light over five consecutive days, at a wavelength of 470 nm or 630 nm. Findings suggested that wound epithelialisation was accelerated by day seven, whilst levels of keratin-10 mRNA were found to be elevated in both light groups.23 A prospective, double-blind human study enlisted subjects (n=80) with a chronic wound below the knee, with or without diabetes mellitus.37 The experimental group were treated with a mixture of LED light ranging from 625 nm to 850 nm, three times weekly over a single eight-week period. The control group received simulated LED. Wounds were evaluated at eight weeks using laser Doppler flux sensors, laser light sources and the Falanga wound bed score. The LED-treated groups showed marked increases in microcirculation, granulation, and wound bed healing compared with the control. There were no significant changes to fasting glucose levels, fibrinogen or haemoglobin, in any of the groups.37

Dermatological skin conditions With so much crossover between aesthetics and dermatology, the below provides an overview of clinical trials conducted on the effects of LED light on common dermatological conditions. Acne vulgaris The treatment of acne vulgaris poses a challenge and the disease may cause emotional anxiety for the patient, whilst many of the treatments are often ineffective or create complications for the skin such as xerosis and soreness.9 One randomised UK study (n=41) analysed the effects of B-LED light application in combination with specified non-comedogenic skincare in subjects compared to those exposed to B-LED alone. The treatment group creams contained salicylic, glycolic, lactic acids and niacinamide. Treatment was performed daily over eight weeks, with a dose of 220J over a 12.5cm2 treatment surface area. At 12 weeks, the inflammatory lesions in the treatment group had decreased by 50.02%, with initial inflammatory lesion reduction typically observed at week three, and maximal between weeks eight and 12.9 An in vitro trial using skin samples developed to mimic the keratinisation and inflammation commonly observed with acne lesions, were exposed to oleic acid and low doses of R-LED (0.2-1.2J/ cm2). Proinflammatory cytokine IL 1α levels and stratum corneum thickness were reduced, whilst epidermal barrier integrity was improved, highlighting a basis for similar human trials.25 This highlights that patient education in terms of managing expectations and time scales is essential before starting an acne vulgaris treatment programme. Another small-scale combination therapy trial (n=11) applied 5% ALA-PDT every two weeks over a six-week period. Improvement in acne lesions was observed, as well as reduction in surface levels of cutibacterium acnes.24 Psoriasis This is a growing problem for dermatologists globally,10 historically treated with some success using UV light therapy.10 Results with LED therapy are promising when used in combination with other treatments. A double-blind, randomised comparative study looked at the effect of either B- or R-LED in combination with 10% salicylic acid on 20 plaque psoriasis patients, three times weekly over a single fourweek period. Improvement to scaling and induration was seen in both the B- and R-LED groups, with no significant difference between them,

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


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whilst erythema resolution was significantly better in the B-LED group.11 Combining curcumin-infused nanoparticles with B-LED was shown in one Thai trial to significantly reduce plaques compared to stand-alone therapy.45 Future phototherapy options for psoriasis treatment may be developed to include a UV light emitting diode (LED), and at-home phototherapy systems.43 Atopic dermatitis It’s difficult to find any significant trials analysing the effects of treatment of atopic dermatitis (eczema) with LED. One prospective, randomised study treated subjects (n=20), in the experimental group with B-LED three times weekly over a four-week period.44 At the review stage, the local Eczema Severity Index in the treatment group was significantly reduced compared to control, (p=0.0152). All subjects tolerated the B-LED with no adverse effects, suggesting that there is a case for further investigation.

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Aesthetics

Emma Coleman is a dermatology and advanced aesthetic nurse practitioner. She trained in aesthetics in London in 2015 and gained a distinction in Clinical Dermatology Diploma with the University of South Wales in 2019. She is a member of the British Dermatological Nursing Group (BDNG) and clinical director at the four Emma Coleman Skin clinics across Kent and London. Qual: RGN, DipDerm

Test your knowledge!

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

Possible answers

1.

a. 495-570 nm b. 570-600 nm c. 650-950 nm d. 450-495 nm

According to clinical evidence, what is the most effective LED wavelength to initiate wound healing through fibroblast and keratin modulation?

2. Which is the most effective LED light

The most common adverse reaction reported by subjects across all trials reviewed is erythema, which tends to resolve within 24 to 48 hours.1,7 Two subjects (0.6%) reported swelling and blistering following R-LED therapy in one study.8 There is no recorded increased skin sensitivity when LED is used in combination with topicals or other treatments. B-LED wavelength of 415 nm may exert a cytotoxic effect, therefore excellent device knowledge and understanding of parameter settings are of vital importance when treating patients.33

Conclusion Where possible, data from trials completed since 2017 have been included in this article, and although results show promise with use of both in-clinic and certain at-home devices, there is a need for future long-term, larger scale investigation.14,15 Much of the current research uses R-LED light and there is a need for more in-depth study into the efficacy of Y-LED and G-LED light. Week nine to 12 is the average time scale at which to expect results in most treatment cases, although this is the most popular timescale used in trials and investigating longer term LED treatment programmes with a variety of skin issues in the future would be valuable. Several studies set the LED devices to apply pulsed light to subjects, which appears to yield superior results,9,26,27,32 although further validating trials are required. Combination therapies also appear to enhance the efficacy of LED light therapy at various wavelengths in the treatment of keloids, fine lines and wrinkles, melasma, elasticity and skin thickness, acne vulgaris and plaque psoriasis.24,26,27,28,32,35,45 Misunderstandings regarding parameters such as wavelength, power density, and dose (energy density), can lead to positive results in one study and negative results in another.

Aesthetics Clinical Advisory Board Member and dermatologist Dr Stefanie Williams says... Light-emitting diode (LED) therapy can offer a range of benefits for the skin, including to help ease certain dermatological conditions. Different wavelengths have different applications. Red light for example, offers anti-inflammatory benefits, and we might use it as an adjunct therapeutic tool for rosacea prone skin, or to calm the skin after in-clinic procedures.

for the treatment of rhytids?

a. A combination of red and blue b. Green c. There is insufficient evidence at this stage to pinpoint a specific type of LED light in optimal rhytid therapy d. Yellow

3. What type of therapy combined with

a. Microdermabrasion b. Chemical peels c. Microneedling d. Intense pulsed light

4. According to the clinical evidence

a. 3 weeks b. 4-6 weeks c. 7-8 weeks d. 9-12 weeks

5. In order of incidence, what are the

a. Cytotoxic effect, burning, pain b. Erythema, blistering, swelling c. Skin rash, visual impairment,

red LED showed promising results in effective melasma treatment in female subjects?

available to us what is the optimal treatment course time for LED light therapy in patients or clients? three most common complications associated with LED light therapy?

pustules

d. Swelling, worsening of the skin condition, erythema

Answers: C,C,A,D,B

Complications

aestheticsjournal.com

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

Blue light has been shown to have anti-bacterial effects and may help reduce cutibacterium acnes, a bacterium contributing to acne vulgaris. However, as a dermatologist I don’t recommend relying on LED treatment alone for treatment of medical skin conditions such as acne or rosacea. In my experience, light treatment can be a useful adjunct for some patients but should ideally be combined with topical prescription treatment. Also, more is not always better, as there seems to be a ‘sweet spot’ with regards to delivered LED energy dose.

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


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Advertorial Galderma

Celebrating 25 Years of Restylane A bright past, a brilliant future In the fast-paced world of aesthetics, not many brands can boast the dual strengths of an impeccable heritage and a forward-looking business model of consistent innovation. This year, Galderma celebrates the 25th anniversary of Restylane – a gold-standard and globally-recognised brand which continues to grow and evolve, with over 50 million treatments now delivered worldwide.1

Restylane was the first non-animal HA filler to receive European approval – back in 1996 – and shortly after in 2003, it was the first dermal filler to secure FDA approval.3 This pioneering brand represents the gold-standard for dermal fillers in terms of clinical efficacy, practitioner trust and patient satisfaction – with new product innovations continually brought to market, the latest of which will be unveiled at AMWC this month.

Leadership quote “Restylane has not only stood the test of time, but it continues to innovate and is recognised as the world's most diverse filler range, thanks to the NASHA and OBT gel technologies. As the original 'poineer' of dermal fillers, we at Galderma are proud to be continuing the Restylane story and look forward to supporting practitioners worldwide in delivering the highest possible quality and results for their patients.” Baljit Parmar, Aesthetics Business Unit Head, Galderma UK & Ireland

KOL quotes “Restylane at 25 years to me means something that has stood the test of time; something that is tried, tested and trusted. With Restylane – day in, day out for the last fifteen years, I’ve been able to deliver reproducible, reliable results for every single patient." Dr Kuldeep Minocha

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“Restylane at 25 years is an incredible achievement – it’s huge. There are medically proven and scientifically robust data out there to support all their fillers, which for me as a plastic surgeon is of paramount importance. The biggest impact Restylane has had in terms of my practice – it’s the versatility that Restylane brings to the practice. In my opinion the uniqueness of Restylane is the fact that it can complement any stage of ageing – for me, this translates into confidence for my patients!” Dr Priya Chadha

Join the celebration! In celebration of this 25th anniversary milestone, Galderma is launching a variety of commercial special offers – to find out more, please contact your Galderma Key Account Manager or contact Galderma’s distributor MedFx.

REFERENCES 1. REF – 07440 – Studies for Restylane Eyelight 2. REF – 04435 – Restylane SubQ, a Non-Animal Stabilized Hyaluronic Acid Gel for Soft Tissue Augmentation of the Mid – and Lower Face 3. REF – 04820 – Galderma Announces FDA Approval of Restylane® Silk as the First HA Dermal Filler Approved for Injection via Cannula.

Adverse events should be reported. For the UK, reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store. For Ireland, suspected adverse events can be reported via HPRA Pharmacovigilance, www.hpra.ie; Adverse events should also be reported to Galderma (UK) Ltd. E-mail: Medinfo.uk@galderma.com Tel: +44 1 923 208 950

Aesthetics | September 2021

This advertorial was written and supplied by Galderma

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Post-inflammatory hyperpigmentation Post-inflammatory hyperpigmentation (PIH) occurs when the skin reacts to inflammation by creating extra pigment, causing brown patchy pigmentation in the peeled areas.2 PIH is an issue that can occur with superficial or deep peels, but is particularly common with medium depth peels. This is because TCA can be used on individuals with darker skin types who are more prone to pigmentation, whereas phenol deep peels are not performed on skin of colour. PIH is a problem usually associated with darker skin photo types IV, V and VI because they can create pigment more easily and their skin reacts to inflammation by going darker.3 However, it can occasionally present with lighter skin types.2

Preventing Chemical Peel Complications Dr Xavier Goodarzian outlines the common complications caused by chemical peels and advises on how to avoid them Chemical peels have been in use for decades and their formulas and applications have dramatically improved over the years. This has led to products that are much safer and cause fewer side effects. While peels can be a wonderful way of improving skin quality and reducing sun damage, pigmentation, acne, acne scarring and wrinkles, they are powerful tools and like any aesthetic treatment they have the potential to cause complications. Skin peeling is now a significant part of most aesthetic practices and a common treatment sought by patients, so it is more important than ever for practitioners to be aware of how to avoid and manage these complications, should they arise.

Common side effects Chemical peels can address various issues and can be adapted for the individual’s skin by altering the combination of ingredients, their percentages, and acidity (PH level). They are also very versatile and can address issues very superficially at the stratum corneum level all the way down to the reticular dermis level, depending on the active peeling agent used (Table 1).1 As a rule of thumb, the more superficial a peel, the less potential side effects one might expect. So, the deeper the peel penetrates, the higher the risk of having side effects. However, this is not to say that superficial peels are totally harmless and cannot cause any side effects at all so they should still be used with the respect they deserve as a medical treatment. Depth of peel

Primary ingredients

Targeted concerns

Light/superficial

• Alpha hydroxy acids: glycolic acid, citric acid, lactic acid • Trichloroacetic acid (TCA) 10%-15%

Skin tone, fine lines, acne, pigmentation

Medium

• Trichloroacetic acid (TCA) 15%-35% • Jessner (contains salicylic acid, lactic acid and resorcinol)

Hyperpigmentation, fine lines, acne scarring, skin tightening, sun damage

Deep

• Phenol, sometimes mixed with TCA

Wrinkles, sun damage, acne scarring, xanthelasma and hyperpigmentation

Table 1: Overview of chemical peels and possible complications1

The primary cause for this is a lack of proper skin preparation and/or aftercare.3 In my experience, darker skin types must be prepared for longer than the commonly accepted two to three weeks prior to the peel. I would recommend at least six or eight weeks of skin prep in these skin types, and the prep should include the use of skin lightening agents with anti-tyrosinase activity. This is because these agents stop the skin from creating excess pigment.3 This is less important for superficial peels but a must for medium or deep peels. Also, darker skin types are generally not suitable for aggressive medium or deep peels due to the risk of PIH, and even with great skin prep there is always a risk of causing PIH.2 So, understanding the science behind choosing the correct peel for the correct skin type is essential. Prolonged downtime and/or erythema In my experience when undergoing a medium or deep peel, a week of downtime is the minimum that you would expect. With deeper peels the erythema can last for one to two months after the peel, sometimes even longer.2 The downtime can be prolonged by lack of or insufficient skin preparation, so the better the skin is prepared for a peel, the quicker it will recover afterwards and the less chance for potential side effects. Skin prep is really peel dependent, but also very much dependent on skin type, skin condition and skin concern. It’s hard to give a general guideline for this as there are so many variations, but generally I would recommend the use of antioxidants and sun protection at the very least. It is important to explain the length of downtime to your patient during the initial consultation so they can decide

Reproduced from Aesthetics | Volume 8/Issue 10 - September 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

1

@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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whether they are able to commit to this as well as the aftercare, so they can plan their social calendar around it. In my opinion, a chemical peel should never be sold to a patient as a single treatment, but as a package along with the skin prep products so that they can use the correct products for prepping and aftercare. There is no room for negotiation here, and practitioners should be confident to say no to the patient if this is the case and explain the risks fully. Rebound pigmentation Pigmentation, especially melasma, can be very difficult and stubborn to treat. Melasma is particularly difficult to eradicate because it has the tendency to come back. This often seems to be the case when the skin preparation phase has been shortened or neglected. Apart from skin prep, aftercare is also vital to keep pigmentation away. Again, the treatment does not simply end with the peel. Skincare products that come afterwards are part of the treatment and so is a good broad-spectrum sunscreen and sun avoidance. I would typically recommend at least two to three months of sun protection after peeling, although of course patients should be using SPF all year round. Viral or bacterial infections Chemical peels can reactivate viral infections, with the most common being herpes simplex. A lot of us carry the virus and this can be an issue with medium or deep peels because the virus regularly reactivates with stress, sunlight, low immunity, or irritation.4 It is unlikely to get a reactivation of the virus with superficial peels, but it is not impossible. For medium and deep peels, it is advisable to start the patient on prophylactic antiviral treatment before the peel. For medium peels a five-to-seven-day course would suffice, whereas with deep peels usually 15 days are required.4 Usually the course of treatment starts one or two days before the peel itself. If this is neglected there is a real danger of the herpes virus spreading across large areas of the face and potentially cause pigmentation and scarring. Bacterial infections are not very common with peels except in cases where hygiene has been an issue. This can be more of a problem with deep peels because they essentially cause an open wound on the whole area so it would be very easy for bacteria to infect this.4 In my practice, with deep peels a prophylactic course of antibiotics is sometimes prescribed to avoid a potential bacterial infection, typically lasting for a course of seven days.

Aesthetics

aestheticsjournal.com

Scarring Scarring is a rare side effect but can happen with peels of any depth. I have known even superficial peels, when performed incorrectly, to cause scarring. A good example of this would be a glycolic peel that has not been totally or uniformly neutralised and has a much deeper local action than expected. So, the problem could be down to the practitioner performing the peel, but it could also be due to the patient using products that would increase skin permeability such as benzoyl peroxide or tretinoin. This makes it essential for practitioners to perform a thorough consultation in which they gain detailed knowledge of the patient’s skincare regime and medical history. Often patients don’t mention creams they use as they don’t recognise them as medication, but any product put on the face could potentially influence the peel. If scarring does occur, it is important to recognise it early on, so practitioners should always ensure to schedule a follow-up appointment. The first follow-up for medium and deep peels should be as soon as the crusting comes off, which is typically eight to 10 days after the peel. To treat scarring there are several options, including intralesional steroid injections, topical steroid application, topical silicone application, LED light therapy and sometimes even microneedling.2 The treatment will depend on the severity of the scar, and I have found that a combination of treatments usually gets the best outcome. Insufficient results Generally, this occurs because the wrong type of peel was chosen for the wrong indication. For example, a superficial peel that was chosen to remove medium to deep wrinkles. No matter how many superficial peels are performed on this skin type, in my experience, those wrinkles will not disappear. To avoid this problem one should manage the patient’s expectations from the beginning and choose the correct type of peel for the indication. Therefore, it’s key that practitioners ensure they have undertaken the correct training/education so they are able to choose the right peel. In this instance, only a deep peel of reticular dermis level would be able to remove medium to deep wrinkles.

because of insufficient skin preparation or an uneven application of the peel itself. To avoid this problem, make sure that your patient has been using their prep products correctly and make sure that the application of the peel is as even as possible. If this complication occurs, the peel may need to be repeated.

Always consider complications Chemical peels are a wonderful tool to use for skin rejuvenation; however, they can cause various side effects if not used carefully. Although complications are more common with medium and deep peels, superficial peels can also cause adverse events and so particular care should be taken by all practitioners regardless of the depth. All peels should be accompanied by the necessary prep and aftercare products, which practitioners should communicate clearly during the initial consultation and follow-up appointments should be scheduled to ensure this is being implemented correctly. Dr Xavier Goodarzian is the medical director and co-owner of the national award-winning Xavier G. Clinic in Southampton. He is a lecturer and trainer at major conferences throughout the UK and abroad and the past lead trainer for Innomed Training. Qual: MD(Hons), MRCGP, DipClinDerm, PGCertCosMed, MBCAM

14 + 15 October 2021 | ExCeL London

Dr Goodarzian will speak at the ACE Group World conference at CCR on October 14 Register on p.21!

VIEW THE REFERENCES ONLINE! WWW.AESTHETICSJOURNAL.COM

Uneven results Sometimes the skin may look uneven in colour or texture after a peel. The colour changes could be pigment related or induced by localised erythema. This could be

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


anddermis antioxi ificant changes to see hasher what she had done?” That is what concerns were roughness of skin uneven pigmentation, dilatedshe is in the superficial part of the dermis. gaining too much and volume; deep thinning and atrophy, degeneration to have anti-inflammatory subtle, smooth changes that occur loss of firmness and blood pigmentation. firmness of thealso skinknown can be achieved fferent light. We need although th texture, tiredness, loss of skin glow, vessels.a lot of her girlfriends Improvement of the elasticity and I want to hear. and antioxidant properties, conscious of elastic tissue, loss of collagen continuously over time. So when you Microscopically these changesfirmness of the skin can bewith a treatment plan of three sessions effects bec h changes that occur loss of firmness and pigmentation. achieved although the significance of these hear people saying, have overboard with and increased melanin of in serial the skin. She wanted to improve thisgone without are seen byaesthetic atypical skin cells, skin puncture injections in the midBENEFITS over time. So when you “She looks great, Microscopically these changes with a treatment plan of three sessions effects because of treatment BELOTERO with Advertorial what has she had done?” That is what When BELOTERO® Revive first hit gaining too much volume; she isatypical skin deep dermis four weeks apart. thinning and atrophy, degeneration aying, “She looks great, benefici medical and skin therefore BELOTERO® Revive is an ideal choice She wanted to improve this without are seen bytreatments cells, of serial puncture injections in the mid Pure glycer BELOTERO® Revive is notThe known. toThat hear. hadI want done?” is what conscious girlfriends of elastic tissue, @aestheticsjournaluk loss of collagen @aestheticsgroup aestheticsjournal.com absorb its o Merz Aesthetics the UK, I gaining was extremely excited asaisIlot of herwanted too much volume; she dermis four Aesthetics weeks apart.signs or thinning and atrophy,look. degeneration theseen skin a subtle fordeep anyone showing these for Pure glycerol has also been tohave BENEFITS OF GLYCEROL have overboard aesthetic increased melanin in the skin. just three8d conscious a lot of this her girlfriends of with elastic tissue, loss ofand collagen its own weight in more water over needed a product like ingone my clinic. than patients who want to improve their absorb When BELOTERO® Revive hitoverboard OF GLYCEROL havefirst gone with aesthetic and therefore increased melaninBELOTERO® in the skin. Revive is an ideal BENEFITS The beneficialjust effects glycerol on to provide threeofdays, helping medical treatments and choice patients wi patients say to you, “I look for its moistu BELOTERO® Revive is suitable for skin’s appearance without drastic ERO® firstHow hit many theRevive UK, I was extremely excitedtreatments as I effects of glycerol onhave been medical and therefore BELOTERO® Revive is for an ideal choice patients with results one the skin recognised forafter justtreatment. wanted a subtle look. anyone showing these signsThe or beneficial for tired”, I am sure is nearly extremely excited as I like in all patients withwho signs ofto improve volume Revive the skinchanges. have beenBELOTERO® recognised wanted aitsubtle look. for anyone showing these signs or forwant treatment. combination of theGlycer HAdiff needed a product this in my clinic. morefor than 85 years. It is The widely used effects patients their and duct likemany this inpatients my clinic.say than 85 years. It is widely who want to improve their equates to 37.5mg of every second That is How to you,one. “I look photodamaged facial skin. is amore perfect early intervention that and Glycerol for itsused moisturising and smoothing BELOTERO® Revive patients is suitable for moisturisin skin’s appearance without drastic tients say Ito you, “I look for its moisturising and smoothing BELOTERO®Revive Revive is suitableall forpatientsskin’s moisturising agents to improve skin without drastic tired”, am sure it isBELOTERO® nearly in different dermatological hydration f withappearance signs of volume changes. BELOTERO® Revive why will The unique combination offers a natural-looking,effects enhanced re itevery is nearly effects in different dermatological hydration from one to nine months. all patients with signs of volumefacial changes. BELOTERO® Revive secondbe one. That is photodamaged skin. is a perfect early intervention that great for your clinic; who of Cohesive Polydensified skin look. one. That is photodamaged facial skin. is a perfect early intervention that UP TO why BELOTERO® Revive will The unique combination offers a natural-looking, enhanced RO® Revive will doesn’t want 37.5mg/ml HA and glycerol The uniqueof combination offers a natural-looking, enhancedwould be great for your clinic; who of Cohesive Polydensified skin look. our clinic; who hydration in theirofskin? P TO Cohesive Polydensified skin look. UP TO UM ONTH FIRST TREATMENT/TECHNIQUE P TO UP TO doesn’t want 37.5mg/ml of HA and glycerol wouldrevitalise her skin and Improved Decreased 9NTHS UImproved 9NTHS 37.5mg/ml of HA and glycerol would 9 9 skin hydration give her the outcome With all my patients, I consent them, in their skin? revitalise her skin TREATMENT/TECHNIQUE and MO FIRST TREATMENT/TECHNIQUEMONTHS S skin hydrationMO skin pigmentation heirhydration skin? revitalise her skin and MONTH FIRST BELOTERO® Revive is athe outcome give her the outcome With allthem, my patients, I consent them, she desired. take photographs and prep their skin give her With all my patients, I consent BELOTERO® Revive is a or skinshe she desired. and prepfor their skin revitaliser booster. Revive is a desired. treatment. Before the treatment, take photographs andtake prepphotographs their skin UP TO booster. for treatment. Before the treatment, kinrevitaliser booster. or skin for treatment. Before the treatment, It has 20mg/ml of HA, and As we know, photodamage I informed her about the device and UP TO UP TO P TO UP TO UIncreased Increased Improved has and 20mg/ml of HA, and As we know, photodamage I informed her about the device and 6 ml ofIt HA, As we know, photodamage I informed her about the device and 6side 7ONTH 7 17.5mg/ml of glycerol in a is defined as the change possible contraindications and S skin firmness skin softness MM ONTHS ONTHSfirmness MONTH Mskin 17.5mg/ml glycerol in a of glycerol in a is defined possible as the change possible contraindications and side MONTHS is defined as the change contraindications and side 1ml syringe for appearance, structure, appearance, I also applied some LMX dicated for in structure, effects. I alsoin applied some LMX 1ml syringe indicated for indicated in structure, appearance, effects. I also applied some effects. LMX hotodamage. early-onset photodamage. and function of the skin cream around the function perioral lines. and of the skin cream around the perioral lines. early-onset photodamage. and function of the skin cream around the perioral lines. after ongoing exposure She received 20 superficial-mid after ongoing exposure She received 20 superficial-mid after ongoing exposure SheAdverse received 20 superficial-mid events should be reported. Reporting forms and information for reported. United Kingdom can forms be found www.mhra.gov.uk/yellowcard Adverse events should be Reporting andatinformation for United Kingd events sho found at https://www.hpra.ie/homepage/about-us/report-an-issue/mdiur. Adverse events should also be reported toAdverse Merz Pharma UK Ltd b NT/PATIENT to harmful light rays to with injections of cohesive injections of cohesive https://www.hpra.ie/homepage/about-us/report-an-issue/mdiur. Adverse event ASSESSMENT/PATIENT harmfulmicropuncture light rays with micropuncture found at https://ww ASSESSMENT/PATIENT to harmful light rays with micropuncture injectionsfound ofatcohesive NDBACKGROUND advancing age. Exposure polydensified matrix HA filler (CPMadvancing age. Exposure polydensified matrix HA filler (CPMReferences: 1. Merz BELOVE Study, 2019. 2. Samson N et al. Journal Cosmetic Derm 2011. 3. Fink B et al., Int Journal Cosmetic Sci age. Exposure polydensified matrix HAReferences: filler (CPMLinearadvancing Thread Technique Bolus 1. Merz BELOVE Study, 2019. 2.Technique Samson N et al. Journal Cosmetic Derm ® Dermatology female patient BACKGROUNDcan start in the first lidocaine Investigational 2019:12 563-572. 5. Succi IB, Da Silva RT, Orofino-costa R. Rejuvenation of periorbital area: treatment A 60-year-old female patient can start inHA20G the firstBELOTERO® Revive HA20G BELOTERO® Revive lidocaine References: 1. Merz Investigational Dermatology 2019:12 563-572. 5. Succi IB, Da Silva RT, Orofino-cos hyaluronic acid preparation. Dermatol Surg 2012;38 2 192-198 h uneven skin A 60-year-old female decade without visible free) in a gridcan pattern in in thethe midfirst and patient start HA20G BELOTERO® Revive lidocaine hyaluronic acid preparation. Dermatol Surg 2012;38 2 192-198 Investigational Derm presented with uneven skin decade without visible free) in a grid pattern in the mid and aid she felt like presented with uneven signs on the skin. As the lower face and around the periorbital hyaluronic acid prep skin decade without visible free) in a grid pattern in the mid and 30G needle 27G 30G needle (40mm) texture. She said she felt like signs on the skin. As or the lower face and around the periorbital ry tired. She is exposure continues, early region. I injected slowly using the

CASE STUDY: THE MERZ APPROACH WITH BELOTERO® REVIVE BY JULIE REDMOND CASEBolus STUDY: THE MERZ Technique

9

APPROACH WITH Julie Redmond RGN. NIP shares why30G she is needle so excited about using Merz Aesthetics’ new ® 6 BELOTERO REVIVE product BELOTERO® Revive, to revitalise, Superficial to mid dermis. restore, regain life, and strengthen patients’ RGN. NIP shares why she is Julie Redmond skin, especially after the yearso weexcited have just had.using Merz Aesthetics’ new about pass Bolus technique 0.05mls per bolus product BELOTERO Revive, to revitalise, or maximal using a grid pattern with even distribution restore, regain life, and strengthen patients’ skin, oint. ofAsproduct inface eacharound square of the grid. texture. Sheissaid she felt like signs onregion. the skin. the she looked very tired. She lower the periorbital exposure continues, early I injected slowly using the especially after the yearand we have just had she looked very tired. She is exposure continues, region. I injected slowly using the Superficial to mid dermis. early Superficial to mid dermis.

Z APPROACH VE NO FILTER, JUST YOU

the ex-wife of a famous rock star and Date ofsigns M-BEL-UKI-1189 Preparationsuch June 2021 as tanning, freckles and M-BEL-UKI-1189 Date of Preparation June 2021 Skin surface and pigmentation was a Top of the Pop’s dancer and sunspots emerge. Other symptoms Linear threading 0.05mls/ pass Bolus techniqueof0.05mls pe strongly impact perceived facial This advertorial is sponsored by Merz Aesthetics UK & Ireland M-BEL-UKI-1189 Da model in the 80s. She has a Fitzpatrick photodamage include fine wrinkles No filter, loss of firmness and pigmentation. skin’s appearance without drastic technique in star pattern for maximal using avolume grid pattern with ev attractiveness, and type andthis ispoint. originally from (<1mm in depth), coarse wrinkles justeven you small She III-IV wanted improve without gaining changes. BELOTERO® Revive is a perfect reach fromskin ato single entry of product in each square o SUMMARY andofcosmetic preparations. However, tity of gel changes 25%Skin drive differential Cyprus. She she has isgreat volume (>1mm in depth), skin laxity, dryness, surface and too much volume; conscious a lotstill of early intervention that offers a naturalBELOTERO® Revive can I really believeof this; we do the availability this molecule in he area perception. pigmentation her girlfriends havebeautiful gone overboard with looking, enhanced skinbe look.used and is a very lady, however, sallowness, rough texture, patchy and not need significant changes SUMMARY strongly impact to see supplied aesthetic medical The treatments and therefore her concerns were roughness skincosmetic uneven pigmentation, and dilated and preparations. However, needles. quantity of gel in all of ages for early intervention injectable preparations is relatively ction you people BELOTERO® Revive ca in a different light.facial We need to perceived wanted a subtle look. on First treatment/technique the availability of this molecule in betexture, injected depends theof area tiredness, loss skin glow, blood vessels. or in later years. It is excellent for in all ages for early int injectable preparations is relatively subtle, smoothGlycerol changes thatis occur beingloss treated and the correction you recent. a polyol found attractiveness, and With all my patients, I consent them, of firmness and pigmentation. in later years. It is ex recent. Glycerol is aand polyol is found to achieve. continuously over when youwant even small changes of 25%time. driveSo differential BELOTERO® Revive is suitableskin for all revitalisation take photographs and theirorskin Microscopically these changes aprep well endogenously in humans and skin endogenously in humans andthe treatment, I revitalisation and perception. really believe this; we looks do notgreat,patients with signsto of improve photodamaged facial forare treatment. hear Ipeople saying, “She She this without seen byBefore atypical skin cells, skin and effectiv tolerated Revive canwanted be used with other tolerated is thought to be important for and effective er need significant changes see be people in skin.gaining The of Cohesive informed herand about thetreatment. device and possible thought to important forunique whatishas she hadto done?” That is whatBELOTERO® toocombination much volume; thinning atrophy, degeneration In the BELOVE study, B products in the same she ismaintaining hydration of the light. need subtle, smooth Polydensified HA and glycerol would contraindications and side of effects. I also was shown to d I want toWe hear. In the BELOVE study, BELOTERO® e same a different conscious a lot of her girlfriends of elastic tissue, loss collagen Revive session. I gently massaged the treated epidermis. It is mainly responsible maintaining hydration of the her skin and give her the outcome changes that occur continuously over time. revitalise applied some LMX cream around the perioral for up to se such as tanning, freckles and roughness areas after the injection to distribute have gone overboard with aesthetic and increased melanin in the skin. for attracting and retaining water Revive was shown to decrease skin hesigns treated So when you hear people saying, “She she desired. lines. She received 20 superficial-mid epidermis. It is mainly responsible sunspots emerge. Other symptoms of increase skin firmness uniformly. She found the When BELOTERO® Revive first hit the product medical treatments and therefore is an ideal choice molecules,BELOTERO® strengtheningRevive the looks great, what has she had done?” ThatasisI treatment As we know, photodamage isroughness defined as micropuncture injections of cohesive photodamage include fine wrinkles months and decrease tolerable withlook. no redness for up to seven months; stribute the UK, I was extremely excited hyaluronic acid matrix through wanted a subtle for anyone showing these signs or for for attracting and retaining water (<1mmwhat in depth), wrinkles I needed wantcoarse to hear. the change in structure, appearance, and polydensified matrix HA filler (CPM-HA20G for up to nine months. or bruising afterwards. Atrophic scars, hydrogen patients bonding, who enhancing a product like this in my clinic. want toup improve their increase skin firmness for to six ound the (>1mm in depth), molecules, skin laxity, dryness,strengthening that 86% of patients ra photodamaged skin after and fine lines are function of the skin ongoing exposure BELOTERO® Revive lidocaine free) in a the the potency of hyaluronic acid in How many patients say to you, “I look BELOTERO® Revive is suitable for skin’s appearance without drastic sallowness, rough texture, patchy and asface having an improved treated through one treatment sessionage.promoting When BELOTERO® Revive first hit the UK, I to harmful light rays with advancing grid pattern in the mid and lower and skin hydration. Glycerol is months decrease skin redness redness tired”, I am it is nearly all patients with signs of and volume changes. BELOTERO® Revive hyaluronic acid matrix through unevenwas pigmentation, andsure dilated outcome at six month the superficial part thefirst dermis. to have extremely excited as I needed a product in Exposure can start inofthe decade also known around the anti-inflammatory periorbital region. I injected every second one. That is photodamaged facial skin. is a perfect early intervention that blood vessels. of patients would reco Improvement of the elasticity and forAsup to antioxidant nine months. It also showed phic scars, properties, like this in my clinic. How many patients say toenhancing without visible signs on the skin. the and slowly using the supplied needles. 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HA and glycerol would as having an entare session will be great for your clinic; who doesn’t want Other symptoms of photodamage include youimproved want to achieve.aesthetics promoting skin hydration. Glycerol is apart. deep dermis four weeks thinning and atrophy, degeneration Pure glycerol has also been seen to hydration in their skin? revitalise her skin and FIRST 37.5mg/ml of hydration in their skin? fine wrinkles (<1mm in depth), outcome coarse absorb Revive canTREATMENT/TECHNIQUE bein used with other BELOTERO® of elastic tissue, loss of collagen own months weight water over atits six and 90% dermis. also known to have anti-inflammatory give her the outcome With all my patients, I consent them, wrinkles (>1mm in depth), skin laxity, products in the same session. I gently BENEFITS OF GLYCEROL and increased melanin in the skin. just three days, helping to provide BELOTERO® Revive is a she desired. take photographs and their ofonpatients would recommend y and BELOTERO® Revive is achoice revitaliser or skin dryness, sallowness, rough texture, patchy the treated areasprep afterthe the skin The beneficial effects of glycerol BELOTERO® Revive is an antioxidant ideal patientsmassaged with results after just one and properties, revitaliser orsigns skinof booster. for treatment. Before the treatment, the skin have pigmentation, been recognised for booster. It has 20mg/ml HA, and 17.5mg/ and uneven and dilated injection to distribute the product uniformly. for anyone showing these or for treatment. The combination of the HA treatment toI a friend. chieved although significance these It has of the HA, and As we her aboutoftolerable the device more than 85 years. 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sponsored by Merz Aesthetics UK & Ireland

This advertorial is sponsored by Merz Aesthetics UK & Ireland

skin firmness

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Adverse events should be reported. Reporting forms and information for United Kingdom can be found at www.mhra.gov.uk/yellowcard. Reporting forms and information for R 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 o

polydensified matrix HA filler (CPM44 HA20G BELOTERO® Revive lidocaine

Aesthetics | September 2021

References: 1. Merz BELOVE Study, 2019. 2. Samson N et al. Journal Cosmetic Derm 2011. 3. Fink B et al., Int Journal Cosmetic Science 2018. 4. Hertz-Kleptow et al. Cl Investigational Dermatology 2019:12 563-572. 5. Succi IB, Da Silva RT, Orofino-costa R. Rejuvenation of periorbital area: treatment with an injectable nonanimal non cro hyaluronic acid preparation. Dermatol Surg 2012;38 2 192-198


to mid dermis. althoughSuperficial the significance of these ear threading passplan of three sessions Bolus technique 0.05mls per bolus with a 0.05mls/ treatment effects because of treatment with hnique in star pattern for maximal using a grid pattern with even distribution ch from single entry point. injections in the mid of product in each square of the grid. ofaserial puncture BELOTERO® Revive is not known. deep dermis four weeksandapart. PureHowever, glycerol SUMMARY has also been seen to cosmetic preparations. plied needles. The quantity of gel BELOTERO® Revive can be used the availability of this molecule in be injected depends on the area absorb its own inearly water over in weight all ages for intervention injectable preparations is relatively ng treated and the correction you or in later years. It is excellent for recent. Glycerol is a polyol found nt to achieve. BENEFITS OF GLYCEROL justandthree days,skinhelping to provide revitalisation and is a well endogenously in humans tolerated and effective treatment. ive can be used with other is thought to be important for In the BELOVE BELOTERO® LOTERO® in the same Theproducts beneficial effects ofmaintaining glycerol on hydration of the patients with results after study, just one Revive was shown to decrease skin sion. I gently massaged the treated epidermis. It is mainly responsible roughness for up to seven months; as after the injection to distribute for attracting and retaining water the skin have been recognised for treatment. The combination of the HA increase skin firmness for up to six product uniformly. She found the molecules, strengthening the months and decrease skin redness atment tolerable with no redness hyaluronic acid matrix through more than 85 years. It is widely used and Glycerol equates tomonths. 37.5mgIt also of showed for up to nine bruising afterwards. Atrophic scars, hydrogen bonding, enhancing that 86% of patients rated themselves otodamaged skin and fine lines are the potency of hyaluronic acid in for itsone moisturising and smoothing moisturising skin as havingto animprove improved aesthetics ated through treatment session promoting skin hydration. Glycerol is agents outcome at six months and 90% he superficial part of the dermis. also known to have anti-inflammatory patients recommend provement of theinelasticity and dermatological effects different and antioxidant properties, hydration fromoftreatment one totowould nine months. the BE a friend. mness of the skin can be achieved

perficial to mid dermis.

Linear Thread Technique

Bolus Technique Advertorial 27G@aestheticsgroup or 30G needle (40mm) 30G needle Merz Aesthetics @aestheticsjournaluk Aesthetics aestheticsjournal.com Linear Thread Technique Bolus Technique Superficial to mid dermis. Superficial to mid dermis. 27G or 30G needle (40mm) 30G needle Linear threading 0.05mls/ pass Bolus technique 0.05mls per bolus Superficial Superficial midpattern dermis.with even distribution techniqueto in mid stardermis. pattern for maximal using ato grid Linear Thread Technique Bolus Technique reach from a single entry point. of product in each square of the grid. Linear threading 0.05mls/ pass Bolus technique 0.05mls per bolus technique in star pattern for maximal using a grid pattern with even distribution 27G or 30G needle (40mm) 30G needle reach from a single entry point. of product in each square of the grid. SUMMARY and cosmetic preparations. However, supplied needles. The quantity of gel Superficial to mid dermis. Superficial to mid dermis. BELOTERO® Revive can be used the availability of this molecule in to be injected depends on the area in all ages for early intervention injectable preparations is relatively SUMMARY being treated and the correction you and cosmetic preparations. However, Bolus supplied needles. The quantity of gel Linear threading 0.05mls/ pass technique 0.05mls bolus for or in later years. It is per excellent recent. Glycerol is a polyol found want to achieve. BELOTERO® Revive with can be used to be injected on the technique in depends star pattern forarea maximalthe availability of this molecule in using a grid pattern even skin revitalisation and is a distribution well endogenously in humans and inproduct all ages in foreach earlysquare intervention injectable preparations is relatively being treated and the correction you reach from a single entry point. of of treatment. the grid. tolerated and effective Revive can be used with other is thought to be important for or in later years. It is excellent for recent. Glycerol is a polyol found want to achieve. In the BELOVE study, BELOTERO® BELOTERO® products in the same maintaining hydration of the skin revitalisation and is a well endogenously in humans and Reviveand waseffective shown to decrease skin session. I gently massaged the treated epidermis. It is mainly responsible tolerated treatment. Revive can be used with other is thought to be important for SUMMARY roughness for upBELOTERO® to seven months; areas after the injection to distribute and cosmetic preparations. However,In the supplied needles. Theinquantity for attracting and retaining BELOVE study, BELOTERO® products the sameof gel maintaining hydration of the water BELOTERO® Revive can increase skin firmness forbe upused to six the product uniformly. She found the the availability of this molecule in to be injected depends on the area molecules, strengthening the was shownagents to decrease skin session. I gently massaged the treated epidermis. scars, photodamaged skin and fine endogenously in humans and is thought toRevive of moisturising to improve skin It is mainly responsible in all ages for early intervention months and decrease skin redness treatment tolerable with no redness is relativelyof roughness being treated and the one correction you forinjectable hyaluronic acid matrix through forfrom up one to seven months; areas after the injection to distribute lines are treated through treatment be importantpreparations for maintaining hydration hydration to nine months. attracting and retaining water or in years. It is excellent for for uplater to nine months. It also showed or bruising afterwards. Atrophic scars, recent. Glycerol a polyol want toinachieve. the product found hydrogen bonding, enhancing session theuniformly. superficialShe part of the the the epidermis. It is is mainly responsible molecules, strengthening the found for increase skin firmness for up to six skin revitalisation and is a well that 86%decrease of patients themselves photodamaged skin fine lines are hyaluronic months and skinrated redness treatment tolerable with noelasticity redness endogenously in humans the potency of hyaluronic acid in dermis. Improvement of and the and attracting and retaining water and molecules, Summary acid matrix through tolerated and effective treatment. Revive can beskin used other scars, as having an improved aesthetics treated through one treatment session for up to nine months. It also showed or bruising afterwards. Atrophic firmness of the canwith be achieved with hydrogen strengthening the hyaluronic acid matrix BELOTERO® Revive can be used in all ages is thought to be important for promoting skin hydration. Glycerol is bonding, enhancing In the BELOVE study, BELOTERO® BELOTERO® products infine thelines same outcome at six months and 90% the superficial part of the dermis. aintreatment plan of three sessions of serial through hydrogen bonding, enhancing the for early intervention or in later years. It is that 86% of patients rated themselves photodamaged skin and are themaintaining hydration of the also known have anti-inflammatory potency of to hyaluronic acid in although theofsignificance ofpromoting these Revive was shown to decrease skin session. Iinjections gently massaged the treated puncture in the mid deep dermis potency hyaluronic acid in excellent for skin revitalisation and is a well of patients would recommend the Improvement of the elasticity and as having an improved aesthetics treated through one treatment session epidermis. It hydration. is mainly responsible and antioxidant properties, promoting skin Glycerol is h a treatment plan of three sessions effects because of treatment with four skin hydration. tolerated and effective treatment. outcome at six months and 90% in theweeks superficial part can of the roughness for up to seven months; areas after the to distribute treatment to a friend. firmness ofapart. theinjection skin bedermis. achieved also known to have anti-inflammatory for attracting and retainingofwater although the significance these erial puncture injections inofthe mid Glycerol isRevive alsoproperties, known to have In the BELOVE BELOTERO® Revive of patients would recommend Improvement of the elasticity and increase skin study, firmness for the up to six the uniformly. She found the BELOTERO® not known. withproduct a treatment plan three sessions and antioxidant molecules, strengthening thewith effects because ofistreatment Benefits of glycerol anti-inflammatory and antioxidant was shown to decrease skin roughness treatment to a friend. firmness of the skin can beno achieved ep dermis apart. of four serialweeks puncture injections in the mid months and decrease skin redness treatment tolerable with redness the significance of these Purealthough glycerol has also been seen to hyaluronic acid matrix BELOTERO® Revive is through not known. The beneficial effects ofofglycerol on the properties, although the significance of for up skin with a treatment plan three sessions deep dermis four weeks apart. for uptotoseven nine months; months.increase It also showed or bruising afterwards. 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Adverse events should 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-1189 Date ofbePreparation June 2021 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) 333 200 4143. M-BEL-UKI-1189 Date of Preparation June 2021

Adverse events should be reported. Reporting forms and information for United Kingdom can be found at www.mhra.gov.uk/yellowcard. Repo found at https://www.hpra.ie/homepage/about-us/report-an-issue/mdiur. Adverse Ltd by ema Aesthetics | September 2021events should also be reported to Merz Pharma UK45 References: 1. Merz BELOVE Study, 2019. 2. Samson N et al. Journal Cosmetic Derm 2011. 3. Fink B et al., Int Journal Cosmetic Science 2018. 4. Hertz-Kleptow et al. Clinical, Cosmetic and Investigational Dermatology 2019:12 563-572. 5. Succi IB, Da Silva RT, Orofino-costa R. Rejuvenation of periorbital area: treatment with an injectable nonanimal non crosslinked glycerol added hyaluronic acid preparation. Dermatol Surg 2012;38 2 192-198

L-UKI-1189 Date of Preparation June 2021


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hormones, thereby picking up on these hormones more than they would normally. This leads to an increased gland formation in these patients.5 There are also pharmacological agents that can increase gynecomastia as well as rare tumours of the adrenal glands and testes.6

Treatment

Understanding Gynaecomastia Mr Alex Karidis outlines the causes of gynaecomastia and his approach to treatment Gynaecomastia is a common condition affecting almost 35% of the male population.1,2 The condition impacts men physically and psychologically and the treatment remains one of the most popular male procedures to date. Towards the end of last year, gynaecomastia contributed to 38% of the treatments we performed at the Karidis Clinic, with the average age of patients between 25 and 35. Due to an acceleration in men turning to aesthetics to enhance their appearance and boost their confidence over the past year, I wanted to share my knowledge concerning the condition, my take on the most effective approaches to treatment, the technique I use at my clinic as well as patient considerations for other practitioners to be aware of. Currently, there are not any non-surgical solutions to eradicate gynaecomastia. Therefore, this article should act as guidance for other practitioners to offer the appropriate pathways to their patients who wish to receive more information about gynaecomastia and whether they are a suitable candidate for surgery.

Causes of gynaecomastia Gynaecomastia refers to the Greek meaning for ‘female breast’ and refers to the development of obvious breast tissue in men.3 While the term gynaecomastia strictly refers to the enlargement of the glandular component of the breast, many patients have an excess of both fatty and glandular tissue. Whether male or female, the breast is usually made from two components – glandular tissue and fatty tissue. The ratio of tissue in any breast varies from patient to patient. The severity of the condition differs across each patient, ranging from mild to significant enlargement of the male breast, possibly accompanied by sagging of the skin. The condition can affect one or both breasts, sometimes unevenly.3 Gynaecomastia is largely hereditary or idiopathic, meaning there is no specific reason for the cause. Although, it can also occur because of the hormonal imbalances caused by certain types of anabolic steroid.4 The hormone levels in patients with gynaecomastia, no matter what the degree of gynaecomastia is, are usually normal. We all have male and female hormones in our body; however, it is likely that patients who do have gynaecomastia have increased receptors of cells in the chest area which are more sensitive to the circulating female

I have found non-surgical treatments which target fat reduction such as cryolipolysis are ineffective when treating gynaecomastia patients. This is because most gynaecomastia patients have a combination of gland and fat in the male breast area and if you target the fat through non-surgical methods, the gland will be more visible leaving the patient disappointed and still facing the same problem. The majority of gynaecomastia cases can be treated with minimally-invasive surgical procedures. These procedures can minimise scarring through a combination of power assisted liposuction and a modified pull through technique of the gland via a piecemeal fashion through small incisions. The condition of the skin needs to be taken into consideration as good elasticity is required for optimal results. The better the quality of the skin, the better the ability of the skin to contract and shrink around the pectoral muscle contours. In my experience, if a patient suffers from stretched skin that has little elasticity and is ptotic, perhaps due to previous weight gains and losses, then increased surgical techniques such as dermolipectomy are required to reduce the redundant skin to give a taut look. However, such procedures do involve extensive scarring. The gynaecomastia surgical procedure is minimally invasive, meaning an incision of less than one centimetre is made on the nipple, where the areola is located and where the brown or darker skin meets the lighter skin. Another incision of around half a centimetre is also made in the armpit. We then use a combination of liposuction and gland removal to dispel the offending elements, at the same time sculpting the area into a more chiselled chest. When I carry out a gynaecomastia procedure, I always use a technique called ‘external quilting’ which I established to use in the chest. The technique was extrapolated from a facelift technique and the idea was to quilt the skin down. When you’re removing tissue from underneath the skin, you’re effectively leaving an empty space between the skin and muscle and,

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


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Before

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After

Figure 1: Patient before and after gynaecomastia surgical procedure at Karidis Clinic Before

After

exercise must be avoided for at least three weeks after surgery. If practitioners are receiving concerns from their patients regarding bruising, swelling and minor initial lumpiness to the area after surgery, we find this to be a very common issue which usually settles over the course of the coming weeks and months with the aid of localised massaging techniques. These concerns and likely outcomes are highlighted prior to surgery in the consultation phase. Occasionally minor revision surgery is required. Patients can also experience numb or tingling sensations in some areas due to nerve irritation. In my experience, this usually resolves within the first six months of surgery which is in the approach to seeing the final results of the procedure after six to nine months.

Summary

Figure 2: Patient before and after gynaecomastia surgical procedure at Karidis Clinic

immediately after surgery, you can be left with broken blood vessels that leak into the empty space, filling and causing a haematoma. In the male breast reduction, this isn’t desirable as you want a flat chest so with the quilting technique, I stitch the skin to the muscle to close off that empty space. Suturing the skin to the pectoral fascia effectively eliminates the dead space and therefore minimises the possibility of haematoma formation. Moreover, sutures help guide and contour the skin around the natural pectoral contours. It also helps guide the skin where you want it to heal. The technique, which won the Hackett Memorial Prize awarded by the British Association of Aesthetic Plastic Surgeons (BAAPS), is now widely used by other surgeons in the industry.7

Recovery for patients The recovery time after a gynaecomastia procedure varies from each patient and their day-to-day activity. Whilst the incisions made during surgery are very small, liposuction creates a large wound hidden under the skin. The healing process takes time, and I make sure to communicate this thoroughly to the patient, advising that adequate rest in the days after surgery is essential. I suggest to all patients that sleeping with your upper body slightly elevated will also help any reduction in swelling and bruising. Most patients will return to their place of work within three to four days, resuming light exercise after two weeks. Patients going through the recovery process must wear a special compression vest for approximately two weeks post-procedure. I also say to our patients that all strenuous upper body

The better the quality of the skin, the better the ability of the skin to contract and shrink around the pectoral muscle contours

Gynaecomastia affects a large percentage of the male population. With modern techniques, treatment of gynaecomastia involves a relatively straightforward surgical procedure, with minimal scarring, that yields lifelong results. The single most important aspect that determines the success of this procedure is the experience of the surgeon using current surgical procedures to ensure the best possible result for their patients. I have found that the procedure offers an effective solution to the issues of gynaecomastia, and I expect to see an increase in men requesting treatment for this condition in the future. Mr Alex Karidis has more than 25 years of experience in plastic surgery and has run his own practice in St John’s Wood, London for 17 years. Mr Karidis has now expanded his non-surgical offering outside of London with the opening of the first Karidis Medispa in Beauty Bazaar, Harvey Nichols in Liverpool. Qual: MD, FDCS REFERENCES 1. Thiruchelvam, P, et al., ‘Gynaecomastia’, BMJ, 354 (2016). 2. Niewoehner C, Schorer AE ‘Gynaecomastia and breast cancer in men’, British Medical Journal, 336 (2008) pp. 709-13. 3. Arya R, et al., ‘Gynecomastia: A review of literature’, 2(2016), pp.69-75. 4. Hoffman J, ‘Medical Issues Associated with Anabolic Steroid Use: Are They Exaggerated?’, US National Library of Medicine National Institutes of Health, 5 (2006), pp.182-193. 5. Cuhaci N, et al., ‘Gynecomastia: Clinical evaluation and management’, US National Library of Medicine National Institutes of Health, 18 (2014), pp.150-158. 6. Swerdloff R, et al., ‘Gynecomastia: Etiology, Diagnosis, and Treatment’, FHKAM, (2019) <https://www.ncbi.nlm.nih.gov/books/ NBK279105/> 7. Karidis Clinic, ‘Mr Alex Karidis publishes paper on gynaecomastia stitching technique’, (2019) <https://www. karidis.co.uk/our-blog/mr-alex-karidis-publishes-paper-ongynaecomastia-stitching-technique/>

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


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A new approach to address the two biggest patient body concerns, in a single treatment EMSCULPT NEO® is the first and only procedure to eliminate fat cells and build muscle non-invasively by a specially designed and patented combination of simultaneous emission of radiofrequency and high-intensity focused electromagnetic energy in a single therapy. The end result is more fat reduction and muscle growth than any single gold standard procedure, in less time and for less money. With recently launched small contour applicators, EMSCULPT NEO® offers highly customisable treatments for up to nine body areas. The new applicators are designed to fit on smaller body areas such as arms, legs or inner thighs. Miss Sherina Balaratnam, surgeon, cosmetic doctor and medical director and founder of S-Thetics Clinic, shares how she incorporates EMSCULPT NEO® into her practice.

What led you to bring EMSCULPT NEO® into your practice? Since introducing the original EMSCULPT® in August 2018, we had already seen the consistent, reproducible results the technology could bring to our patients. Not only for aesthetic improvements, but also for a greater feeling of strength. As a doctor, I was impressed by the comprehensive range of methods used in used in the EMSCULPT studies (MRI, CT, ultrasound, histology) to record and demonstrate the physiological changes. For me, the scope and credibility of the HIFEM technology clinical studies were a key factor

in my decision to introduce the technology. With the enhanced results and greater depth of clinical studies, it was an easy decision to introduce EMSCULPT NEO® and take our patients’ results to the next level. We also communicate the strength and breadth of this clinical research to our patients, as part of their decision-making process.

What do you believe are the most important features and advantages of EMSCULPT NEO®? HIFEM+ delivers more energy to further enhance results. The synchronised radiofrequency and combined energies mean we are seeing results even quicker. They are now often visible post session one, with patients reporting improvements at this early stage, such as improved posture and a stronger core. Being able to treat patients with a higher BMI up to 35 also opens up the treatment to a wider category of patients. As well, the reduction in diastasis recti helps our post-baby mums regain their body confidence and more easily return to their exercise regime. The treatment is also ‘hands free’ so our practitioners can focus on the conversation with the patient and optimising their treatment experience.

Why do your patients love the unique double effect of EMSCULPT NEO®? We are seeing positive results on an almost daily basis. As well as strong results

Advertorial BTL Aesthetics immediately post the fourth treatment, we are now seeing enhanced results at 90 days, with the fuller benefits of the fat cell apoptosis. Our clinical photography records the more apparent aesthetic improvements of fat reduction; however, our patients also report a greater sense of mobility and strength and are able to more easily return to exercise or take their training to a new level. We ask them to try a plank exercise and they typically report that they are able to hold this pose for longer. We regularly share our results on our social media channels, illustrating what kinds of results can typically be achieved across different body types, ages and lifestyles. As well as enhanced results, the radiofrequency energy provides a ‘pleasant distraction’ and a relaxing feeling of warmth. As this temperature is consistent, it helps to make the treatment even more comfortable throughout.

What do you think about being able to treat additional body areas with EMSCULPT NEO® and what does this versatility bring to your practice? Many patients who have already achieved strong results for the abdomen are then willing to try additional areas, as they have seen for themselves the results that can be achieved. These new areas also open the treatment to more male patients.

Is there anything further about EMSCULPT NEO® you wish to share? EMSCULPT NEO® is a game changer in regenerative and longevity medicine, helping our patients age in a more dynamic and positive way. In my experience, it improves both the physical and functional aspects of our patients’ lives.

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Figure 1: Patient before and after 4 treatments using EMSCULPT NEO®

Aesthetics | September 2021

51


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Dr. Victoria Manning BM DFFP MBCAM

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inflammatory reaction in a patient who has previously undergone a filler treatment, as detailed below. Post-filler injection complications vary and can be categorised based on their timing in relation to the filler injection as early events (occurring up to several days post-treatment) or delayed events (occurring weeks to years post-treatment).1,3,8,9 Delayed hypersensitivity reactions are characterised by induration, erythema, and oedema and are mediated by T lymphocytes rather than antibodies.2 They typically occur 48-72 hours after injection but may be seen as late as several weeks postinjection and can persist for months.3

Case Study: COVID-19 Vaccine Reaction Dr Victoria Manning and Dr Charlotte Woodward explain their management of a collagenstimulating dermal filler complication arising after the COVID-19 vaccine Delayed inflammatory reactions to soft tissue fillers are uncommon and usually self-limited, with frequent spontaneous resolution. However, considering the ongoing pandemic and the worldwide demand for vaccines against COVID-19, we as aesthetic providers should be conscious of the risks posed by the interaction of such vaccines in patients who previously had or are seeking dermal filler injections. In this case, we present a delayed reaction to polycaprolactone (PCL) soft tissue filler treatment of the cheek area following vaccination against SARS-Cov-2. The 55-year-old female who previously had her cheeks treated developed symptoms 48 hours after receiving her second AstraZeneca COVID-19 vaccine.

Filler complications and COVID-19 A wide range of dermal fillers are now available for use in facial aesthetics.1 All are potentially capable of causing complications,2,3 but fortunately, serious occurrences are rare. Careful attention to patient selection, education, and injection technique can minimise the incidence of complications, and an understanding of the early signs of complications and their proactive management can decrease their impact.4 Reactions caused by vaccinations to SARS-CoV-2 in patients with pre-existing filler is now a cause of concern. There are currently few published cases that demonstrate a delayed inflammatory reaction (DIR) following either the COVID-19 vaccination or COVID-19 infection.5 Specifically, with regard to the Moderna mRNA-1273 trial, there were a total of three reactions possibly related to dermal fillers out of 15,184 vaccine recipients. It is unknown how many subjects in the trial had previous treatment with dermal fillers.6 Over the past six months, River Aesthetics has had one case involving hyaluronic acid and one involving PCL. It is known that reactions can occur weeks, months or even years after receiving a soft tissue filler treatment when the immune system is challenged.1,2,3,7 Similarly, acute infection with COVID-19 can also profoundly stimulate the immune system and create a delayed

Vaccines The AstraZeneca vaccine works by delivering the genetic code of the SARS-CoV-2 spike protein to the body’s cells. Once inside the body, the spike protein is produced, causing the immune system to recognise it and initiate an immune response. This means that if the body later encounters the spike protein of the coronavirus, the immune system will recognise it and destroy it before causing infection.10,11 Vaccines safely deliver an immunogen (antigen able to elicit an immune response) to the immune system in order to train it to recognise the pathogen when it is encountered naturally by activating CD4+ helper T cells. This in turn stimulates B-cells to produce neutralising antibodies specific to the virus CD8+ cytotoxic T cells to recognise and kill cells infected by the virus.10 A type IV delayed hypersensitivity reaction occurs following a challenge, namely a vaccination in a sensitised individual. This is the only type of hypersensitivity reaction which is not mediated by antibodies and is instead dependent on the generation of T cells, specifically the TD cells, which contribute to the inflammation and the accompanying tissue damage by the generation and release of a variety of cytokines.12,13 It is known that the spike protein of SARSCoV-2 enters cells by binding and blockading the angiotensin 2 receptors (ACE2), thus creating a pro-inflammatory response and a proliferation of T cells. A study by Li et al. (2020) demonstrated that the skin has moderately high levels of ACE2 proteins in the basal layer of the epidermis and also lining the vasculature, which may provide the mechanism to why soft tissue fillers may react in an adverse manner.13,14 From studies on other vaccinations, it is known that the immune response from

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


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Figure 1: Patient marked up before treatment

Aesthetics

Figure 2: Patient 6 months after Ellansé treatment

administration to developing an antibody response that the first three weeks are pivotal, and this is when the immune system is most stimulated.15 Data from a study in Israel with a population of 500,000 has provided further evidence. Following the Pfizer vaccine, immunity within the first two weeks of administration remained almost at zero but then rose to about 90% at three weeks and then did not rise any further.15 Considering the above, current guidance from the Aesthetic Complications Expert (ACE) Group World inducates that practitioners should not be performing soft tissue filler treatments either two weeks before or three weeks after COVID-19 vaccination.5

Polycalprolactone properties The non-hyaluronic acid bioresorbable PCLbased filler has a proven safety profile, but rare potential complications such as nodules and granuloma can occur.16,17 Furthermore, PCL-based fillers cannot be immediately removed by injection of hyaluronidase as it is a polymer but is broken down into H2O and CO2 by cleavage of the ester bonds shortening the polymer over time. These potential drawbacks have yet to be described in the literature. The PCL-based filler is a collagen stimulator composed of PCL microspheres (30%) suspended in an aqueous carboxymethyl cellulose (CMC) gel carrier (70%),17 which provides an immediate but temporary filling effect. The PCL microspheres contribute to long-term volume by stimulating new collagen production.16 As the CMC gel is absorbed in the first six to eight weeks, the loss in volume from the carrier gel is gradually replaced by the newly formed collagen because of the PCL-induced neocollagenesis.16 In our clinical practice it is used in 60% of our patients due to its compatibility with threads (which we do a lot of) and its natural rejuvenating effects.

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Figure 3: Patient 72 hours post second COVID-19 vaccination

The PCL microspheres degrade into non-toxic, bioresorbable products that are metabolised into CO2 and H2O and excreted through normal pathways. The total bioresorption time of the product depends on the length of the PCL-polymer chain; in this regard, three product versions of Ellansé are available: S, M, L and which have bioresorption times of at least one, two, three years, respectively.18 At the time of writing, there were no documented cases of delayed onset nodules (DON) or delayed onset reations (DOR) with the non-replicating adenovirus vaccination that is used for the Oxford/ AstraZeneca COVID-19 vaccination and we were aware of three cases globally regarding DIR with the use of Ellansé.

Case study In the initial treatment, formal consents were signed and images were taken. Maintaining a sterile technique Ellansé M was diluted with 0.2ml of 2% Lidocaine for ease of injection and patient comfort. Skin was prepared with Clinisept+ and makeup and other potential skin contaminants removed before injection. The patient was marked out as per Figure 1. Local anaesthesia using 0.1ml of xylocaine and adrenaline were injected at

Figure 4: Patient five days into prednisalone treatment

the entry points. Using a retrograde fanning technique, 1ml of product was placed along the zygoma, in the subcutaneous plane, placing 0.05ml per pass using a 25 gauge cannula and 0.2ml was placed into the marionette line bilaterally. Treatment was uneventful. Both two week and three month reviews were satisfactory with no concerns. The patient had their first COVID-19 vaccination on 22/01/21 with the AstraZeneca vaccine with no adverse effects. She then received her second vaccination approximately three months later. Within 48 hours of her second dose, the patient developed a scratchy throat, progressive periorbital swelling and allergy symptoms. They took over-the-counter antihistamines and reported mild improvement. However, over the next 48 hours she developed hard masses in her face and worsening facial oedema. The patient contacted the clinic at this point and was advised to come in urgently for a face-to-face assessment (Figure 3). Patient examination When the patient presented to the clinic she was anxious and upset, but afebrile. Her blood pressure and pulse were normal, there were no signs of facial erythema or infection,

Reactions can occur weeks, months or even years after receiving a soft tissue filler treatment when the immune system is challenged

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


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The complication was thought to be immunological in nature, as all injected areas were affected

but she had marked periorbital oedema. Solid, non-fluctuant, non-tender masses along zygoma were palpated in areas of product placement and in the marionettes. The case was reported to the manufacturer Sinclair Pharma and the Medicines and Healthcare products Regulatory Agency (MHRA), and a management plan was discussed with the clinic team. Once a hypersensitivity reaction was suspected, the time of onset was established and the patient’s medical history was re-reviewed and a full medical examination was undertaken. Blood tests for inflammatory markers CRP, ESR, FBC and autoimmune profile were also arranged. Management plan The case was discussed with Sinclair Vigilance and ACE Group World guidance was considered.5 The complication was thought to be immunological in nature, as all injected areas were affected. In the event of infection, symptoms would be localised or restricted to a discrete area rather than global.19 Moreover, at presentation the patient was systemically well and had been asymptomatic in the injection area for eight months between the last treatment and reaction onset. The lumps reported were hard and non-fluctuant and atypical of infection.20,21 Therefore, there was no need for an empirical antibiotic treatment. Consensus opinion was to prescribe prednisolone at a dose of 1mg per kg of body weight, 60mg of for five days (Figure 4). Following a review on day five, the patient showed clinical signs of improvement, remained afebrile and all vital markers were normal, with less periorbital swelling, nodules shrinking, no erythema, and no evidence of infection. In view of improvement, the prednisolone course was extended for a further 10 days. The patient was reviewed on day 12 of 15 days of treatment, and the symptoms were

seen to be resolving. The autoimmune profile and CRP reported normal, and the only anomaly on FBC was slight neutrophilia. In view of the high dose and duration of treatment, a gradual diminution of the dose was carried out. During this time there was open communication with her GP to ensure holistic care, and following cessation of her prednisolone, the GP started her on fexofenadine 180mg daily as she had mild recurrence of itchy throat symptoms, but no further recurrence of oedema or nodule formation. Completion of care The patient was seen again in the clinic four weeks following her presentation, where she had made a full recovery with complete resolution of her swelling and nodules. Following her experience, the patient has not been put off further filler treatment, but we will wait and see how she progresses over the next few months. She was relieved she had been seen by qualified medical professionals who were able to recognise and manage this complication. This was both a stressful time for patient and practitioner. We have a duty of candour to our patients, which should be upheld at all times and throughout this process an open line of communication was kept with the patient. The patient was very anxious, so empathy and clear explanations were greatly appreciated. With regards to the potential for the need for booster COVID-19 vaccinations in the future, we have advised her to proceed with this, and to liaise with us immediately should there be any recurrence of symptoms.

Conclusion

procedure.19,22,23 As observed in the described cases, type IV hypersensitivity reactions are unresponsive to antihistamines and steroids are required to alleviate the inflammatory signs.24 The main limitation of this article is the absence of a histological analysis. Biopsies were not performed due to the patient’s desire to have minimally-invasive resolutions for their symptoms as quickly as possible. Due to the relatively new nature of the COVID-19 vaccines, there is not enough research into how they will react with aesthetic products, and many questions remain unanswered. There are still many studies needed to determine why some people experience complications related to the vaccine and some don’t, the effects of booster vaccinations, and whether patients who experience complications will be able to receive fillers again. It is essential that we are mindful of this risk, consent our patients appropriately, risk assess our patients, carefully time their treatments around their expected vaccination date and are knowledgeable on how and when to intervene if a complication does occur. Dr Victoria Manning is an aesthetic practitioner and GP, with more than 20 years’ clinical experience and is the co-founder of River Aesthetics in New Forest and Wimpole Street. She is a global threads trainer and is also an aesthetics industry media contributor, writer and speaker. Quals: BM, DFFP, MBCAM Dr Charlotte Woodward is an aesthetic practitioner and GP with more than 25 years’ experience. She is the co-founder of River Aesthetics in New Forest and Wimpole Street, which specialises in threadlifting and feminine rejuvenation. She was one of the first in the UK to offer nonsurgical breast lifting using PDO threads and is a national trainer. Quals: MBCHB, MRCGP, MBCAM

VIEW THE REFERENCES ONLINE! AESTHETICSJOURNAL.COM

Due to the current minimal evidence concerning COVID-19 vaccine and hypersensitivity, it is even more important that cases are reported. Delayed complications are particularly difficult to diagnose and treat due to the time lapse from the last

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


Advertorial Thermage FLX

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Considering Radiofrequency for a Younger Demographic Dr Kristy Lau presents her advice for treating patients in their twenties The demand for cosmetic enhancement amongst the younger population is growing. In fact, a recent study from Real Self suggested that 62% of 18-34-year-olds were thinking about having a non-surgical treatment within the next 12 months, compared to 28% of the 35+ age group. Close to half of millennials (44%) were also considering a surgical treatment as opposed to 14% of the over 35s.1 Dr Kristy Lau, aesthetic practitioner and medical director of Yuchi Medical, says, “Many patients now request simply to ‘freeze their skin age’ rather than changing anything and so now, more than ever before, prevention is absolutely better than cure.” She explains, “Collagen is the most abundant protein in the human body, found naturally in the bones, muscles, tendons, and in our skin. In our late 20s, our collagen production starts to decline by around 1% a year,2 due to both internal and external factors, such as smoking, UV light, and our diets. Alongside an effective skincare regimen and healthy lifestyle, radiofrequency treatments like Thermage® FLX can help to rebuild this lost collagen3 to result in healthier, more resilient skin that looks plump. What’s more, Thermage FLX® is also the only treatment available in the UK that has received the CE mark for treating the eye area with radiofrequency and has been cleared by the FDA in the US for the same indication – an area of the fact that often shows the signs of ageing first.” 58

Radiofrequency as a treatment for preventative ageing While, traditionally, ablative lasers were the primary mechanisms to improve skin laxity non-surgically, by injuring the epidermis and causing dermal collagen4 remodelling and second skin tightening, these treatments came with associated risks such as burns, scarring and dyspigmentation.5 Thermage FLX is the latest generation of monopolar radiofrequency system which offers an effective6 and well tolerated7 treatment for those wishing to pause the signs of ageing. “I think that Thermage FLX is an incredibly effective6 treatment. It relies on a fluctuating current of electricity to create heat which in turn is then delivered at specific temperatures to the tissues of the face. It’s this controlled heat that helps to stimulate the production of new collagen.3 Collagen is a natural protein in the body which gives our skin the firmness and elasticity that we associate with looking youthful,” explains Dr Lau. She adds, “The cost for Thermage FLX is arguably the same as purchasing expensive facial products where there is often limited or no clinical backing behind their effectiveness. This is a completely non-invasive treatment which needs to be carried out only once a year.6”

What is Thermage FLX? Thermage FLX is different to anything else available in the marketplace at the moment because it’s the only radiofrequency treatment Aesthetics | September 2021

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that requires a single treatment3 as opposed to a full course. Thermage FLX is also a noninvasive solution. The procedure offers significant clinical improvement with few potential side effects8 and little to no downtime,7 so patients can quickly return to their normal routine. In addition, Thermage FLX has demonstrated a good safety profile.7 The treatment can be used on all skin types9 and can be carried out all year round. Thermage FLX uses radiofrequency technology to heat the deeper, collagen-rich layers of the skin to offer a deep rejuvenation of tissues. 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. It can be used at different ages, in men and women. Dr Kristy Lau is the medical director at Yuchi Medical. Dr Kristy Lau completed her Bachelor of Medicine and Bachelor of Surgery and qualified as a doctor at Imperial College of London. She is registered with the General Medical Council and Royal College of General Practitioners. This advertorial was written and supplied by Thermage FLX

Find us on @ThermageEurope - www.thermage.co.uk ®/™ are trademarks of Bausch Health Companies Inc. or its affiliates. ©2021 Bausch Health Companies Inc. or its affiliates. THR.0029.EU.21

REFERENCES 1. Aesthetics Trends Report by Real Self 2018. 2. Ganceviciene R, Liakou AI, Theodoridis A, Makrantonaki E, Zouboulis CC. Skin anti-aging strategies. Dermatoendocrinol. 2012;4(3)308-319. 3. D Zelickson, et al. Histological and ultrastructural evaluation of the effects of a radiofrequency-based non-ablative dermal remodelling device: a pilot study. Arch Dermatol. 2004 Feb;140(2):204-9. 4. Atiyeh BS, Dibo SA. Nonsurgical nonablative treatment of aging skin: radiofrequency technologies between aggressive marketing and evidence-based efficacy. Aesthetic Plast Surg. 2009;33:283–294. 5. Prohaska J, Hohman MH. Laser Complications. 2021 Feb 17. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. 6. R. Fitzpatrick et al. Multicenter study of noninvasive radiofrequency for periorbital tissue tightening. Lasers Surg Med. 2003;33(4):232-42. 7. M. Fritz and al. Radiofrequency treatment for middle and lower face. Arch Facial Plast Surg. Nov-Dec 2004;6(6):370-3. 8. 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. 9. Dayan E, Burns AJ, Rohrich RJ, Theodorou S. The Use of Radiofrequency in Aesthetic Surgery. Plast Reconstr Surg Glob Open. 2020 Aug 17;8(8):e2861. Thermage FLX® is a medical device CE 0344 (DEKRA) Please read the Instructions for Use (IFU) for important product use and safety information with Medical Devices.


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A summary of the latest clinical studies Title: A Randomised Controlled Pilot Study of a Proprietary Combination Versus Sunscreen in Melasma Maintenance Authors: Chatterjee M, et al. Published: Indian Journal of Dermatology, Venerology and Leprology, August 2021 Keywords: Hypermelanosis, Melasma, Sunscreen Abstract: Melasma is the most common cause of facial hypermelanosis in skin types IV-VI. First-line treatment includes a triple combination containing topical corticosteroid and hydroquinone which have side effects with prolonged use. Sunscreen is a must to prevent relapses. The aim was to compare the effects of treatment with a proprietary combination (phenyl ethyl resorcinol, nonapeptide-1, aminoethyl phosphinic acid, antioxidants and sunscreen) versus sunscreen alone in reducing melasma and preventing recurrence after the initial use of triple combination. 46 subjects were recruited and randomised to 23 each in case and control groups. The study period was eight months with three phases. Phase one was the application of triple combination for eight weeks by both groups followed by phase two with the case group applying proprietary medicine and the control group applying sunscreen. Phase three was a follow-up period to see results in both groups as well as evidence of relapses. Sunscreen was applied in all phases. Case group in the study showed improvement in the melasma severity score and mean melanin index as measured by a mexameter but did not attain statistical significance compared to the control group. The melasma area and severity index score showed a consistent reduction in the case group, whereas it increased in the control group from baseline. Title: Comparison of Upper Blepharoplasty Skin Excision Using Scalpel Incision vs Microdissection Electrocautery Needle Tip vs Continuous Wave CO2 Laser Authors: Carqueville J, et al. Published: Dermatologic Surgery, August 2021 Keywords: Blepharoplasty, Needle, Skin Excision Abstract: The techniques of upper blepharoplasty have been compared based on time to perform, post-operative healing, scar cosmesis, and cost. Few studies have evaluated the histology of the excised tissue, and no study has compared the tissue histology of three blepharoplasty methods using scalpel, microdissection needle with electrocautery, and CO2 laser excision in the same patient. Upper blepharoplasty skin excisions were examined from specimens obtained using scalpel incision, microdissection needle tip with electrocautery, and CO2 continuous wave beam. Specimens were sent for permanent sections for evaluation. The skin that was removed using scalpel incision showed no cellular necrosis or heat artifact. The tissue treated with the CO2 laser demonstrated significant thermal injury, including loss of cellular polarity, keratinocyte necrosis, and separation of the epidermis from the basement membrane. The skin excised using the needle demonstrated fulguration artifact, including spindling of the epidermal nuclei with palisading of the keratinocytes. Necrosis was not prominent in the needle specimens. The histologic tissue injury was greatest in the skin treated with the CO2 laser, followed by the needle. The scalpel incision showed no cellular necrosis.

Title: Combination of Hyaluronic Acid Fillers and Personalised Skincare as a Tool in Aesthetic Medicine Authors: Barańska-Rybak W, et al. Published: Dermatologic Therapy, August 2021 Keywords: Antiageing, Hyaluronic Acid, Personalised Skincare Abstract: The most popular non-invasive rejuvenation method is hyaluronic acid filler injection. However, ageing of the skin involves pathological processes which can be managed using topical formulations with sophisticated active agents, addressing problems such as extracellular matrix degradation. A single trial was conducted to assess the efficacy of hyaluronic acid dermal filler injections combined with prepared, bespoke formulations on epidermis and dermis condition. 15 females participated in the study. Mid- and lower face were treated with Saypha hyaluronic acid fillers injection with volume chosen by the investigator, performed with 25G/50mm cannula. Formulations for topical skincare consisted of substances chosen from 19 active agents which were scientifically proven. Subjects were to use for six weeks. 14 subjects completed the study, and one was lost to follow-up. The age ranged from 36-58 years. amounts of Saypha Volume Plus, Saypha Volume and Saypha Filler used per subject were 2.8ml, 2.25ml and 1.7ml. The typical skin dysfunctions were loss of elasticity, hyperpigmentation, erythema and hyperseborrhea with enlarged pores. After completing the study all subjects were satisfied. Combined therapies based on HA fillers and personalised skincare show promising results in patients with skin problems due to ageing. Title: Experience of Excess Skin and Attitude to Body Contouring Surgery of a Chinese Post-Bariatric Population Authors: Jiang Z, et al. Published: Obesity Facts, August 2021 Keywords: Body Contouring, Excess Skin, Post-Bariatric Abstract: Western studies have explored post-bariatric patients concerning their views on excess skin and body contouring surgery (BCS), but Asian data was lacking. This study aims to investigate the experience of excess skin and attitude to BCS of a Chinese post-bariatric population. 210 Chinese patients who underwent bariatric surgery from March 2015 to September 2018 were studied using the Sahlgrenska Excess Skin Questionnaire and a study-specific questionnaire. Survey response rate was 61.4%. Most responders (78.2%) reported they had excess skin, and the common sites were the abdomen (70.2%) and upper arms (61.3%). Responders reported being bothered by impaired health-related quality of life, and the common problem was ‘the feeling of having unattractive body appearance.’ Many patients (37.9%) desired BCS, but ‘the impact of excess skin was not serious enough’ was why not undergoing BCS was chosen the most (28.1%), then ‘the cost is too high’ (20.2%) and ‘worrying about the risk of complications of BCS’ (18.4%). Younger age, female gender, higher weight loss, having full-time job, and earning higher income were independent factors increasing their desires for BCS. The abdomen and upper arms are the sites where patients are most seriously affected and most eager for BCS. The conservative attitude toward BCS and the cost without reimbursement are the main barriers.

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


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experience in writing skills, so I also included the possibility of this. As a result, the School of Medicine approved the clinic initially for elective placements and I had students spend six weeks with us over the summer. By preparing an engaging placement we were able to make it rewarding for both ourselves and the students.

Our structure

Hosting Undergraduate Medical Students Dr Uzma Qureshi explores the benefits of undergraduate placements for both the student and practitioner Clinical teaching and learning on the job with ‘real’ patients is at the core of medical education. Most healthcare professionals have been on placements and had the opportunity to experience a specialty to see if it ignites their passion for learning and future career aspirations. I have been teaching undergraduate medical students at Leeds University for 14 years in my role as a GP partner. Since 2018 I have also run a medical aesthetic clinic with my team consisting of a plastic surgeon, pharmacist and two therapists. Many of the students on GP placements show a keen interest in my aesthetics role, so it seemed a natural progression for me to consider how I could offer placements for them in my aesthetic clinic. By involving fifth-year medical students in aesthetics, it is hoped that we can raise awareness of this exciting speciality amongst medical schools and undergraduates who are early on in their career. A placement in aesthetics allows students to gain an understanding of the skillsets that are necessary to become competent professionals, better their knowledge of the types of procedures performed, and identify if this career path is for them.

Getting started While you may be interested in teaching students in your clinic, it can be difficult to know how to put this thought into action. To begin my journey, I contacted Leeds University School of Medicine and offered elective placements for any fifth-year students interested in aesthetics. In my initial email, I explained what aesthetic medicine involves and how it is evolving. This helped the School of Medicine understand this relatively new specialty, and why it’s so important to provide students with the opportunity to explore it. In particular, I highlighted that the specialty attracts a breadth of experts – GPs, surgeons, dermatologists, dentists and nurses – and emphasised the crossover of skills between traditional medicine and aesthetics. Universities want reassurance that its students will be in a safe environment, with educators that have the skills to teach and nurture,1 and are being taught skills that will help them meet the professional standards as set out in documents such as GMC Good Medical Practice.2 As such, the university tutors were signposted to the BCAM, BCAN and JCCP websites so that they could see that aesthetics is a growing and serious branch of medicine. I also listed the potential areas of learning that students could gain experience in, such as aesthetic consultations, skin conditions, minor surgery, and head and neck anatomy. I provided a sample timetable to give an overview of what the learning may involve. Opportunity for projects/audits such as writing up a case-based report for publication or auditing impact of treatments is attractive for students looking to gain some additional

Students interested in the placement submitted their CV and reason for wanting to spend time in aesthetics, and in total we had seven apply. After a telephone discussion to fully understand their motivation and what they hoped to gain from the placement, three students were chosen to attend from July to September. We limited numbers as this was the first time we had medical students attending. Preparation and setting out clear objectives were imperative for an engaging placement that was rewarding for both students and tutor. We planned a four-day per week placement over six weeks and planned to utilise a range of teaching methods, from direct patient consultations to tutorials, to keep the placement engaging.3 The students were allocated teaching with clinicians for two days per week, one day with the therapist and one day doing their own research, study, reception, and admin at the clinic. As adult learners, the students were involved in setting their own learning objectives and were expected to participate in patient consultations. Objectives set included: learning how to conduct an aesthetic consultation, building on facial anatomical knowledge, and understanding how to run a business. The placement involved a combination of teaching methods, but predominantly used ‘real patients’ where students progressed from observing to conducting consultations using an apprenticeship model.4 There were many opportunities to take aesthetic medical histories and understand the importance of eliciting a patient’s ideas, concerns, expectations, and motivations as it forms the basis of developing trust and a treatment plan that meets patients’ expectations – an aspect of aesthetic medicine that is important to get right. Fifth-year students are at the end of their undergraduate training and usually skilled enough to conduct solo consultations and present the case to the clinician in charge of the patient. Being involved in the

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


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assessment and treatment planning of the patient further involves them in that patient’s journey, helping them to learn about the nuances of treating patients in aesthetics. The students learnt about common skin conditions, the ageing process, and its anatomical basis, and how we address patient concerns. They were not allowed to inject toxin or fillers but were given the opportunity to learn about the different types of filler, types of toxin, how to reconstitute and assist in many surgical, injectable and therapist-led treatments. As part of the placement students were encouraged to write up a short case-based discussion around an interesting case study or conduct an audit for submission to the university. Topics chosen included a patient with scleroderma wanting dermal fillers for ‘smoker’s lines’, and an audit of the use of botulinum toxin for medical conditions within the clinic. The topics were chosen by the students where they had found an interesting case or an area that they wanted to explore. Writing reports such as these helps students to develop useful writing skills and provides them with a platform to be involved in scientific writing. Exposure to the business side of aesthetics was gained by participating in reception desk duties, being involved in invoicing, and being part of team meetings.

Feedback from students By the end of the placement student feedback was positive overall. We had comments like, ‘the opportunity to have a placement in aesthetics is sparse so it was really valued’, ‘I developed a more wellrounded understanding of the similarities and differences between aesthetics and other branches of medicine’, ‘I have a better understanding of the ethics involved’, and, ‘I am now more well-informed as to whether to embark on a career in this field’.

Benefits for your clinic Not only do aesthetic placements benefit medical students, but they can also benefit you/your clinic. Inevitably, teaching inquisitive, young minds leads to an improvement of your own knowledge, a need to keep updated and overall having to ‘raise your game’. Indeed, those that provide clinical teaching report greater job satisfaction and morale as teaching provides variety.5 These benefits extend to the wider team, including therapists, who can be involved in teaching as they are often a font

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of knowledge on areas such as energy-based devices. We found our placement students to be very keen and enthusiastic. They can offer a useful pair of extra hands in managing patients and as fifth-year students, they had the skills to take a thorough, detailed medical history from a patient so that when the clinician starts the consultation there is a lot of information to hand. In addition, having an affiliation with a University brings with it a certain kudos and stamp of approval. It’s a great advertisement to your patients that you and your team are knowledgeable enough to be teaching future healthcare professionals, in turn helping to build up patient trust in your clinic.

Considerations While having a student placement is extremely rewarding, there can be challenges when it comes to organisation. Teaching is time consuming and when you are trying to run a business, and time is money. In my experience, renumeration from universities will either be nil or minimal, so teaching undergraduates has to be done by those with a passion to pass on their skills and expertise. Time constraints and impact on finances can be managed by offering a limited number of placements e.g. one six-week block per year or offering a regular day per week but over a longer time frame. Knowing in advance when our students were spending time at the clinic enabled us to ensure they were timetabled in with the correct clinician/therapist to get the most out of their placement. Other capacity issues which may prevent teaching are concerns around being a singlehanded practitioner, however single-handed practitioners can offer a fantastic teaching experience as very rarely will students get one-to-one training. Remember every patient interaction or treatment can be a teaching opportunity – simply asking them to take the calls and deal with patient enquiries teaches students a myriad of communication skills. Many clinicians will have no specific training in teaching but should not be put off from exploring teaching opportunities as clinicians usually already possess a number of skills that make an effective teacher – approachable, knowledgeable, enthusiastic, good role model.6 Training modules in teaching are easily accessible from sites such as e-Learning For Health (free for NHS staff) and the Royal Colleges.7 These can provide an understanding of how adults learn, different teaching methods and how to adapt your

style. As well as the longstanding red-brick universities, remember there are also a number of newer schools of medicine that may be looking for innovative placement ideas. Teaching undergraduates doesn’t have to be limited to medical students as nursing, dental and other allied healthcare undergraduates could also benefit. Teaching healthcare undergraduates from different backgrounds is possible so long as you are able to understand and meet the teaching requirements of that group. Remember to also check with your insurer whether you require any amendments to your insurance e.g. employer’s liability.

Share your knowledge Having undergraduate students come to spend time in aesthetics clinics sends out the message that increasingly, science and evidence-based decisions underpins what we do in aesthetics. By reaching out to those starting out in their careers, we can hopefully encourage a desire for high standards, attract practitioners who want to strive for excellence and are patient centric, whilst at the same time adding a rewarding dimension to our day jobs. Ultimately, I felt that this was a small step towards improving the perception of aesthetic medicine to those on the outside and helping shape the minds of those already showing an interest in this field. Our team found the whole process enjoyable, and we are really looking forward to welcoming our next undergraduate student. Dr Uzma Qureshi is an NHS GP partner who runs a CQC registered medical aesthetics clinic with her pharmacist business partner. She has been teaching undergraduates for more than 15 years, has worked at Cambridge University and completed her basic surgical training in the North West and plastics training in Yorkshire before becoming a GP. Qual: MBChB, MRCGP, MRCS REFERENCES 1. GMC, Promoting excellence: standards for medical education and training -GMC, 2015, <https://www.gmc-uk.org/-/media/ documents/promoting-excellence-standards-for-medicaleducation-and-training-0715_pdf-61939165> 2. GMC, Good Medical Practice – duties of a doctor, <https://www. gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/goodmedical-practice> 3. Peter online, Washer, ‘Teaching medical students’, 2011 4. The apprenticeship model of clinical medical education: time for structural change The New Zealand Medical Journal, 2017 5. S Hartley 1 et al., ‘Influence on general practitioners of teaching undergraduates: qualitative study of London general practitioner teachers’, British Medical Journal, 1999 6. Shvaita Ralhan et al., ‘Effective teaching skills—how to become a better medical educator’British Medical Journal, 2012 7. ELH, E-learning for healthcare from NHS Health Education England, <https://www.e-lfh.org.uk/>

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


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Sawing logs is one thing, but in the world of medical aesthetics the consequences of professional burnout can be profound. If things do go wrong, they can have a substantial impact that could be expensive in both time and money. So, how can aesthetic practitioners ensure they have time to sharpen their metaphorical saws?

Getting sufficient sleep

Preventing Burnout Business consultant Stuart Rose shares advice on the importance of maintaining your own production capability and avoiding burnout You must be exhausted! Since restrictions lifted across parts of the country the pent-up demand, coupled with healthy bank balances through money left unspent on holidays, has seen the aesthetics specialty boom to unprecedented levels. This is great, right? Like many things in life, it’s a bit like the curate’s egg – good in parts. In terms of generating positive cash flow, employment, and a general buzz in the industry it is, without doubt, great news. But life is a marathon, not a sprint. The latter covers ground quickly but burns up energy and is never sustainable. What the industry has lived through after the lockdown has been a sprint, and the phenomenon known as pandemic burnout is on the increase.1 The World Health Organization (WHO) recently published research to show the impact that excess working hours have on our morbidity and mortality. Working 55 hours or more a week was associated with a 35% higher risk of stroke and 17% higher risk of dying from heart disease, compared with a working week of 35-40 hours.2 Businesses are built on people, and they can only function properly if those people can function. For that to happen we all need regular rest and recuperation which, as this article aims to convey, are mission-critical for sustainable business success and for our own personal health and wellbeing.

Sharpen the saw The concept of sharpening the saw was originally developed by Stephen Covey in his book The 7 Habits of Highly Effective People.3 He describes the seventh habit (Sharpen the saw) as the principle of balanced self-renewal. To remain productive, we need to nourish our production capability. So, what does this mean? Before we delve deeper let’s take a look at the analogy that Covey uses. A walker in the forest comes upon someone sawing a fallen tree trunk. At their feet is a great pile of logs but there are many more to be cut. The woodcutter is toiling away and sweating profusely, barely able to look up as the other individual approaches and asks what they are doing. “Sawing logs. Can’t you see!” answers the irritated woodcutter. “Why don’t you take a break for a few minutes and sharpen your saw. I’m sure it would be quicker and easier,” suggested the onlooker. “I don’t have time to sharpen my saw,” the woodcutter says emphatically, “I’m too busy sawing!” We can all see the way this plays out. The saw gets blunter, the cutter becomes more exhausted, and progress slows until either the saw, the woodcutter, or both, break.

Our brains are amazing. They comprise only 2% of our body weight yet consume 20% of our energy.4 Therefore, working hard for a long time consumes a lot of energy and generates a lot of waste metabolites. Sleep is the very best form of recuperation since it allows the brain to fully detoxify, and to transfer new knowledge and memories into the equivalent of the brain’s (energy efficient) hard drive, freeing-up the brain space for the energy-heavy tasks of new learning. A recent study by University College London and the University of Sydney showed how important rest and exercise are. Investigators found that those who did not sleep well, or exercise regularly, had a staggering 57% increased likelihood of premature death. Specifically, their risk of cardiovascular disease was 67% higher and cancers 45% higher.5 So, exercise and sleep fall squarely into no-brainer territory, but there are many other things that we can all do to keep ourselves in good physical and cognitive condition and avoid burnout.

Personal management Countless writings, lectures and business seminars have talked about time management. In his book, Covey inverts the paradigm3 and utilises a tool initially used to optimise military resources. He talks instead of personal management. Time carries on, regardless of what we try to do to it. So, better to accept this and focus on ourselves to make informed decisions about how we manage what we do in the time available. Understanding this concept has real applications in the world of professional development and managing burnout risk. It may help to apply some everyday situations to the four quadrants (Figure 1). Consider your clinic and how you would act in four scenarios. Scenario #1 A patient with nose blanching after nasolabial fold filler (Quadrant 1: important and urgent). This is a top priority and warrants immediate action. This is a real emergency and needs your time.

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


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Q1

Q2

Do

Delegate

Important

Urgent but not important

Urgency

and urgent

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kit could lead to terrible outcomes which end up consuming so much more of our time in the long run than addressing them, (whilst they sit within quadrant 2), in the short-term.

Your personal MoT

How we manage our cars is a good real-life example of self-management, Plan and do Abandon particularly with regard Important but Neither important to time and money nor urgent not urgent investments. Consider servicing and MoT. In the UK the average cost of a Figure 1: The Eisenhower matrix – the balance between urgency and importance and how to prioritise yourself3 full service for a mediumsized car is £205.7 For 8 Scenario #2 an MoT it’s £55. Do we spend the same Ensuring your emergency bag is properly amount of time and money on our own packed, ready to use and all drugs are in date health and wellbeing? Anecdotal research (Quadrant 2: important but not urgent). This provides an overwhelming ‘no.’ Unless may get overlooked, particularly when you somebody is part of a corporate health are really busy, since there is no emergency scheme where their employer prompts situation and no obvious stimulus. To do this and funds a full health check or the NHS we have to proactively plan the time and prompts us for periodic health screening, build it into our routine. When done properly it we tend to continue in our busy lives allows you to deal with the Q1 situation above focusing on the here and now and only calmly and effectively. addressing health when it becomes an important and urgent (Q1) issue. Scenario #3 The reality is that, if we actually spent Time-limited offer (in your email inbox) for the same £520 (half a day, once every discounted clinic stock from your distributor two years) on our health as we did on (Quadrant 3: urgent but not important). our cars then we would likely be able Every time we open our emails, we see that to maintain our production capability the time limit is approaching. It constantly better and, statistically, live longer. An attracts our attention and has a much higher annual health check is a classic Quadrant likelihood of getting addressed. In reality, 2 activity, but it requires us to plan it in, there will always be offers and this could be protect the time and make that investment. delegated to others. According to Jim Bruckbauer, Q2 activities of self-renewal are broadly split into four Scenario #4 categories:9 Updating the brand colours on your website (Quadrant 4: neither important nor urgent). 1. Physical: Exercise, sleep, nutrition, health The consequences of not addressing this are checks/screening virtually nil but because we are emotionally 2. Mental: Reading, thinking, planning, attached to such things, we often devote problem-solving, writing, painting/drawing substantial amounts of time. In reality, if the 3. Social/emotional: Relationships, colours remain unchanged the world keeps conversations turning! Covey’s observation is that those 4. Spiritual: Meditating, prayer, thought people who do make time for Q2 activities ultimately have fewer Q1 crises in their lives So what can you do? over time.6 They effectively rebalance how The first thing to recognise is that it is they spend their time and, because they have incredibly tempting to keep turning the delegated their Q3 activities and abandoned wheel, treating patients, and keeping that their Q4 ones, (until they really do have spare cash register full. So, the approach to time), they have become more effective in building in Q2 time is to be pragmatic and what they do. Not regularly checking the gradually evolve your way of working and whereabouts and contents of an emergency living. Try this simple step-by-step plan:

Q3

Q4

Step 1: Try to allocate your typical week into the four quadrants. You can do this with just post-it sheets on a wall and move things around until you’re happy that everything is in the correct quadrant. Then roughly allocate the amount of time you spend on each and add them all up. This way you will have an approximation of your typical working week and how much time you spend on each quadrant. Step 2: Once you’ve identified your Q4 tasks, (neither important nor urgent), try to simply stop doing them. The world won’t stop, and you will free up time. Step 3: Then see if you can delegate your Q3 (urgent, not important) tasks to another team member. If you run a small and lean practice this may not be practical, and these could become tasks which you decide you will no longer do or perhaps look to outsource. Step 4: Re-allocate some or all of the Q3 and Q4 time that you freed up into Q2 activities. Actually plan them in your calendar and make them sacrosanct. Some simple practices could be things like ensuring you take a break for lunch every day, even if it’s only half an hour. Schedule-in another break in the day, possibly at a time when you usually feel like you’re flagging a little. In that time, you could catch-up on this month’s edition of Aesthetics journal, plan some annual leave with your family, even just snooze for 10 minutes! It is all time well spent.

Food for thought Like so many of life’s most important things, properly looking after ourselves is not as easy as it seems. It does require effort, but maybe think about it this way. If, five years from now, you hadn’t sharpened your saw, would you wish that you had? Stuart Rose is an independent consultant with 35 years’ experience in pharmaceuticals in a variety of commercial and leadership roles. Latterly, he spent 13 years as managing director for Merz in the UK and Ireland and has created MiViVa Ltd to help private aesthetic practitioners create winning cultures and strategies.

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Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


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Installing Standards into Your Clinic Business consultant Taruna Chauhan outlines the benefits of implementing CQC standards within your clinic setting In 2019, 102 aesthetic clinics were registered with the Care Quality Commission (CQC) and this has since risen to 276.1 The increase in registrations is a good sign and I have personally found more and more clinics are thinking about applying. Aesthetic clinics in England undertaking a regulated activity such as thread lifts and hyperhidrosis treatments, if conducted under the regulated activity of disease, disorder, or injury, should be registered with the CQC.2 However, in clinics where registration isn’t a requirement, benchmarking against the CQC standards means your clinic can be aiming for the highest clinical standards and be ready when it does need to be registered, whilst equally being a great marketing tool if implemented correctly. This article outlines how CQC standards within England can be used in your clinic setting even if the clinic does not need to be registered with the organisation. Other organisations such as the Healthcare Improvement Scotland, Care Inspectorate Wales and The Regulation and Quality Improvement Authority in Ireland have their own care standards, but as I have worked with clinics mainly in England, I will focus on the CQC for this article.

SCREW The CQC assessment framework looks at the key lines of enquiry and how these are being met. These enquiries look at five areas and I like to use the pneumonic SCREW to remember these: Safe, Caring, Responsive, Effective, Well-led. When you complete a task or process, remembering SCREW will help gather relevant evidence and ensure you are aware of which criteria each process aligns with. 1. Safe: This looks at how you can keep your patients safe by recruiting staff with the correct knowledge and skills, but also ensuring they are given a thorough induction and have regular training and development. Do you have a good safeguarding process in place? How do you store and organise medicines? How do you ensure lessons are learnt when things go wrong? 2. Caring: This is more intangible. CQC want you to show how you treat patients with compassion and dignity, as well as how you involve them in decisions regarding treatments. How do your staff address patients? Do they speak to them in a kind, friendly manner?

3. Responsive: Are you a patientcentred organisation? Do you take into consideration the needs of different patients? Do you learn from concerns and complaints? Do you give patients the opportunity to book appointments in a variety of ways? 4. Effective: Do you monitor outcomes? Do you take consent for treatments? Are your staff equipped with the right skills and knowledge? 5. Well-led: The CQC will want to know you have a governance framework in place within your clinic. Is there a positive culture? Are there processes in place to ensure staff are developed and skills are up to date? Is there an emphasis on safety and the wellbeing of staff? Do you have a solid grievance procedure? As a clinic owner you should be covering some of these areas as a matter of course. It is also a good idea to have evidence of this because if/when you choose to exit your business any potential buyers will not only be interested in the data assets you have, but also in all areas as it gives them a rounded image of your clinic. Turnover and profit are important but the story behind them is gold. Building a reputation and having low staff turnover are also key. As you grow your business, run it as if you are going to sell it, which means you want it to be attractive to a buyer in all aspects of the business. So how can you implement these standards into your own clinic? Let’s go through each key line of enquiry – some of these you are likely doing already so I will focus on showing how it meets the CQC standards.

Safe I recommend clinics start at the beginning and look at recruitment. Are you using valuesbased recruitment, thereby attracting staff who have similar values to the organisation? This is important as it helps with employee retention and with the culture of the organisation. Once you have recruited the right person, you also want to ensure that you have a robust induction procedure in place. Clearly informing them of key policies which are usually required at operational level and checking competency of understanding is vital. Arming your staff with the information about the premises, for example fire exits, and your holiday leave is important, as it makes your staff aware of your whereabouts throughout the year. Ensure your staff are informed of what outcomes you expect from

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


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them during their induction or if there are any changes in their job role, then a meeting with the clinic owner should be arranged. How do you maintain good infection control? Do you have a sharps policy, and a good waste management process? Are you auditing for compliance? Hand hygiene should be audited regularly with posters being added to appropriate areas of the clinic. You can contact your local infection prevention control team who can offer an audit and forums to keep up to date with this topic.3 For cleaning, use the Health and Safety Executive (HSE) guidance and the national colour coding system for cleaning areas.4 These are red for sanitary areas, blue for general areas including waiting and consulting rooms, yellow for treatment and minor operations and green for kitchen food areas. There are kits you can buy to ensure your cleaning company is doing this; it is good practice and a benchmark for cleaning standards as this system is widely used in the NHS and assists with infection control. Check if they are a member of the British Institute of Cleaning Science (BICSc) as they should be following guidance and standard protocols if they are.5

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major, and a system to respond to these is imperative. Asking for feedback is a good way to see if you need to improve or change anything in your clinic. A patient may see things differently to you, therefore gaining an understanding of their viewpoint is important.

Effective Do you have processes and procedures in place which are followed consistently? Do you have a governance framework or standard operating procedures in place to check and audit that staff are following processes? This is particularly important when something goes wrong as you can usually pick out a step missed or a move away from the written process. Processes and procedures do not need to be tomes. They need to be clear, to the point and easy to understand. It is good to consistently check the competency of your staff and to have a training matrix within your clinic, so you are aware that all staff are up to date with relevant learning and CPD. In a busy environment, it is easy to forget mandatory training refresher courses, so schedule in some time to ensure this is completed.

Well-led Caring Showing dignity to your patients means being respectful of their culture and needs. Being kind and compassionate involves the language and tone used, and you can show evidence of this through the feedback you receive from your patients. Within the staff room, you could have a gratitude wall to highlight good feedback. This practice enables you to have a team that cares for each other, and this will be reflected in how they speak with patients too. I find it useful to look at the patient journey and how you personally would like to be spoken to, treated and feel whilst at the clinic.

Responsive Showing that you are responsive to your patient’s needs covers a couple of key areas. CQC want to know how accessible your booking system is. Are patients able to book in a manner which suits their needs? Are they able to book a time which suits them? Do you have evening and weekend slots? When situations arise, do you have a process in place to deal with it and how responsive are you in this situation? Ideally you want to be able to deal with the issue straight away. Everyone should have a complaints policy as errors will occur, often minor but sometimes

A collaborative approach is now seen as a better way of leading. The hierarchal way of working is slowly becoming less popular, with organisations moving towards working collaboratively at all levels. This ensures that everyone takes responsibility for the whole business, rather than one area. All staff should know what is expected of them in their role, and their outcomes. Performance should be managed well so that anyone within a role can take the lead at any given time. This also supports a team atmosphere where each member of staff gives back to their colleagues. I recommend asking staff to undertake psychometrics tests to see the makeup of your team and help with the communication, allowing you to recognise the key skills of your staff. There are many free ones which I use with my clients, including Via Character and 16Personalities.6,7 How well do you manage information? Are you meeting the General Data Protection Regulation? Are you registered with the Information Commissioner’s Office? Are your staff aware of cyber security and the importance of strong passwords and not sharing them? In an age where we rely on IT, cyber security is essential. The Exercise in a Box is an online tool which helps organisations find out how resilient

they are to cyber-attacks and practice their response in a safe environment.8 This is available on the National Cyber Security Centre website.9 By looking at how your organisation can meet the Healthcare Assessment Framework you will be benchmarking against robust criteria. Once you have gone through a cycle of quality assurance and audit, you should be looking at how you can continuously improve. Use the Deming Cycle which states you should Plan, Do, Check, Act.10

Try it yourself! It is important to remember that being CQC registered should not be seen as a tick box exercise. You really can use it to show continuous improvement within your clinic setting. By doing everything I have mentioned above, looking at the CQC key lines of enquiry and implementing them in your clinic, you will be ensuring that you are heading towards the CQC standards, meaning that if you wanted to start conducting a regulated activity, you will have the correct processes in place. By following the criteria, you will also be able to show to patients that you are benchmarking yourself against standards set by a regulatory body. Taruna Chauhan is the director of T Chauhan Consultancy. Her work involves supporting aesthetic businesses who undertake a regulated activity with the Care Quality Commission (CQC). Chauhan has worked within the health and care sectors for 20 years and worked in quality management for the NHS. REFERENCES 1. Care Quality Commission, The independent regulator of health and social care in England, (2021) <https://www.cqc.org.uk/ search/services/clinics/aesthetics%20clinics?location=&latitude=&longitude=&sort=default&la=&distance=15&mode=html> 2. Care Quality Commission, Key lines of Enquiry for healthcare services, <https://www.cqc.org.uk/guidance-providers/ healthcare/key-lines-enquiry-healthcare-services> 3. Infection Prevention Control, A General Practice IPC Resource Booklet, (2020) <https://www.infectionpreventioncontrol.co.uk/ resources/a-general-practice-ipc-resource-booklet/> 4. Nexon Hygiene, Colour Coded Cleaning Essentials, (2021) <https://www.nexonhygiene.co.uk/cleaning-c3/colour-codingessentials-c406> 5. British Institute of Cleaning Science, Our Training, (2020)<https:// www.bics.org.uk/> 6. VIA Institute on Character Survey, Take the Test <https://www. viacharacter.org/> 7. 16Personalities, Take The Test, (2011) <https:// www.16personalities.com/> 8. NI Cyber Security Centre, Exercise in a Box <https://www. nicybersecuritycentre.gov.uk/exercise-box> 9. National Cyber Security Centre, Small and Medium Sized Organisations <https://www.ncsc.gov.uk/section/information-for/ small-medium-sized-organisations> 10. The Deming Institute, PDCA Cycle <https://deming.org/explore/ pdsa/>

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


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Assessing Your Clinic’s Risk Accreditation and safety leader Thomas S. Terranova explains the importance of emergency preparedness plans and considering unexpected scenarios The response to the COVID-19 pandemic is a perfect example of the breadth of analysis required to anticipate emergencies. Although your chance of encountering some of the emergency situations mentioned in this article are likely very slim, the pandemic has highlighted that it is important to consider the possibilities of such events and have an allhazards emergency preparedness plan (EPP) in place. This article provides insights on EPPs to help businesses prepare for foreseeable contingencies and provide a mechanism to effectively adjust to surprises.

Importance of your emergency preparedness plan (EPP) An all-hazards EPP aims to address the resources and steps a business may need to take both before and after an emergency happens, such as infectious diseases, natural, and man-made disasters. To be effective, it is crucial to integrate EPP throughout operations in a cycle to assess risk, plan and test responses, examine deployments, and utilise lessons through training all staff on their respective roles in the EPP. It is easy to think of your clinic in isolation. However, it should instead be viewed as part of the community response, more importantly, many offices of emergency management consider all facilities to be part of a coordinated community effort. This is more than the average fire evacuation plan,

which concerns how fire would affect your facility and how to evacuate. Continuing from facility-centric risks, a solid plan builds outward; a water main break on your block, a citywide blackout, flooding in your area, or a massive natural disaster or pandemic. Even small businesses must understand their roles within the community, which requires coordinating with first responders, community leaders, hospitals, and other businesses.

Risk assessment Most are familiar with risk assessment for regionally relevant disasters, like flooding or heavy snowfall, which might be more prevalent in the northern areas of the UK.1 As mentioned in the recently published Intergovernmental Panel on Climate Change (IPCC) report by the United Nations, severe weather is changing the frequency, ferocity, and even type of disasters each region

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should consider.2 The same approach to risk assessment should apply to human-made disasters such as civil unrest, terrorist attacks, pandemics, and risks posed by equipment used in nearby businesses. To create your all-hazards EPP, you need to think creatively, beyond apparent and obvious risks like a fire in your clinic. Addressing each risk point-by-point according to the following areas creates a more complete emergency plan with appropriately diverse responses to risks. Note that this is not an exhaustive list, and not all responses or risks are identical; they depend on geography and community capabilities. For example, a nearby plant that uses volatile chemicals or dangerous equipment presents very specific risks, and you should consider the risks their operations present to you, your staff, and your patients. Safety and security Much like seismically active locations should investigate specialised equipment that protects from debris, in the UK it may be appropriate to evaluate protections against safety concerns around road and building collapses from extreme heat, for example earlier this year when roads melted in several areas of England.3 In times of civil unrest for example the London riots of 2011, plans for lockdowns involve securing people and information. Specific to COVID-19, EPP intersected with normal infection control practices to enhance protections. Facilities with isolation protocols could quickly apply these protocols to treat all patients as potentially exposed, screen staff and patients, limit visitors, and increase hand hygiene and mask protocols. Many increased existing turnover practices to allow terminal cleaning and air exchange to reduce transmission. They increased scrutiny on aerosolising cases. Facilities with quality protocols for sanitisation of high-touch items quickly broadened their focus by removing reading material, cleaning doorknobs, and elevator buttons outside care areas.

To create your all-hazards EPP, you need to think creatively, beyond apparent and obvious risks like a fire in your clinic

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


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Health and medical Healthcare providers specialising in same-day care can sometimes overlook the potential possibility of encountering chronic or acute medical conditions, such as diabetes, epilepsy, or heart attack. Of course, you should have a designated first-aid officer and it's quite likely you have personal experience working with medical emergencies in the NHS, but the possibility should be considered, and plans should be in place. Ensure in your consultation you are asking if a patient has chronic condition(s), make sure this is on file, and know how you and your staff might manage a situation should it occur. It is critical to overcome the sense that ‘no one stays in the clinic for very long, so we do not need to worry about it’. Power and electricity Consider what might happen to your business if there is a power cut? Flooding, extreme heat or snow may interrupt your clinic’s electricity, for example, which could cause a cut for hours. Consider what a lack of power means for your business and have a plan in place to follow should this happen. For example, what will this mean for your temperaturecontrolled medications? Will you be able to access patient records to contact patients and rearrange treatment times? If your data is not cloud based, then perhaps you will not be able to access all of your records. During the recent and unprecedented flooding in east London on July 25, damage was caused to Whipps Cross Hospital, resulting in a loss of power and a damaged electrical system. This issue could equally be applied to the aesthetic industry, as a random power cut during a treatment that relies on electricity such as laser or LED treatment. Communications and data Contingency plans for when communications fail are often overlooked because internet capable mobile phones are ubiquitous. However, extreme weather or industrial accidents can interrupt internet and phone service. Businesses that have a cloud-based data system should ensure alternative access for critical information during an interruption (e.g. emergency contact numbers). If mobile service is interrupted, consider alternative means of communicating with patients and staff, such as walkie talkies or a Tannoy system. Hazardous materials Many businesses are adept at handling hazardous materials daily and are fully aware of how to deal with such materials. However,

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additional precautions may be appropriate based on your clinic’s neighbours – research here is vital. Consider the 2020 fertiliser warehouse explosion in Beirut, where nearly 2,750 tonnes of improperly stored ammonium nitrate exploded.5 If a neighbouring business processes chemicals that could potentially compromise your safety should something go wrong, evaluate what you might need to do to keep you, your patients, and staff safe.

not precisely applicable, became a framework from which to proceed when the severity of the pandemic became obvious. In other cases, flu planning, a major source of EPP in much of the world, provided concepts that spring boarded businesses to how they are functioning now. The process of planning, as required by accreditation, proved quite useful in developing a response.

Integration with other businesses As the world continues to respond to COVID-19, facility-centric, locally executed, and government coordinated incident response remains essential. In the future, your business may need to join others to help when disaster strikes. There must be advanced communication between businesses and the local communities and government, including the capacity of your facility to participate. Central authorities will focus on major institutions, while local responders will coordinate equipment, space, and supplies with small facilities that can contribute to the collective effort.

EPP Guidance updates to RPP

Activate EPP Document, Analyse & Revise EPP

The process of a successful EPP

Reviewing your EPP In an emergency, you should follow your EPP. Throughout the emergency and after, you should evaluate your performance, revise its plan, and incorporate specific information into the plan for future use. You should see the changes you have implemented throughout. Discuss the execution of the EPP with leadership and document insights. Review, discussion, and evolution of an EPP is an integral part of the plan. You should analyse tabletop and live exercises to revise your EPP. Minimally, after action reports must examine the plan, conduct, successes, and failures. Such feedback not only promotes safety and protects lives but demonstrates your business has made all reasonable efforts to protect the wellbeing of your staff and patients, which can be protective in reducing liability, particularly during a prolonged emergency like the pandemic. Catastrophes will surely not fit the EPP exactly, but the act of planning gives your clinic a template from which to deviate in meaningful ways to respond appropriately. By several accounts, facilities worldwide that implemented EPPs to comply with accreditation requirements, never contemplated COVID-19 exactly; however, existing EPPs allowed them to adapt quicker and reopen more safely by applying principles and processes to the extant emergency. In some instances, businesses had EPPs for bioterrorism or infectious agents, which while

Expect the unexpected Not every contingency plan needs to be complex, but you should know the risks, incorporate guidance from authorities, and establish reasonable mitigation steps. By just considering that the unexpected can happen, brainstorming what risks you have and having some procedures in place for your staff to follow, you can really help manage the situation in the best possible way, should the unexpected happen. Tom Terranova is the executive Director at The American Association for Accreditation of Ambulatory Surgery Facilities, Inc (AAAASF). He received a BA in Political Science and Government from Loyola University Chicago, an MA in International Relations and Affairs from the University of Chicago, and a JD in International and Comparative Law from Loyola University Chicago School of Law. REFERENCES 1. Met Office, 10 of the Snowiest Places in the UK, <https://www. metoffice.gov.uk/weather/learn-about/weather/types-ofweather/snow/snowiest-places> 2. International Plant Protection Convention, AR6 Climate Change 2021: The Physical Science Basis, 2021 <https://www.ipcc.ch/ report/ar6/wg1/> 3. The Independent, UK Weather: British Roads Melt in Heatwave Ahead of’ Torrential Weekend Rain¸ 2021 <https://www. independent.co.uk/climate-change/news/british-roads-meltingheatwave-weather-b1888042.html> 4. BBC News, Whipps Cross Hospital Cancels Operations After Flooding, 2021 <https://www.bbc.co.uk/news/uk-englandlondon-57964769> 5. BBC News, Beirut Explosion: What We Know So Far, 2020 <https://www.bbc.co.uk/news/world-middle-east-53668493>

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


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“Education is crucial within this industry so invest appropriately” Aesthetic trainer and Merz Innovation Partner Dr Chris Hutton discusses his career and the importance of education and training within aesthetics Dr Chris Hutton has always had a keen interest in education. He was born in Derry city, Northern Ireland, but after completing his medical degree in 2009 at Queen’s University, Belfast, he decided to continue living in the city and has stayed for the past 17 years. He reflects, “Although I studied medicine at university, I have always had an interest in the arts, particularly visual art. Obviously, art is a big part of aesthetic practice, and I thought the mix of science and art was a marriage made in heaven for me!” He began working within the aesthetics specialty in 2011. “I joined foundation courses initially and progressed from there. I started injecting on a small-scale, and my interest in the industry and passion grew,” he says. Dr Hutton then undertook postgraduate training in aesthetic medicine at Queen Mary University of London. “My education at Queen Mary allowed me to consolidate my knowledge and understanding, while furthering my technical skills within aesthetics and I believe that I got the most use out of my training from here. I personally think some university level education in aesthetic medicine would benefit all,” notes Dr Hutton. In 2013, he opened his own clinic in Belfast, Array Aesthetics, which specialises in aesthetic treatments. Dr Hutton explains, “Leaving the NHS was a scary time! Medical training felt like a conveyor belt to me at times and I just didn’t want to do it anymore... I felt the time was right to take the leap into my aesthetics career. The first two years of starting Array Aesthetics were the most difficult – trying to balance learning and developing technical skills, along with the business elements was a challenge but I was enjoying it.” Dr Hutton now offers bespoke training courses for medical professionals through his training academy, Array Academy. “Recently, the academy has celebrated training 1,000 delegates within four years, which I am extremely proud of,” he says. In July 2021, Dr Hutton became a Merz Innovation Partner, alongside aesthetic practitioner Dr Dev Patel and dermatologist 72

and hair restoration surgeon Mr Max Malik, as part of the company’s new educational team. He comments, “I have been using the Merz portfolio of injectable products since I first began practising almost 10 years ago. I have a really good sense of how they work, and after doing around 10,000 treatments I really should do! Being invited to become an Innovation Partner with Merz is something I’m very proud of and is definitely up there as one of my proudest achievements within medical aesthetics so far.” His role as an Innovation Partner is to educate fellow medical professionals on the use of the Merz portfolio, specifically the BELOTERO® dermal filler range and he will be doing training events online and face-to-face very soon. He adds, “I believe there are genuine, definitive advantages to using the Merz portfolio of products over other brands which I am really passionate about and want to convey to other aesthetic practitioners.” Finding a work-life balance can be a challenge for Dr Hutton and being a father of four with triplets can have its challenges. He adds, “My triplets are two years old, and I have another daughter who is three so there is a lot of balancing between performing treatments, teaching at the training academy and having time for family life. My wife is a doctor and is heavily involved in the business, so this allows us to both be able to take control and have time for aesthetics and family.” After working in aesthetics for more than 10 years, Dr Hutton continues to enhance his own knowledge as he notes that the industry is evolving rapidly every year. He says, “Within this industry you need to keep up to date. A treatment which was accepted practice one month ago might not be in the next. You only need to look at the increasing popularity in the use of ultrasound, for example, to see this. As such, I plan to further my own understanding of this topic to help maximise patient safety.” Similarly, Dr Hutton says arterial mapping of the face was not commonly used six months ago and is now becoming more popular in standard practice, which he thinks should Aesthetics | September 2021

increase as time goes on. He adds, “Arterial occlusion with dermal filler is every injector’s greatest fear. One thing I have learnt about the face is that you can never be certain where exactly the arteries lie. It’s not always like the textbooks! Having a means to map out where they are pre-treatment in each individual is only going to increase patient safety. This should be the top priority for anyone injecting filler. As technology inevitably improves and awareness grows amongst the injecting community, then so will the use of facial ultrasound. I am certain of this.”

My favourite treatment to perform…

I enjoy performing full facial rejuvenation treatments. I find it satisfying to see the results on patients who are noticing signs of ageing and want to improve their appearance. It can be a great confidence booster.

Best piece of career advice given to you…

Consultant plastic, reconstructive and aesthetic surgeon Mr Dalvi Humzah once told me to concentrate on being good at it while keeping my patients safe. Everything else will fall into place!

My industry pet hate…

Aesthetic training activities in locations such as hotels should not be happening. To be taken seriously by the medical community at large and to keep patients safe, we should only be performing treatments in clinical settings.

This article is sponsored by Merz Aesthetics UK and Ireland

M-MA-UKI-1542 – Date of Preparation: August 2021


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In The Life Of Sharon Bennett

The BACN chair and clinic owner gives us an insight into her busy working schedule My morning begins with…

Finding time for other work commitments…

A cup of Yorkshire tea! It’s my first drink of the day and it sets me up for a busy schedule. I’m not a morning person at all, as I tend to go to sleep late in the evenings. My alarm is usually set for 7:45am and once I’m awake I like to spend 20 minutes sitting in bed and catching up on emails, messages, social media, and reply to anything before I get up. If I have time, I will make poached eggs or oats, but if not, I will eat some fruit in the car on the way to the clinic. My first patient is generally booked in for 10am and I usually get to the clinic for five to 10! It’s a 30-minute drive from my home to my clinic Harrogate Aesthetics, and I should leave earlier, anticipating a tractor or roadworks, but I don’t! Before I arrive, my staff will get the patient notes ready (which I will have looked at the night before) and the room prepped. I’m able to get changed and start treating patients as soon as I walk through the door.

My working day focuses on facial treatments… At the clinic, we have five staff members and a medical facialist who performs all the machine-based treatments including HIFU, radiofrequency and skin peels. I mainly perform dermal fillers and botulinum toxin treatments throughout my day. I tend to dedicate an hour to full-face dermal filler treatments and 30 minutes to toxin patients. We can perform toxin treatments quicker, but I believe your patients deserve your time and treatments should not be rushed, so I like to spend longer to deliver the best possible care. I usually have five minutes at the end of each treatment to update medical records and not rush into treating the next patient. I tend to have a 30-minute lunch break slotted in the day but if it is very busy I’m happy to squeeze in patients during this time. On average, I will treat around 12 patients a day and usually finish at 6pm. Tuesdays and Wednesdays are my late nights when I work until 8pm, which allows me to see patients who cannot get to me during the day. As well as seeing patients at my

Harrogate clinic, I also treat in London and will get the train down the night before, complete a day’s work and then travel back late in the evening.

Favourite treatment to perform… Full face dermal filler rejuvenation. I love seeing the transformation from a tired, sagging face into a brighter and more sculpted appearance!

In my spare time… I love cooking! My favourite chef is Yotam Ottolenghi, who cooks Middle Eastern food. His recipes are so vibrant, healthy, and delicious.

Anything I would change about my working routine… I would reduce my hours in clinic to give myself more personal time. I hope to establish a better work/life balance in the future but when you enjoy your job, it's difficult to do.!

I teach for Galderma which involves training on advanced injectables and am a member of many nurse faculties. I have recently become the lead for the nurse Clinical Advisory Group for Prollenium. I also sit on the Joint Council for Cosmetic Practitioners (JCCP) Clinical Advisory Group, and work with, and represent nurses, on the British Standards Institute (BSI) Committee on their aesthetic standards which is ongoing work. I’m chair of the British Association of Cosmetic Nurses (BACN) and we have general and work meetings on Mondays. I talk to my colleagues on the way to the clinic and handle messages and emails from members which the administrative team are unable to answer, due to them being too technical or medical. I dovetail BACN into evenings and weekends. Larger work pieces, such as the new Code of Conduct which was recently published, or writing responses to the JCCP, usually take more time and I need to shut myself away for a few hours in the evening and not be interrupted. I tend to work until 12:30am when it is the quietest in the house.

Memorable days in my career… Looking back, bringing Restylane into the UK is up there. It’s 25 years ago exactly and we’ve just filmed the Restylane anniversary campaign video. Winning the Aesthetics Award for Aesthetic Nurse Practitioner of the Year and the Outstanding Achievement in Medical Aesthetics was also amazing. I was greatly honoured, especially as many other practitioners were worthy of it, but it was so memorable and exciting! The BACN reaching 1,000 members in April was also a wonderful moment. With the organisation being in a difficult position last year due to the pandemic, reaching this landmark was such an achievement. The staff worked so hard and to have achieved this from September onwards was great. We really hope to keep progressing in numbers in the future and I can’t wait to see what lies ahead next for the BACN! Finally, every day I have a patient who is happy with my work is memorable at that moment in time. It’s what makes me carry on!

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


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The Last Word Dr Arreni Somasegaran debates whether free injectable treatments should be provided to bloggers and influencers for marketing purposes Have you ever bought a sofa or made a dinner reservation at a London hotspot on the recommendation of someone you follow on social media? If that’s the case then like many, you have been subject to influencer marketing. Influencer marketing is a type of marketing strategy which involves a brand collaborating with an online influencer to market a product or service. These influencers are considered experts by the public within their niche and have a dedicated following. But is it appropriate for us to be giving away injectable treatments in exchange for coverage?

The rise of influencers Use of social media has grown exponentially and is a major source for news, information and advertising. On average people spend almost three hours every day on social media1 and with medical aesthetics being a visual business, it’s no surprise platforms such as Instagram and Facebook are seen to provide a massive reach to consumers. Unsurprisingly, clinics and clinicians want to make use of the screen space to target potential customers as demand for medical aesthetics grows. In general, gifting products or services to bloggers can elicit a great response at very little expense. This type of marketing tool is becoming more popular in the aesthetics field, where collaborating with a micro-influencer (someone who has between 1,000-100,000 followers) could bring more

patients and brand awareness. Although it presents great opportunities for us professional and ethical practitioners, it can also be the source of many challenges.

Potential concerns As medical professionals, we should be wary of gifting certain services to influencers. Whilst I am more than happy for a blogger to share their experience, providing them with a complimentary injectable treatment in exchange for a feature doesn’t sit right with me. I think we clinicians should think long and hard before considering adding influencer gifting to our social media strategy. In the UK, a growing proportion of children join various forms of social media by the age of 12.2 This younger audience are highly impressionable, and I believe it is dangerous to normalise cosmetic procedures such as botulinum toxin and dermal fillers amongst this age group. Although the UK’s advertising regulator – the Advertising Standards Authority (ASA) – enforces that influencers ensure promoting a brand, product or service is made clear to the audience,3 sometimes things slip through the net. Giving away these treatments to bloggers, especially if they are not disclosed clearly, can make these procedures appear too easily accessible and necessary. This is far from the truth, as we know these procedures are not cheap and not always needed, resulting in younger patients seeking treatments with inexperienced and unprofessional injectors. This is concerning as cosmetic procedures

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carry risks making complications more likely to arise when patients are in the wrong hands. I feel it is our responsibility to protect all patients, especially those who may not be positioned to make an informed decision. The relationship between an influencer and their audience is highly trust dependent and being transparent is in everyone’s interest. Followers are clued up nowadays and if they interpret an influencer as being dishonest or misleading about a cosmetic procedure, this can be damaging to your business by way of association. If you choose to gift treatments, I strongly advise you to ensure the influencer is upfront with their followers and abides by the ASA’s influencer guide.3 When approached by an influencer, or if you’re considering working with an influencer, you should be cautious of whether they're controversial or have had any recent controversies, as this can have damaging consequences to your brand and reputation.

Take care with your marketing Influencer marketing is a powerful tactic in various industries; however, in an unregulated industry such as aesthetics, there is an onus on professionals to use social media as a platform to educate and empower our audience. It is imperative to promote safety in aesthetics and overall encourage body confidence. I believe when giving away cosmetic procedures to influencers you should consider the points made above and ensure it is done conscientiously. Alternatively, giving away less invasive treatments such as facials and peels may be a safer and sensible choice rather than injectables. Overall, there are many positives to working with a blogger or influencer, but the key is to ensure we use influencer marketing responsibly. Dr Arreni Somasegaran graduated from the University of Birmingham as a dental surgeon in 2015. Since then, she has followed her true passion in advanced non-surgical aesthetic treatments. She works at Define Clinic, Beaconsfield, alongside Dr Benji Dhillon, the founder and director. She specialises in a ‘whole face approach’ and is focused on helping her patients obtain a balanced and refreshed look. Quals: BDS (Birm) REFERENCES 1. Statista, Daily social media usage worldwide 2012-2020, <https://www.statista.com/statistics/433871/daily-social-mediausage-worldwide/> 2. Statista, Social media usage in the United Kingdom (UK) – statistics & facts, <https://www.statista.com/topics/3236/socialmedia-usage-in-the-uk/> 3. ASA, Influencers Guide, <https://www.asa.org.uk/resource/ influencers-guide.html>

Reproduced from Aesthetics | Volume 8/Issue 10 - September 2021


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