SEPTEMBER 2022: The Skin Health Issue

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S ! C R T I OW TE HE N EN ST 23 AE 20 E DS TH AR AW

VOLUME 9/ISSUE 10 - SEPTEMBER 2022

A DVA N C E D LE A R N I N G A N D C LI N I C A L TR A I N I N G “There’s never been anything like this in the industry before” DR ESHO

F O R H E A LT H C A R E P R O F E S S I O N A L S O N LY Developed and funded by Merz Aesthetics UK & Ireland. This contains promotional information. M-MA-UKI-2281 Date of preparation August 2022.

Managing Psoriasis CPD

Dr Lola Meghoma discusses treatments for psoriasis and their efficacy

Treating Skin Lesions

Dr Keli Thorsteinsson outlines how to treat skin lesions safely and effectively

Understanding the Microbiome Piroska Cavell investigates the relationship between the gut and skin health

Integrating Psychology into Business

Kimberley Cairns explains psychological business models


One Treatment. Endless Options. HydraFacial is for everyone. It’s suitable for all skin types and addresses all skincare needs. The HydraFacial delivers immediate, noticeable results, with no downtime, that keep your customers returning regularly. HydraFacial is your connection to millions of believers that know that beauty is more than a physical attribute – it’s a feeling. Our customers’ want to give their clients the best experience possible. The HydraFacial Company helps them deliver it.

give your customers what they want! Simplification

Personalisation

Recommendation

Multi-benefit solutions that save time1

Treatments tailored to specific skin concerns2

Skin health technology and regimen education1

Consumers want to be pro-actively offered personalised solutions for skin health and provide them with education on their ideal, easy-to-follow skin health regimen1. And your clients needs are as individual as they are, which is why HydraFacial has partnered with the best brands in aesthetics to bring you advanced booster options that meet the emerging consumer trends that are influencing our industry more than ever before.

HydraFacial is scored as a ‘99% Worth It’ rating by www.realself.com and on average, somewhere in the world, a HydraFacial treatment is now carried out every 10 seconds! 1 EddieWouldGrow Facial Research 2018, n=2000;

2

Mintel Trends 2017


How we deliver Personalisation... Boosters to Target Skin Concerns HydraFacial delivers personalised skin health through boosters that are designed to: • Smooth and Refine • Restore and Firm • Brighten • Hydrate • Calm • Revitalise Lips & Eyes

Tips Tailored FOR Skin Type Only HydraFacial uses a unique, patented Vortex-Fusion delivery system to exfoliate, extract and hydrate skin. The spiral design of HydroPeel® Tips, used in conjunction with the HydraFacial proprietary vacuum technology and serums, creates a vortex effect to easily dislodge and remove impurities while simultaneously delivering hydrating skin solutions. • Convenient, single use, saves time; eliminates the need for sterilisation equipment • Range of exfoliation levels allows for custom treatment results • Spiral design delivers painless extractions

INTRODUCING KERAVIVE SCALP HEALTH Expand into a new category with HydraFacial Keravive scalp heath treatment that leads to fuller looking hair. HydraFacial Keravive is a first of its kind 3-step treatment that includes an in-clinic component, as well as a 30-day take-home spray.

W: hydrafacial.co.uk E: infoUK@hydrafacial.com T: 01788 572 007 To see the HydraFacial in action follow us @hydrafacialuk


CELLUMA AT CCR 13-14 OCTOBER 2022 STAND #B20

“I use Celluma LED in my clinical practice on a daily basis. In addition to the skin benefits, Celluma has been incredibly beneficial to my clients for joint and muscular conditions. The Celluma rental part of my business has proved popular for both skin and musculoskeletal concerns.” Alison Fulford Independent Nurse Prescriber Harbourside Aesthetic Clinic (Poole, UK) PAIN ACNE ANTI-AGEING WOUND HEALING MEDICAL CE MARK FDA-CLEARED

13 CLINICALLY PROVEN LED DEVICES


Contents • September 2022 08 News

The latest product and industry news

16 News Special: Tackling Body Image Advertising

Aesthetics explores MPs’ report on body image and mental health concerns

19 Producing Revanesse Fillers

Aesthetics visits Prollenium HQ in Canada to learn about Revanesse fillers

20 Shaping the Future of the Aesthetics Industry

CCR dedicates two days to the development of medical aesthetic practice

CLINICAL PRACTICE 23 Case Study: Concertina Lines Miss Rachna Murthy explores her treatment of fine lines on the face

News Special: Tackling Body Image Advertising Page 16

25 Special Feature: Optimising Skin Health Practitioners discuss using chemical peels to enhance skin quality

34 Case Study: Treating the Mid-Face and Perioral Area Susan Young reveals her treatment tips for the mid-face and perioral regions

37 CPD: Managing Psoriasis Dr Lola Meghoma outlines treatments for psoriasis and their efficacy

45 Treating Skin Lesions Dr Keli Thorsteinsson explains how to treat skin lesions safely

48 Dermal Fillers for Male Patients

Dr Kishan Raichura discusses popular non-surgical treatments for male patients

52 Treating Folliculitis

Dr Thuvarahan Amuthalingam talks treatment of folliculitis in SOC patients

Special Feature: Optimising Skin Health Page 25

54 A Revolution in Lip Treatment

Introducing the latest addition to the Revanesse portfolio, Outline

56 Techniques for Filler Dissolving

Alex Henderson outlines techniques for effective use of hyaluronidase

59 The Pioneers of Skin Health

Discover the history of skincare brand SkinCeuticals since 1997

61 Treating Female Hair Loss with APRP

Practitioners explore combining APRP and adipose tissue to treat hair loss

64 Understanding the Microbiome

Piroska Cavell investigates the relationship between the gut and skin health

66 Injecting with Cannulas

Mrs Sabrina Shah-Desai offers tips for cannula use

67 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 68 Increasing Pricing in Your Clinic

Richard Crawford-Small encourages considering a pricing increase

71 Entering a Mentorship Scheme

Dr Emma Arjemandfar looks at the benefits and challenges of joining a mentorship scheme

73 Integrating Psychology into Business

Kimberley Cairns explains psychological business models for clinics

77 In The Life Of Dr Wassim Taktouk

Dr Wassim Taktouk provides insight into his day as well as his KOL role

78 The Last Word: Scottish Regulation

Frances Turner Traill debates proposed new Scottish aesthetic regulation

80 Introducing Evolus

Evolve the future of beauty with Evolus

Clinical Contributors Dr Lola Meghoma is an internal medicine trainee at East Surrey Hospital, after studying at the University of Liverpool. She is passionate about dermatology, and will be starting as a clinical fellow in dermatology at Whittington Hospital. Dr Keli Thorsteinsson is an NHS dermatology doctor and a cosmetic practitioner. He is the co-owner and director of Freyja Medical clinic in Wrexham and Nantwich. He also co-runs Clinic Courses training academy. Dr Thuvarahan Amuthalingam is an NHS GP with interests in dermatology, minor surgery and aesthetics. He is the founder of Dr.Derme Skin and aesthetic clinics in Harley Street, Solihull, Birmingham and Manchester, and is a Derma Medical trainer. Alex Henderson is an independent nurse prescriber with 12 years’ experience. She has opened two clinics in the Southwest of England and a third on Harley Street. Henderson has trained practitioners on fillers, toxins and PDO threads. Dr Aamer Khan has been an aesthetic practitioner for the past 15 years from the University of Birmingham in 1986, and specialises in non-invasive treatments of the face and neck. He is the co-founder of The Harley Street Skin Clinic. Dr Sadequr Rahman is a GP and aesthetic practitioner with clinics in Harley Street and Newport. He has discussed aesthetic procedures on television and written about stress and burnout in his book Superdoc, and regularly mentors new practitioners. Piroska Cavell is a qualified nurse prescriber who specialises in weight management and obesity. She retrained in aesthetics in 2015 and went on to open her holistically focused Aesthetics clinic, Clinic Sese, in Whitstable in 2019.


Letybo�

go go go

Botulinum toxin type A

new ways Letybo® brings practitioners a new option to the current aesthetic market and provides aesthetic professionals and their patients with a notable efficacy and confirmed tolerability.1,2,* 94% response rate 4 weeks post injection1,**

Proven consistent efficacy and tolerability with repeated injections for up to 12 months 1,2

Demonstrated high patient satisfaction2

Letybo 50 units powder for solution for injection; Abbreviated Prescribing Information: Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: One vial contains 50 units botulinum toxin type A produced by Clostridium botulinum. After reconstitution each 0.1 mL of the solution contains 4 units. Indication: For the temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows in adults <75 years old seen at maximum frown (glabellar lines), when the severity of the facial lines has an important psychological impact. Dosage and administration: Should only be administered by physicians with expertise in this treatment. Posology: The recommended dose is a total of 20 units divided into five injections of 4 units (0.1 mL) each: 2 injections in each corrugator supercilii muscle and 1 injection in the procerus muscle. Botulinum toxin units are not interchangeable from one product to another. Doses recommended are different from other botulinum toxin preparations. Treatment interval should not be more frequent than every three months. In the absence of any undesirable effects secondary to the previous treatment session, a further treatment session with at least a three-month interval between the treatment sessions is possible. The efficacy and safety of repeat injections beyond 12 months has not been evaluated. Special populations: No specific dose adjustment is required for use in the elderly older than 65 years of age. Letybo is contraindicated in patients 75 years or older. There is no relevant use in the paediatric population. Method of administration: Intramuscular use. Care should be taken to ensure that Letybo is not injected into a blood vessel. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome, amyotrophic lateral sclerosis). Presence of acute infection or inflammation at the proposed injection sites. Patients with bleeding disorders. Warnings and Precautions: Injection into vulnerable anatomic structures must be avoided. Avoid use when the muscle shows excessive weakness or atrophy. Risk of eyelid ptosis following treatment. Procedure-related events: Needle-related pain and/or anxiety have resulted in vasovagal responses, including transient symptomatic hypotension and syncope after treatment with other botulinum toxins. Pre-existing neuromuscular disorders: Patients with unrecognised neuromuscular disorders may be at increased risk of clinically significant systemic effects including severe dysphagia and respiratory compromise from typical doses of botulinum toxin type A. Hypersensitivity reactions: An anaphylactic reaction may occur after injection of botulinum toxin. Epinephrine (adrenaline) or any other anti-anaphylactic measures should therefore be available. Local or distant spread of toxin effects: Adverse reactions possibly related to the spread of toxin distant from the site of administration have been reported. Patients may experience exaggerated muscle weakness. Swallowing and breathing difficulties are serious and can result in death. Use not recommended in patients with a history of dysphagia and aspiration. Patients should be advised to seek immediate medical care if swallowing, speech or respiratory disorders arise. Pregnancy & Lactation: Not recommended during pregnancy or lactation and in women of childbearing potential not using contraception. Undesirable effects: Most common effects are headache and injection site reaction. Very rarely aspirational pneumonia. For full list of side effects, consult SmPC. Legal Category: POM; Pack size: Packs containing 1 5ml vial. Multipack containing 2 (2 packs of 1) vials; Price list: UK - 1x5ml: 65GBP, 2x5ml: 120GBP; MA Number: PL 29863/0002; PA Number: PA0846/001/001; MA Holder: Croma-Pharma GmbH, Industriezeile 6, 2100 Leobendorf, Austria; Date of preparation: 11/04/2022; Unique ID no CRP001/001; Adverse events should be reported. Reporting forms and information can be found at: UK - http://yellowcard.mhra.gov.uk/ or search for MHRA Yellow Card in the Google Play or Apple App Store. IE - HPRA Pharmacovigilance Website: www.hpra.ie. Adverse events should also be reported to Croma Pharma GmbH on 0118 206 6513

ADLET0622UKf Date of preparation: June 2022

* Letybo® is indicated for the temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows in adults <75 years old seen at maximum frown (glabellar lines), when the severity of the facial lines has an important psychological impact. **Response rate was defined as a ≥ 1-point reduction in FWS at maximum frown based on the investigators assessment. References: 1. Mueller DS, Prinz V, Adelglass J, Cox SE, Gold M, Kaufman-Janette J et al. Efficacy and Safety of Letibotulinum Toxin A in the Treatment of Glabellar Lines: A Randomized, Double-blind, Multicenter, Placebo-controlled Phase 3 Study. Aesthet Surg J. 2022; Jan 29: sjac019. doi: 10.1093/asj/sjac019. Epub ahead of print. PMID: 35092418.; 2. Letybo® smPC, https://www.medicines.org.uk/emc/product/13707 2022


Editor’s letter Now that you’re all back from sunny summer holidays and other adventures (I myself just got back from Toronto – read about it on p.15/19) we are about to get stuck into conference season! Is it just me, or is your diary already full until December? I’m not complaining… in fact, I’m excited to see more of you! The team will be going to all of the events listed on p.10 so be sure to say hello to us if you see us there.

Shannon Kilgariff Editor & Content Manager @shannonkilgariff

Importantly, remember to register for our next event – CCR in October. Featuring more than 150 brands, talks from renowned KOLs, and free CPD points, it’s one not to miss! Read all about it on p.20. This month in the Aesthetics journal, we focus on skin health and how to promote lovely skin for your patients. We have some great articles that are skin and dermatology focused, including tips for effective chemical peel results (p.25), safely treating skin lesions on p.45 and folliculitis, which I’m told is commonly mistaken for other skin

conditions like acne, on p.52. You can even get one CPD point to use in your appraisals by reading what the literature says regarding psoriasis diagnosis and management on p.37. Mental health is a huge topic right now, with a new report released by the Health and Social Care Committee on advertising and its impact on body image – read our report on p.16. Along a similar theme, in our business section we also discuss how you can incorporate wellness practices into your clinic on p.73 – a thought provoking read! Finally, The Aesthetics Awards entry closes this month! The Aesthetics Awards are the UK’s longest serving awards ceremony dedicated to recognising excellence and best practice in aesthetic medicine. Get those entries in by September 30 to be in with a chance of becoming a Finalist for the UK’s most prestigious awards. Got any questions? Or would you like some encouragement? You will have noticed that Beauty Uncovered magazine is out again this month! This is a great resource for your patients so be sure to put it in your clinic waiting room. Send me or the team a PM on Instagram and we will be more than happy to help @aestheticsjournaluk. Huge good luck to all, and I look forward to seeing you next month at CCR!

Clinical Advisory Board

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

WE WANT TO HEAR FROM YOU!

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

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

Jackie Partridge is an 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 Anti-Ageing 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 founder of the Great British Academy of Medicine and Revivify London Clinic. Dr Samizadeh is a Visiting Teaching Fellow at University College London and King’s College London.

EDITORIAL Shannon Kilgariff • Editor & Content Manager T: 0203 196 4351 | M: 07557 359 257 shannon@aestheticsjournal.com Holly Carver • Senior Journalist | T: 0203 196 4427 holly.carver@easyfairs.com Ellie Holden • Journalist | T: 0203 196 4265 ellie.holden@easyfairs.com Kate Byng-Hall • Journalist | T: 0203 196 4265 kate.byng-hall@easyfairs.com DESIGN Peter Johnson • Senior Designer T: 0203 196 4359 | peter@aestheticsjournal.com

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Email: editorial@aestheticsjournal.com

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

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ADVERTISING & SPONSORSHIP Courtney Baldwin • Event Director T: 0203 196 4300 | M: 07818 118 741 courtney.baldwin@easyfairs.com Judith Nowell • Business Development Manager T: 0203 196 4352 | M: 07494 179535 judith@aestheticsjournal.com Chloe Carville • Sales Executive T: 0203 196 4367 | chloe.carville@aestheticsjournal.com Emma Coyne • Sales Executive T: 020 3196 4372 | emma.coyne@easyfairs.com MARKETING Aimee Moore • Marketing Manager T: 020 3196 4370 | aimee.moore@easyfairs.com Abigail Larkin • Marketing Executive T: 020 3196 4306 | abigail.larkin@easyfairs.com

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© Copyright 2022 Aesthetics. All rights reserved. Aesthetics is published by Aesthetics Media Ltd, which is registered as a limited company in England; No 9887184

DISCLAIMER: The editor and the publishers do not necessarily agree with the views expressed by contributors and advertisers nor do they accept responsibility for any errors in the transmission of the subject matter in this publication. In all matters the editor’s decision is final.


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Associations

Talk #Aesthetics Follow us on Instagram @aestheticsjournaluk #Aestheticsjournal Elaine Williams @eosaestheticslimited Great to come home from a busy clinic and see my research on the front page of the Aesthetics journal.

#Trip Lou Sommereux @cosmexclinic A sneak peek of our clinical director Lou Sommereux on her trip to Toronto with Prollenium this week.

#Television Dr Ifeoma Ejikeme @dr_ifeoma_ejikeme Catch me and Cherry Healey on Channel 5 for Women’s Health: Breaking the Taboo – a no-nonsense show discussing women’s health.

BCAM appoints new president Aesthetic practitioner Dr Catherine Fairris has been appointed as president of the British College of Aesthetic Medicine (BCAM), succeeding Dr Uliana Gout. Dr Fairris, director of the Wessex Skin Clinic in Winchester, has been on the BCAM board since 2019, and took over direction of education and events in 2020 before becoming vice president of the association. She has overseen virtual educational sessions and two virtual conferences. Dr Fairris commented, “I feel so honoured to be given this opportunity to hold the role of BCAM president. I feel strongly that BCAM’s ethos of striving to advance safe and ethical aesthetic practice is the key to improving standards across the aesthetic sector. I am hopeful that during my tenure of presidency, BCAM will play a pivotal role in the implementation of a register of aesthetic practitioners, a crucial step in introducing more robust regulation within aesthetic medicine.” Dr Gout, director of London Aesthetic Medicine clinic on Harley Street, is moving on from the role in order to pursue global evidence-based education and collaboration. As well as serving as a member of the CCR advisory board, she has recently joined the faculty for the Masters in Aesthetic Medicine at University College London (UCL). Dr Gout said, “BCAM has a long heritage, and I would like to recognise the hard work of the founders, past presidents, board, committees and the wider team. I am grateful to have had the opportunity to devote more than six years to BCAM, and look forward to watching future developments.” Training

#Conference Dr Raj Acquilla @rajacquilla Beautifully inspiring first day to Inner Circle Switzerland with some very moving and powerful keynotes from our global faculty.

#Media Dr Furqan Raja @theprivateclinic Dr Furqan has been busy this Hair Loss Awareness Month, advising how to safely choose your hair transplant surgeon on Talk TV.

Merz Aesthetics Ecademy collaborates with Dr Tijion Esho Pharmaceutical company Merz Aesthetics has announced an upcoming collaboration between Merz Aesthetics Ecademy and aesthetic practitioner Dr Tijion Esho. The Ecademy is an online platform providing medical aesthetic practitioners with virtual, CPD-accredited learning on clinical topics including injection technique, facial assessment and treatment planning. Dr Esho is an award-winning aesthetic practitioner and owner of The ESHO Clinic in Wimbledon, Newcastle and Liverpool, and will now be collaborating with Ecademy. Dr Esho said, “Ecademy is a game-changer when it comes to online learning platforms, to have so much content at your fingertips wherever you are. From one to one tutorials delivered by leading experts, to injection technique videos in high resolution. All modules are CPD-accredited, helping ongoing learning, revalidation and progress as a medical injector. It’s free advanced learning for your own progression.”

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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Industry

New Aesthetics Reviewing Panel unveiled The Aesthetics journal has introduced a new Aesthetics Reviewing Panel (ARP) in order to make the publication peer-reviewed. The ARP is a panel of expert practitioners in the field of aesthetics who are industry leaders and highly experienced in their field. The panel encompasses a wide range of medical professionals with different clinical skills and expertise to ensure that articles published in the journal are clinically approved. The approved articles will be given an ARP kitemark. Shannon Kilgariff, editor and content manager of the Aesthetics journal, said, “It is a pleasure to welcome a new panel to the Aesthetics journal publication. We work closely with our current Clinical Advisory Board, which is led by nurse prescriber Sharon Bennett, to ensure the articles we publish are relevant, science-based, factually accurate and appropriately referenced.” She continued, “However, we feel that to further progress the publication and enhance the value of the journal, we need to implement a peer-review process. You will start to notice the ARP kitemark, which means that the article has been reviewed by a fellow practitioner who specialises in that particular area of aesthetics. With help from our Clinical Advisory Board, I can’t wait to work more closely with our ARP and continue to bring the best educational articles to our readership.” Aesthetic nurse prescriber and Clinical Lead of the Aesthetics Clinical Advisory Board Sharon Bennett added, “By incorporating expert peer reviewing prior to publication, we are taking a further step to ensure Aesthetics journal readers have access to checked, referenced articles and submissions. This not only reassures the readers, but also the authors.”

Vital Statistics 54% of around 100 US Gen Z adults between 18–25 years old believe an SPF 30 offers twice as much protection as SPF 15 (AAD, 2022)

The compound annual growth rate of the global aesthetic/cosmetic laser industry is projected at 7% in 2022-27 (Expert Market Research, 2022)

In a survey of 2,000 UK adults, 34% have suffered from acne at some point in their life (Click2Pharmacy, 2022)

Toxin

Study reveals COVID-19 vaccination reduces toxin effectiveness A retrospective cohort study has highlighted concerns regarding the efficacy and safety of botulinum toxin type A (BoNT-A) injections following COVID-19 vaccination. The study involved 45 patients who underwent periodic BoNT-A treatments after completing two doses of Pfizer-BioNTech vaccine. All patients were injected with BoNT-A in the frontalis muscle, glabellar and lateral periorbital bilaterally to correct forehead and crow’s feet wrinkles by the same physician. The same units were injected for the same area before and after the vaccine. The mean interval between BoNT-A injections before completing COVID-19 vaccination was estimated at 118.64 days, whereas the same interval after getting vaccinated was 95.95 days. Therefore, the average interval between BoNT-A injections was significantly shorter after getting vaccinated as compared to the interval prior to the beginning of the vaccination campaign. None of the injected patients developed swelling, erythema or flu-like symptoms after BoNT-A injections following COVID-19 vaccine. The number of patients who needed correction two weeks after BoNT-A injection was 5% and 30% pre- and post-COVID-19 vaccination respectively. The researchers stated that the study provided an insight into the fact that the vaccine might confer reduced effectiveness of BoNT-A. They concluded that further research is warranted, and studies originating from ethnic populations are critical to reproduce findings.

The incidence of skin cancer in England rose by 26.1% between 2013 and 2019, going from 177,677 cases to 224,092 (British Association of Dermatologists, 2022)

Of 500 skin disease patients, 98% felt that their condition affected their emotional and psychological wellbeing (All-Party Parliamentary Group on Skin, 2022)

Psoriasis affects every 2 in 100 people in the UK, and affects men and women equally (NHS, 2022)

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


Insider News

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Events Diary 10th September

BCAM Conference bcam.ac.uk

15th-16th September

The BACN Autumn Aesthetic Conference bacn.org.uk

4th October

Aesthetics Business Conference aestheticsbusinessconference.co.uk/

13th-14th October CCR ccrlondon.com

13th October

ACE Group World Conference ccrlondon.com/visit/ace-groupworld-2022/

Aesthetics Aesthetics

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Study

Study highlights Letibotulinumtoxin A efficacy A new study has highlighted letibotulinumtoxin A’s efficacy and safety for the treatment of glabellar lines. The results were shown in a randomised, double-blind, placebo-controlled, multicentre, phase three study which included more than 1,200 patients. The research, published in the Aesthetic Surgery Journal, showed that the response rate for letibotulinumtoxin A subjects reached 94% at week four after injection, with a treatment duration of four months. Median time to onset was three days, with almost one in four patients reporting a greater than one-point reduction in facial wrinkle scale within the first 24 hours after injection. The toxin was effective with severe glabellar lines, achieving no or minimal lines at week four in 48.5% of patients who had severe lines at baseline. The toxin was also well-tolerated with a low incidence of treatment-emergent adverse events, and demonstrated efficacy with repeated injections for up to 12 months. Therefore, the authors of the study concluded a high efficacy and safety profile for the toxin in the treatment of glabellar lines.

12th November

Aesthetics United Charity Conference www.aucc.co.uk

19th-20th November

CMAC Conference www.cmac.world/conference

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

10 YEARS YOUNGER IN 10 DAYS RETURNS TO OUR SCREENS TV presenter Cherry Healey and a team of fashion and beauty experts have returned to Channel 5 for a brand new series of 10 Years Younger in 10 Days. The show aims to turn back the clock by a decade in just over a week. Aesthetic practitioner Dr Tapan Patel features in the show, offering non-invasive cosmetic procedures to the programme’s lucky cast. FRANCES TURNER TRAILL TALKS REGULATION ON TALK TV Nurse prescriber and co-founder of the BACN Frances Turner Traill joined host Trisha Goddard on Talk TV to discuss the Health and Social Care Committee’s recent call for increased regulation. She discussed the public dangers behind anyone being able to gain injectable training without medical or anatomical knowledge, and said the UK is a ‘laughing stock’ due to the lack of regulation.

10

Skin

Dermalogica unveils Pro Restore Skincare brand Dermalogica has launched Pro Restore – a concentrate product designed to boost the efficacy of aesthetic treatments and reduce downtime. The company explains that the product aims to accelerate wound healing, resulting in reduced downtime and improving results for microinjury procedures. The product can also be taken home by patients and can be used alongside procedures such as microneedling, laser resurfacing, deep chemical peels and fibroblast skin tightening, Dermalogica adds. Melissa French, medi-aesthetic education and training executive at Dermalogica commented, “Pro Restore is unique in the aesthetic market, as it can be used pre-, during and post-microinjury procedures. For the first time, patients can take home a professional product from Dermalogica which offers them superior results and less downtime, reducing the risk of adverse skin reactions post-microinjury procedures.” Book

New bookkeeping journal launches Accountant Samantha Senior has released a new bookkeeping journal. Founder of the Aesthetics Accountant, Senior’s new book is designed for start-up aesthetic businesses to keep a monthly bookkeeping journal with checklists to be used alongside their accounting software, she explains. The book details income targets, yearly stock logs, break-even points, mileage logs and more. Senior said, “The Aesthetics Bookkeeping Journal is something that I am incredibly proud of. Designed to be an aide for clients, the process of designing and self-publishing this book was ignited from my own love of keeping checklists and being organised. I always tell my clients, prevention is better than cure. This bookkeeping journal combines checklists, tips, space for notes and journaling which we believe (and have been told) have been invaluable to our clients during the process of completing their own bookkeeping, and to use alongside their software accounting platforms.”

Reproduced from Aesthetics 9/Issue Aesthetics| Volume | September 202210 - September 2022


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Awards

Entry for The Aesthetics Awards open until September 30 Now is the time to enter The Aesthetics Awards 2023, as you only have until the end of the month to submit your entries! It is your last opportunity to be in with a chance of becoming a Finalist in the prestigious Aesthetics Awards, recognising the best and brightest practitioners, clinics, products and initiatives in the UK and Ireland aesthetics industry. Shannon Kilgariff, editor and content manager of Aesthetics, said, “The Aesthetics Awards is the ideal opportunity for aesthetic practitioners, companies, suppliers, distributors and clinics to showcase their achievements over the past year. If you haven’t submitted your entry yet, you still have until September 30 when entry officially closes!” We are also excited to announce new Award sponsors this year, including skincare distributor AestheticSource supporting the Nurse Practitioner of the Year Award, skincare brand AlumierMD for the Rising Star of the Year Award, aesthetic manufacturer Croma-Pharma for the Best Clinic Team of the Year and aesthetic supplier John Bannon for the Best Clinic Ireland and Northern Ireland. Other sponsors include antiageing product distributor FILLMED which is supporting Best Clinic Scotland, and medical aesthetic supplier Church Pharmacy which is celebrating the Product Innovation Award. The Aesthetics Awards 2023 will be taking place at Grosvenor House, London on March 11 after the second day of ACE 2023. Go to www.aestheticsawards.com to submit your entries now! Distribution

Celluma partners with Unique Skin Light therapy device company Celluma has partnered with distributor Unique Skin Group. Unique Skin provides products to the aesthetics and dermatology sector, and both companies hope their partnership will help promote Celluma’s growth in the UK and Ireland. Patrick Johnson, president and chief executive officer at BioPhotas, inventor and manufacturer of Celluma LED technology, commented, “We are delighted to partner with Unique Skin. Their dedicated team has the capability to support our large professional customer base and to grow our commercial operations over the coming years as we continue to innovate in this sector.” Julian McGlynn, managing director of Unique Skin Group, commented, “It is a delight to partner with BioPhotas and their award-winning cutting-edge LED technology line, Celluma SERIES. Being able to work with practitioners and to bring them world-class medically credentialled devices is our mantra, and with more FDA condition-based clearances than any other LED manufacturer, it is a delight to have the opportunity to work with BioPhotas.”

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

AUGUST DIGITAL MEETINGS Throughout August, the BACN partnered with Skcin — a melanoma and skin cancer charity that raises awareness through education, promoting prevention and early detection. BACN management committee member Anna Baker hosted an Instagram Live with Marie Tudor, CEO of Skcin. Marie spoke passionately about the issue that most healthcare specialities receive no formal training in skin cancer surveillance, and discussed Skcin’s MASCED (Melanoma and Skin Cancer Early Detection) programme to promote the early symptoms of skin cancer. Skcin was also the focus of the BACN live webinar series, where members were introduced to training with a discount to access their resources. All recordings can be found on the BACN resources section in the members’ area.

REGIONAL MEETINGS Our next round of regional meetings is back, with locations around the country offering educational talks, demos and networking opportunities. Dates can be found below, and booking is available on the events page of the BACN website! • • • • • • • • • • • • •

6 October 2022 – North Wales 20 October 2022 – Cambridge 1 November 2022 – South Coast 3 November 2022 – Leeds 7 November 2022 – Cardiff 9 November 2022 – Scotland 11 November 2022 – Newcastle 15 November 2022 – Kent 17 November 2022 – London 21 November 2022 – Birmingham 24 November 2022 – Belfast 29 November 2022 – Bristol 1 December 2022 – Manchester

AUTUMN AESTHETIC CONFERENCE The BACN Autumn Aesthetic Conference is taking place at Eastside Rooms, Birmingham on 15 and 16 September. The full agenda has been announced, and tickets and information are available on our website, or by scanning this QR code. This column is written and supported by the BACN

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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Recruitment

Teoxane welcomes new product specialist CELEBRATE AND HONOUR YOUR ACHIEVEMENTS AT THE AESTHETICS AWARDS 2023 Have you or your clinic developed an innovative new practice or product that deserves recognition? Have you made great improvements, seen incredible results or become the best of the best in your specialty, region or field? If so, you deserve to be honoured and celebrated at The Aesthetics Awards 2023 – unquestionably the most prestigious and glamourous awards programme in aesthetics!

WHY ENTER? The Aesthetics Awards celebrates the hard work of everyone in our specialty, from small to large practices, across all regions. It is designed to recognise you and your business, colleagues and clients at the longest-standing awards ceremony in the UK’s medical aesthetics specialty, setting the standard for excellence in aesthetics. Whether you make it onto the red carpet or into the Finalists circle, it’s an accomplishment worth celebrating. Winning, receiving Commendations or High Commendations or simply becoming a Finalist in this competitive industry is a huge achievement, and something well respected by your peers and colleagues. It will help excel your business, providing your patients with reassurance that you are top of your game, assuring your staff that they are working for a successful company and giving you something to shout about to the press! Start your entry now to join elite professionals from the aesthetics community on March 11 at Grosvenor House, London Entry is open from now until September 30, and the ceremony will take place following the second day of ACE 2023 on March 11 at Grosvenor House, London. Entry to The Aesthetics Awards is free for all Aesthetics Full, Print & Digital Members. If you are not already a member, you must become one to enter for as little as £60 per year. This includes access to the Aesthetics journal digital edition, the latest news updates and entry to as many Aesthetics Awards categories as applicable, plus many other benefits. To become a member, email contact@aestheticsjournal.com Scan the QR code to enter, or if you have any questions, please call our team on 0203 096 1228

Aesthetic manufacturer Teoxane has recruited Katie Macdonald as its new product specialist. Macdonald has worked in the beauty industry throughout her entire career, with experience in beauty salons, spas, clinics, colleges, large retail outlets and pharmacies. In this new role, she will maintain current relationships and build new ones with new customers. Macdonald said, “I have had the pleasure to work across all areas including skincare, tanning and equipment, and more recently within the aesthetics industry working with medical devices and cosmeceuticals. I am so passionate about this industry, and I am excited to develop further into the world of injectables. I look forward to meeting all my new accounts.” Complications

CMAC announces conference in November The Complications in Medical Aesthetics Collaborative (CMAC) is to hold its inaugural conference in London this November. The conference – entitled ‘New Frontiers’ – will introduce new technologies to delegates, and feature panel discussions. Topics covered will include vascular adverse events, blindness, acute infections, thread complications and more. Speakers will include dentist Dr MJ Rowland-Warmann, aesthetic practitioner Dr Victoria Manning, pharmacist Gillian Murray and aesthetic practitioner and vice chair of CMAC, Dr Cormac Convery. Dr Convery said, “I’m excited to be chairing the devices section which will focus heavily on practical relevance. We feel truly blessed to have a comprehensive faculty, hailing from Europe, the US and beyond. Our aim is to hold a similar event annually, but initially our focus is to ‘knock this one out of the park’.” The conference will be held at the Institute of Engineering Technology (IET), London on November 19 and 20. Ambassador

IMAGE Skincare appoints first KOL Skincare brand IMAGE Skincare UK has unveiled its first key opinion leader as aesthetic practitioner Dr Pradnya Apté. As part of her role, Dr Apté will trial new products before launch and provide feedback, speak at events promoting IMAGE Skincare and act as an ambassador for the brand. Dr Apté has been a dental surgeon for 27 years and has been working in the aesthetics industry for 16 years. She owns the Save Face accredited clinic Skin Southwest in Exeter, where she offers IMAGE chemical peels and at-home skincare. Dr Apté said, “I am delighted and honoured to be the first appointed KOL for IMAGE Skincare UK. Everything they do is about improving skin health, which in turn makes my patients happy, and I am excited to see what 2022 holds and also my personal input and involvement with the team and brand.”

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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Conference

CCR invites delegates to after party At the end of the first day of CCR, the Diwali PHI Lanthropy Party will be the perfect opportunity to get glam and network with colleagues, all while fundraising for charity! Supported by Prollenium and Dr Tapan Patel, the party will be a luxurious event with delicious Indian food, drinks and dancing. With all proceeds being donated to The Childhood Trust charity, the event is an opportunity for the aesthetics community to come together for an amazing cause. CCR has many great opportunities to collaborate and connect, as well as check out our exciting new sponsors, with companies including Croma-Pharma, Galderma, Novo Nordisk, Prollenium and Sinclair all supporting the symposium stage with informative talks from a range of speakers. Medical insurance company Incision Indemnity will be sponsoring the ISAPS lunch at CCR, and SkinCeuticals will be supporting the In Practice theatre. Courtney LeBorgne, event director at Aesthetics and CCR, commented, “This year’s CCR is expected to be the biggest one yet! With some fantastic companies supporting this year’s show, amazing speakers and informative talks, we can’t wait for the aesthetics community to be reunited once again for a jam-packed two days! Plus, this year’s after party is set to bring the glamour and fun after a day of education, as well as showing our support for an incredible charity.” CCR will be taking place on October 13-14 at ExCeL, London. Find out how to register for free on p.20. Charity

New foundation launches to support LGBTQ+ patients Aesthetic practitioner Dr Vincent Wong and gut health and wellness coach Dr Sunni Patel have founded the non-profit #IAMME Living Foundation to promote the wellbeing and aesthetic needs of LGBTQ+ patients. The foundation will take a holistic approach to supporting members of the LBGTQ+ community through addressing gut health and mental health, as well as non-surgical facial aesthetics. This will include providing access to facial masculinisation and feminisation procedures. The foundation will also work to raise awareness of the challenges the LBGTQ+ community faces, including discrimination, bullying and body and gender dysphoria. Dr Wong said, “As a cosmetic doctor, I truly believe that there is scope to elevate the industry beyond antiageing and prejuvenation indications. For me, facial aesthetics is about matching someone’s outer appearance to how they feel and identify themselves on the inside, regardless of age, gender, sexuality and skin colour.” Dr Patel added, “We know that awareness, education and access are barriers to sustainable health outcomes in the queer community, and the #IAMME Living Foundation aims to bring multidisciplinary care where it is most needed and of value.”

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Michele Di Giacomo, head of medical education and training at Galderma UK Tell us about your recent move to Galderma? I recently took on this role at Galderma UK after spending the past five years as the international associate director of medical education at Allergan. I am passionate about aesthetic medicine, and I strongly believe in raising standards through recognised and accredited medical education. What is the Galderma Aesthetic Injector Network? The GAIN programme connects an international faculty of aesthetic experts and injectors. At our first UK Train the Trainer event since COVID, six medical experts with experience using the Restylane portfolio assessed 15 practitioners over two days. The trainers delivered scientific content on our portfolio, alongside tips for improving facial assessments and injection techniques. What were some key learnings from the Train the Trainer session? We received great feedback from the participants – during the training programme, they were able to delineate how the Restylane range can optimise treatment outcomes for patients and share ideas. The delegates were looking forward to sharing their expertise and utilising the whole range moving forward. How else does the GAIN programme support practitioners? For Galderma, providing exceptional scientific education is paramount to help our delegates achieve the desired results. This Train the Trainer revealed how much delegates learnt from their peers and experts over the pandemic. GAIN provides regular networks, peer-to-peer learning opportunities, mentoring and training webinars to help the clinical community continue their growth and development. What is next for the GAIN programme? We’re planning another invitation-only UK Train the Trainer early in 2023, covering our whole product range. If practitioners are interested in learning more about the Galderma portfolio, they can contact their local Galderma account manager. This advertorial was written and supplied by Galderma.

UKI-RES-2200252 DOP August 2022

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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News in Brief Dermalogica partners with anti-domestic violence initiative Skincare company Dermalogica has partnered with anti-domestic violence initiative Shear Haven to provide practitioners with anti-domestic violence training. Practitioners in the UK and Ireland will be provided with training on how to spot the signs of domestic violence in their patients and how to respond accordingly. To date, more than 50,000 aesthetic professionals have accessed the training worldwide. Cosmetic Courses announces toxin training course Aesthetic training provider Cosmetic Courses has launched a new botulinum toxin training course. The one-day, CPD-accredited course will advise delegates on emerging botulinum toxin type A treatments, covering areas including the masseter, excessive sweating, bunny lines, gummy smiles and the Nefertiti lift. Medical director of Cosmetic Courses Mr Adrian Richards commented, “It’s important for us to listen to our delegates, and in doing so we have released a new course which will help them advance their knowledge and understanding of advanced toxin treatments.” WOW Facial launches resized SPF Skincare brand WOW Facial has released a new 100ml bottle of its Synergy 6 NXGen SPF 50, scaling up from 50ml to reduce packaging. The size increase will help the company reduce the amount of plastic involved in its packaging and will negate the need for a box as the company aims for increased sustainability. WOW Facial CEO Claire Williams said, “It is double the size but not double the carbon footprint or double the packaging, and this is a big bonus for us as a business who is looking to be more sustainable in its practice.” Initial Medical releases sustainable waste container Medical waste disposal and infection control solution provider Initial Medical has released a new rigid cardboard waste container. The company explains the product aims to promote sustainability in clinics. The cardboard containers are designed to replace traditional plastic clinical waste bins, thus reducing the amount of plastic waste clinics produce. Category manager at Initial Medical Rebecca Waters said, “The new Rigid Cardboard Waste Containers from Initial Medical are practical, cost-effective and environmentally friendly, constructed from recycled cardboard.”

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Sustainability

Easyfairs commits to ESG Global exhibition organiser Easyfairs, the owner of the Aesthetics and CCR portfolio, has been striving to drive the events industry forward with environmental, social and governance (ESG) plans. ESG is a framework that helps stakeholders understand how an organisation is managing risks and opportunities around sustainability issues. Easyfairs is looking into improving and implementing ESG across all its events, including the Aesthetics portfolio. Courtney LeBorgne, event director of Aesthetics and CCR, said, “ESG is an important concept which is becoming more pivotal as our industry grows. Sustainability is a concept we encourage and is something we are striving to implement more into our events through increasing recyclable waste options, choosing partners and suppliers that align with our long term ESG objectives and supporting the communities we serve in their ESG actions.” Easyfairs is also encouraging other industries to follow suit and bring ESG to the fore. For example, a question regarding ESG has been added to all Aesthetics Awards applications. Shannon Kilgariff, editor and content manager, commented, “In order to promote ESG in medical aesthetics, we felt that it was important to include an ESG-focused question in all applications for The Aesthetics Awards. All businesses and clinics moving forward should be integrating some ESG into their development plans, so it was crucial for us to highlight this in our entry process.” Entry for The Aesthetics Awards closes on September 30 – turn to p.42 to enter. Recruitment

Eden Aesthetics appoints new managing director Skincare distributor Eden Aesthetics has welcomed Lindsay Gray as its new managing director. Gray has more than 15 years’ experience in the aesthetics industry, particularly with Epionce – one of Eden Aesthetics’ brands. The company hopes her experience with the brand will mean she can help build Eden Aesthetics’ portfolio in the UK and Ireland. In her role, Gray will look to expand the salesforce and administrative teams, improve customer experience and launch DermaFrac microneedling – the new addition to Eden Aesthetics’ portfolio. Gray said, “Epionce has become one of the leading cosmeceutical brands in the UK, and I am delighted to have overseen the official UK and Republic of Ireland launch of the Epionce Luminous Eye Serum earlier this year. We now want to grow by developing partnerships with some of the leading aesthetic clinics.” Advertising

MHRA and ASA issue enforcement notice for hay fever injections The Advertising Standards Authority’s (ASA) Committee of Advertising Practice (CAP) has issued an enforcement notice against the advertising of a hay fever treatment injection in the UK. The enforcement notice, published alongside the Medicines and Healthcare products Regulatory Agency (MHRA), states that Kenalog (triamcinolone acetonide) – a prescription-only medicine (POM) – cannot be advertised as a hay fever remedy in the UK because it is not licensed for that treatment. This notice follows rulings against various clinics which have advertised the treatment to the public, breaking the rules which state that POMs cannot be promoted publicly.

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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Conference report

Prollenium Toronto Symposium For the first time since the pandemic, Canadian-based aesthetic manufacturer Prollenium Medical Technologies invited 300 clients from across North America and the UK to its Toronto Symposium. Ario Khoshbin, co-founder and CEO, opened the event and delivered an inspirational talk on business entrepreneurship. Consultant cleft and maxillofacial surgeon Mr Mark Devlin and consultant oral and maxillofacial surgeon Mr Jeff Downie then discussed lip complications and anatomy, and shared their literature research on labial vascular compromise (LVC), suggesting a classification system into type 1 and type 2. They proposed that if accepted, this new classification could allow for better comparison of outcomes and treatments with a common endpoint. International practice management consultant Jay Shoor then presented several talks, and world-renowned Canadian plastic surgeon Dr Arthur Swift spent a full day educating. He explored his world-renowned injection techniques and vectors for assessing facial ageing and shared cadaver anatomy videos from anatomist Professor Sebastian Cotofana. “Understanding the anatomy is still the number one way to prevent complications,” Dr Swift emphasised. He then performed two full-face live

demonstrations using the Revanesse range, explaining how to get consistent, reliable and reproducible results. The learning was accompanied by three lavish evenings of networking events: a welcome dinner at the ballroom in the Four Seasons Hotel Toronto, a cocktail party at the Gardiner Museum and an elegant gala dinner at the Art Gallery of Ontario. Following the event, Khoshbin and fellow co-founder and president Khasha Ighanian said, “We would like to thank each and every one of our clients for joining us for our 2022 Prollenium Toronto Symposium. We like to give back to our clients, and we hope everyone had a wonderful time learning and networking. We are looking forward to inviting delegates from the US, Canada and UK back again next year!” To read more about Prollenium’s research and development, turn to p.19, and to attend talks from top Prollenium KOLs on October 14, learn how to register for CCR on p.20.

Discover Evolus

Advertorial Evolus

Find out about the newest company in the UK aesthetics market Dan Stewart, who are you and what’s your superpower? I’m the vice president of Evolus International. This grand title means I’m living and breathing an evolution within aesthetics and beauty. I have been working in aesthetics for more than 20 years and I’ve seen many aspects of the sector evolve. There has also been an enormous transformation in how practices are run and how companies support practitioners to get the best patient outcomes. Throughout this time, my focus has been on helping customers deliver great aesthetic outcomes for patients My superpower is energising and empowering the people around me. For me, I get my energy by reaching for an ambitious future. I don’t like standing still. I prefer spotting trends and shaping the future, whether that’s as a market leader or as a start-up.

What makes Evolus different? Evolus was set up in 2012 and, from the get-go, was a different sort of company. We describe ourselves as a performance beauty company, taking learnings from the beauty sector and applying this within aesthetics. We know that many consumers walking through your doors have a millennial mindset – they are informed, they want choices, they see beauty as part of their everyday routines. I’m excited about designing Evolus International with our customers in mind. We have some of the best professionals in the sector working in an agile way to mix fresh ideas with deep expertise. From our home base in California, Evolus serves more than 7,000 practitioners across the US. Beyond the US, we are in start-up mode and are launching operations in the UK and Germany in the coming months.

Two years in the future… what are you most proud of? That’s easy. I’ll be proud of the passionate Evolus teams and partners who have done a great job every day for our customers. I’ll be talking about how Evolus helped spark an evolution, driving higher engagement and satisfaction for patients. And, I also hope we’ll have some fun along the way! We are inviting customers to learn how you can evolve with us, so visit hello-evolus.com to learn more.

This advertorial was written and supplied by Evolus

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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Body positivity and diversity Within the MPs’ report, the British Psychological Society notes that there is an overwhelming pressure on women, and more recently men as well, to conform to a particular beauty ideal portrayed in the media and magazines.3 It is therefore suggested that the Government should work with advertisers to feature a wider variety of body aesthetics such as shapes and sizes, as well as introduce legislation that ensures commercial images are labelled with a logo where any part of the body, including its proportions and skin tone, are digitally altered.2 Dr Fairris agrees with the committee’s suggestion to highlight whether images have been retouched. She says, “If marketing images are clearly labelled to show the extent to which they have been digitally altered, this can demonstrate, especially to impressionable minds, that the photos do not represent reality. This, coupled with more adverts featuring models with realistic body images, should have a positive impact. It’s important to note that practitioners should never be doctoring or altering patient’s before and after images. The ASA has published guidance on this, and practitioners should be obeying these rules.”4 However, Dr King considers that the committee only refers to commercial images, Aesthetics explores MPs’ recent report on body not before and after photos posted on image and mental health concerns, and what social media. He notes, “The committee practitioners can do to navigate these issues reports on commercial imagery rather than the unrealistic images we see all over social Social media can be a pivotal tool in your working-day lives media from both medical practitioners and non-medics, so personally, to promote your business and communicate with patients. I would rather see this include all images that are posted online. This However, it can also contribute to body image concerns and could mean that ethical and legitimate practitioners improve their increasing mental health issues. In a recent survey of 7,500 people photography to ensure it is more standardised and taken in the same conducted by Rare: Group, adults who suffer from depression and lighting and positions.” Not having accurate before and after imagery, anxiety are 42% more likely than others to be considering aesthetic even when not done on purpose, is as bad as physically altering treatments in the next 12 months.1 Therefore, ensuring that patients images, according to Dr King. are receiving aesthetic treatments for positive reasons is crucial during the consultation process. Last month, the Health and Social Care Committee published a report on the ‘Impact of Body Image on Mental and Physical Health’. It identifies a rise in body image dissatisfaction as the driver behind many people’s decision to seek aesthetic treatments.2 Within the report, respondents detail potential harm from online content that promotes an idealised, often doctored and unrealistic body image, which further links to low self-esteem and related mental health issues.2 As a result, MPs on the committee believe that the Government, the Advertising Standards Authority (ASA), and the industry itself should work together to discourage advertisers and influencers from doctoring images. We spoke to aesthetic practitioner Dr Martyn King and the new president of the British College of Aesthetic Medicine Dr Catherine Dr Martyn King Fairris about what this means for the industry, and how it could help patients’ mental health.

Tackling Body Image Advertising

“Adding a BDD questionnaire to your consultation process seems a minimal, but important, step to protect both the public and practitioners from seeking treatments”

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


JB-0001381. Date of Prep: April 2022

Body dysmorphic disorder Body dysmorphic disorder (BDD) was another issue raised in the report, with many MPs believing that the condition should be made a priority. It was recommended that Health Education England update the Improving Access to Psychological Therapies (IAPT) and Educational Mental Health Practitioner (EMHP) curriculum to make training in BDD compulsory for all mental health practitioners. As well as improved diagnosis rates, suitable care for those living with BDD must be available.2

Furthermore, Dr Fairris reiterates that practitioners should continually educate themselves on mental health conditions and ensure BDD is in the training they seek out. She explains, “There are numerous educational modules available for practitioners on identifying patients with mental health problems. I would also suggest that practitioners have internal guidelines for what to do if a patient is flagged as having mental health issues and know how to and who to refer them to if managing it is beyond their scope of practice.”

Enhance your education With mental health and body concerns on the rise in the industry, it is important for practitioners to continue enhancing their education on the topic to ensure their patients receive the highest care and safety. They should also be educated in marketing rules and regulations, and how to take accurate clinical photography. Dr King concludes, “I believe that compulsory mental health training is a step that should be introduced, and for practitioners who are not experienced in this area, perhaps they should use an assessment service with other practitioners who are knowledgeable in this field. Adding a BDD questionnaire to your consultation process seems a minimal, but important, step to protect both the public and practitioners from seeking treatments, which could further damage the patient’s mental health and wellbeing.” REFERENCES 1. Rare: Group, ‘CCR Industry Trends Report Stats’, 2022, data on file. 2. House of Commons, ‘The impact of body image on mental and physical health’, Health and Social Care Committee, 2022, <https://committees.parliament.uk/publications/23284/ documents/170077/default/> 3. British Psychological Society, ‘Written evidence submitted by British Psychological Society’, 2022, <https://committees.parliament.uk/writtenevidence/43045/pdf/> 4. Advertising Standards Authority, ‘Before and after photos’, 2021, <https://www.asa.org.uk/advice-online/before-and-after-photos.html#effic>

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Dr King recommends that any practitioner working in aesthetics should have compulsory training in this area and ensure that this forms part of their medical history and consultation, such as including a BDD questionnaire in all consultations. He adds, “Most practitioners have already completed mandatory training, such as basic life support and safeguarding, as part of their appraisal process, so adding in additional training should not be a difficult step to overcome.”

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Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022 167156 KELO-COTE Half page print ads 95x265_FINAL.indd 1

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cause inflammatory reactions because the body is more likely to treat them as a foreign object. To create smooth spheres, Aesthetics visits Prollenium Medical Technologies Prollenium has a two-step process. “First we ensure the crosslinking in that in Canada to learn about the production and goldilocks zone – we don’t want it to be development of Revanesse dermal fillers too hard or too soft. Secondly, what’s truly unique is the piston mill we have designed Quality is the primary focus for dermal filler manufacturer – we push the product through this mill, which creates nice round Prollenium Medical Technologies and when you visit the site, it’s particles. It is important the crosslinking is perfect because if the clear this is at the fore. gel is too hard, it shatters when it’s put through the mill, causing Prollenium produces more than one million hyaluronic acid (HA) more jagged particles. If it’s too soft, it oozes through the mesh syringes per year and is the only dermal filler manufacturer in and it’s not milled down.” By having that optimally crosslinked North America. It has more than 150 full-time employees and has gel going through the screens, Prollenium is able to get nice an impressive new state-of-the-art 70,000 square foot facility in spherical particles. Richmond Hill, Ontario Canada. Having launched Revanesse in the UK with a bang at CCR in 2021, bringing headliner Dr Arthur Swift, it’s an aesthetic company you need to keep an eye on.

Producing Revanesse Fillers

A little bit of history Prollenium was founded as a laser distributor in 2002 by CEO and founder Ario Khoshbin with just a $300 loan. Khoshbin was joined by now president Khasha Ighanian, and in 2004 the pair shifted their focus to distributing HA dermal fillers. “Unfortunately, the product was not up to our standards so we decided to move everything in-house and develop our own product,” Ighanian explains, “We tasked our scientists to create a product that was very safe to inject, highly efficacious and backed with clinical research.” As the only dermal filler manufacturer in North America, Ighanian believes this has created a unique advantage. “Because we didn’t have the experience of European brands, our scientists had to start from scratch, and by doing that, I think we’re able to create something truly unique with fantastic results,” he explains.

The development process Prollenium prides itself in creating everything in-house at the facility in Richmond Hill, from conception to injection. Ighanian says, “Our HA powder is sourced from HTL Biotechnology in France and this is really the only thing that we import – everything else we make.” The process entails mixing HA powder with water and other solutions with the BDDE crosslinking agent to create a gel. “Quality testing is conducted every step of the way,” Ighanian emphasies. “We test the gel throughout the entire manufacturing process, making sure no bacteria is introduced and that we get the end product we want. We do that by controlling every step of the process from beginning to end. After the gel is crosslinked, it’s sterilised and filled into syringes, and quality tested again.” Each and every syringe is manually and visually inspected by a person, and then packaged and ready to be sent around the world.

Why go spherical? According to Ighanian, the other factor that makes the Revanesse dermal fillers unique is the shape of the particles. “All HA fillers are made up of particles, and what we wanted to do was create particles that were more spherical in nature. This is because we know that the body likes particles that are nice and round.” According to Ighanian, jagged particles have more surface area and are more likely to

The Revanesse manufacturing site was recently visited by Aesthetics journal editor Shannon Kilgariff and some UK practitioners, including aesthetic nurses Anthea Whiteley, Lou Sommereux, Sharon Bennett and sales manager July Purdy.

Next in the Prollenium pipeline Headed by director of R&D, Dr Timothy Lee, future advancements are at the core of Prollenium, with a strong pipeline of new products coming in the next four years. Revanesse Shape+ launched last October in the UK, is going through its US FDA trials to hit the US imminently. Prollenium has been working on its very own biostimulating product, aligning with the company’s ethos of round spherical beads, which, Dr Lee states, results in better collagen deposition and fewer adverse reactions. The two R&D facilities have enabled Prollenium to upgrade existing lines of products based on market feedback and new technology. Revanesse Pure for example, an HA skinbooster, has been reworked for longer-lasting hydration and skin texture improvement. The final products in the pipeline look more closely at body indications used to improve the appearance of hip dips and a scale for treatment is also in development. Ighanian says, “We have a robust R&D team, which is the core that has been there from the beginning, so we have a very healthy pipeline. We have as many products as the imagination can handle, and we’re hoping to release a new product pretty much every year for the next five years and continue to be a pioneer in this field.”

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


Event Preview CCR

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Shaping the Future of the Aesthetics Industry CCR dedicates two days to the education and development of medical aesthetic practice The medical aesthetics industry is ever evolving. Scientific advancements, regulation developments, an increase in demand, as well as patient awareness, constantly drive it forwards. As a practitioner, up-to-date education is vital to delivering the very best patient results; and as a clinic owner, understanding the new solutions for your business and patients is critical to running a successful clinic. CCR is the UK’s flagship aesthetics event for medical practitioners to learn, discover, network and celebrate. World-renowned key opinion leaders deliver the very latest in clinical innovation, complication management, business insight and technical demonstrations; and more than 150 brands showcase the latest products, technology and innovation to benefit your patients. With a specialist scientific agenda and a showcase of the latest trends and launches, it is the ultimate destination for all medical professionals. Free, CPD-accredited content, countless networking opportunities and 150+ brands, all under one roof, for two days, at ExCeL, London, on October 13 and 14.

A platform for innovation In recognition of this rapidly developing industry, CCR welcomes three new conferences to its agenda. Bringing the Aesthetics journal to CCR, the main clinical conference on facial aesthetics will take place in The Aesthetics Arena. With sessions dedicated to each area of the face, attendees will learn how to sculpt jawlines, transform tear troughs, master mid-face lifts, harmonise the lower face and tighten necks through a diverse range of patient case studies and demonstrations. The agenda will also cover pioneering innovations in botulinum toxin as well as how ultrasound can improve injection technique and aid complication management. There will be unmissable LIVE DEMOS including ‘Tear Trough Transformations’ with Miss Rachna Murthy (Winner of The Aesthetics Awards 2022 Consultant Surgeon of the Year) and Professor Jonathan Roos, and ‘Mid-face Rejuvenation’ with Dr Raul Cetto and Dr Jeremy Issac, plus many more. The Aesthetics Arena is also home to the Galderma symposiums, 20

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Event Preview CCR

with LIVE DEMOS to be announced very soon. The newly named Innovation Stage welcomes international brands to share exclusives on the latest aesthetics products and devices. With sessions from Prollenium, Vivacy, Cutera and Healthxchange to name a few, plus the return of the Allergan Lunchtime Takeovers, this agenda will reveal how to utilise and implement key technologies to improve the quality of your clinic’s offering.

Progressing and developing patient protocols The third new conference is Progressive Aesthetics, featuring content, methods and practice that is truly at the forefront of the medical aesthetics industry. This agenda will explore the latest clinical and scientific advances that will improve the results and wellbeing of your patients, as well as developing your business and skillset. Renowned aesthetic practitioner and international trainer Dr Tapan Patel, the founder of award-winning PHI clinic, will bring his pioneering concepts to CCR 2022. In this full-day agenda, Dr Patel will showcase his latest injection techniques and theories around rejuvenation, enhancement and beauty. Featuring live injectable demonstrations on up to seven patients of different ages and backgrounds, this unmissable masterclass will showcase how you can optimise your treatments for maximum patient satisfaction. This is a ticketed masterclass, available to purchase for £120 on the CCR registration. Also taking place in the Progressive Aesthetics conference is the brand-new Aesthetic Wellness agenda looking at the close relationship between aesthetic medicine and patient wellness. Dr Mayoni Gooneratne says, “Wellness is a real buzzword and we as medical practitioners are in the perfect setting to introduce the conversation of wellness to our patients. I am delighted to have curated the Aesthetics Wellness agenda at CCR where a whole host of speakers who are incredible experts in their own field will be explaining how and why they deliver these services, services that you can easily plug into your own clinic – adding value for the patients and to the business.” This conference is an industry first and attending will provide you with a new outlook on long-term patient care.

World-leading products and devices CCR is unique to other UK events as it unites products and solutions from a range of brands, from global pharmaceutical companies to cutting-edge start-ups new to the market. CCR is the perfect platform for new products and solutions to be showcased, explored and taught so that together we remain at the forefront of patient innovation and satisfaction. To prioritise innovation and bring to the forefront of your education, CCR will be introducing the Innovation Trail, providing an incredible opportunity for you to discover innovative brands, new product launches and start-ups in the most time effective way. Brands will need to apply to enter and will be highlighted at the show for you to discover all of the latest innovations in one unique trail. With a commitment to the betterment and progression of the aesthetics industry, CCR brings together the Innovation Trail, Aesthetics Arena, Progressive Aesthetics Conference and Innovation Stage in a celebration of inspirational scientific and world-class clinical Party Time innovation. Combining an advanced academic Don’t forget to get your tickets to programme with a show floor of world-leading the very first CCR PHI Lanthropy products provides attendees with the complete Diwali Party, with Dr Tapan Patel, learning experience, experts sharing knowledge supported by Prollenium. Tickets of their craft and how to implement key learnings can be purchased via the CCR practically into your clinics straight away. registration form for £150 with Discover the very latest trends, techniques food and drinks included. The full and solutions at CCR 2022, and remain at amount will be donated to charity. the forefront of development in the medical aesthetics industry.

“Wellness is a real buzzword and we as medical practitioners are in the perfect setting to introduce the conversation of wellness to our patients” Dr Mayoni Gooneratne, Founder, Human Health

13 & 14 October 2022 | ExCeL London, UK

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Case Study: Concertina Lines Miss Rachna Murthy explores how she approaches treatment of fine lines on the face This article is produced and funded by Allergan Aesthetics and is intended for healthcare professionals. UK-HAR-220255 | Date of preparation: August 2022

Improving concertina lines with the products we have in our toolkit has been extremely difficult in the past. These lines, also known as accordion lines, are caused by years of repetitive muscle Miss Rachna Murthy movement due to smiling, alongside a reduction of is a consultant skin quality through ageing.1 They are notoriously oculoplastic surgeon at FaceRestoration. She difficult to treat. Hyaluronic acid (HA) can have an consults for Allergan and is part of its AMI faculty. impact, but there is the risk of over-filling, particularly when injecting high cohesivity products directly into the lines. Energy-based devices like radiofrequency with microneedling are also an option. HArmonyCa™ is a new hybrid collagen stimulating injectable, which combines calcium hydroxyapatite (CaHA) microspheres and HA in a single syringe for both an immediate and sustained lifting effect from one week to at least a year.2-4 It improves collagen stimulation, while also tightening and lifting the skin to provide definition without needing to use high volumes.4,5

Case study This patient (aged 49 at time of treatment, now 51) presented to my clinic because she wanted to improve the signs of ageing, with her main focus being the concertina lines. I first recommended a good medicalgrade skincare regime, consisting of retinol, vitamin C and an SPF, which helped improve her skin quality. However, I felt HArmonyCa™ was the ideal product to use to further these results to provide an immediate lift Before

1 Month After

effect with sustained collagen stimulation.4,5 Treatment was mostly lateral to the line of lateral ligaments and subdermal and I focused on the lateral cheeks and jawline to address the concertina lines and improve the appearance of her jowls. I used two syringes of HArmonyCa™ in total (each 1.25ml).2 I treated along the zygomatic arch (CK1), inserted product into the concertina lines directly and just above laterally (CK4) and along the jawline (JW2 & 4). I also used 1ml of Juvéderm® Voluma® into the deep medial fat pad (CK3) to indirectly treat the tear trough and the chin (C1) to address midline concerns.6 Following treatment with HArmonyCa™, adverse events are typically manageable and self-limiting.7 Common adverse events include erythema, oedema (swelling), pain, tenderness, and itching. Treatment site reactions typically resolve within 24-48 hours and swelling within a week.8 The patient was very happy with her results. As early as one month of treatment, all concertina lines were softened and there was more definition to the zygomatic arch, along with improvement to the jawline and lifting of the jowls. By two months, my patient had noticed continued improvement in the look and feel of her skin and this continued to improve and was sustained in the year review.

Developing techniques

With more experience using newer products, our techniques and approaches develop. Rather than injecting directly into the concertina lines, I now inject HArmonyCa™ into the landmarks where a direct and indirect improvement One year after can be seen, including near the zygomatic arch, the jawline, and the lateral to the jowl. With more studies, which are currently being conducted by Allergan Aesthetics, we may see further progression in techniques.

HArmonyCa™ training

51-year-old patient before, one month after and one year after treatment using 2.5ml of HArmonyCa™ and 1ml of Juvéderm® Voluma®. Patient yet to take 1-year VECTRA images.

Allergan Aesthetics runs regular HArmonyCa™ training days for healthcare professionals. To find out about the next training days, contact Allergan Medical Institute® Training at amitraining@ allerganeventsteam.com. Note that the Allergan Medical Institute® is promotional – Allergan products will be discussed.

©AbbVie 2022. All rights reserved. Material produced and funded by Allergan Aesthetics, an AbbVie company. www.allerganaesthetics.co.uk. HArmonyCa is for patients over the age of 18. Individual patient results may vary. Adverse events should be reported. Reporting forms and information can be found at: UK adverse events reporting https://yellowcard.mhra.gov. uk/ Adverse events should also be reported to Allergan Ltd. UK_medinfo@allergan.com or 01628 494026 Irish adverse events reporting https:// www.hpra.ie Adverse events should also be reported to Allergan Ltd. UK medinfo@allergan. com or 01628 494026.

Disclaimer: this article is based on Miss Murthy’s personal experience and ultimate decisions regarding patient care lies with the treating HCP and the patient.

REFERENCES 1. Kapoor KM, et al. Clin Cosmet Investig Dermatol. 2021;14:1105-1118. 2. Allergan Aesthetics. HArmonyCa™ Lidocaine IFU. M032 V01. 2021. 3. Gonzaga da Cunha M, et al. Surg Cosmet Dermatol. 2020;12:109–17. 4. Allergan Aesthetics. Data on File. INT-HAR-2150040. HArmonyCa™ Lidocaine. Collagen stimulation. Jul 2021. 5. Allergan Aesthetics. Data on File. HArmonyCaTM Lidocaine INT-HAR-2150036. Lift capacity. July 2021. 6. Allergan. Juvéderm® VOLUMA with lidocaine DFU. 73650JR10. CE Revision. 2019-09-09. 7. Allergan Aesthetics. Data on File. INT-HAR-2150007.HArmonyCaTM Lidocaine. Clinical Study Report. April 2021. 8. Allergan Aesthetics. Data on File. INT-HAR-2150040. HArmonyCa™ Lidocaine. Collagen stimulation. Jul 2021

Aesthetics | September 2022

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whereby you take a detailed medical history and go through all of the contraindications, side effects and potential complications, is key.

Choosing a peel

Optimising Skin Health Practitioners discuss using chemical peels to enhance skin quality While injectables can give patients the volume, structure and smoothness they desire, they may not provide the ‘glow’ that treatments like chemical peels can produce. Sex and the City’s Samantha Jones’ experience of a burnt face with flaking skin gave chemical peels a bad reputation 20 or so years ago1, but, these days, patients can see big improvements with minimal downtime. Aesthetic practitioners Dr Beatriz Martín Hernández, Dr Amiee Vyas and nurse prescriber Susan Young share their advice on investing in chemical peels and getting patients on board with treatment protocols.

Why peel? “The first thing I would say is that optimised skin health is the absolute key component of any treatment within medical aesthetics,” says Young. She explains, “If you haven’t got your patient’s skin concerns under control, then you’re not going to get the best results from injectable treatments. Skin health is the first thing we should be looking at.” Dr Vyas highlights that chemical peels are a low-investment treatment option for clinics. “If you’re just starting out and have less of a budget, you can provide your patients with significant skin health benefits through

chemical peeling,” she says. Dr Vyas explains that peels can be a great option for those who are nervous of more invasive treatment, as well as those who want to level up on the results they’re already seeing with injectables. For Dr Martín Hernández, the fact that peels are a non-invasive therapy and can treat so many indications is extremely appealing. “As well as enhancing dull, tired skin, you can address pigmentation, acne, rosacea, skin ageing, scarring and so much more,” she says. Dr Vyas adds that they can also significantly improve skin laxity, particularly if patients are using them alongside home skincare routines. “At the end of the day, if you’re treating the canvas – the skin – and that is looking fantastic, then everything else is going to look better as well,” she says. The terminology associated with this treatment can instil fear in some patients, says Young, explaining, ‘chemical’ can be inferred as being dangerous, while ‘peel’, of course, suggests that your skin will peel. While this is the case, the peeling isn’t always that drastic. “If patients undergo a superficial peel, which is always the starting point, they might just have a couple days of flaking,” she says, continuing, “They’re more than likely going to get lovely results, and really quite quickly as well.” To ease concerns, a thorough consultation,

Strength and ingredients to consider Depending on the patient’s level of concern, peels can feature different ingredients and be applied in varying strengths. Dr Vyas explains superficial peels will work on the stratum corneum and epidermal layers of the skin, so patients won’t see excessive skin shedding. “Depending on the ingredients, these peels can also impact oil control and even skin tone as melanocytes sit in this area,” she says. Alternatively, a medium depth peel works on the full epidermis and papillary dermis, which will increase skin shedding and patients may leave looking fairly red and swollen, while deep peels, which induce controlled tissue injury further into the reticular dermis, will leave patients experiencing more severe side effects for longer, the practitioners advise. “Peels that contain alpha hydroxy acids (AHAs) such as lactic and glycolic acid, as well as beta hydroxy acids (BHAs) with ingredients such as salicylic acid, are great for treating acne,” says Dr Vyas. She explains that these are good starting points, as they’ll exfoliate and brighten skin, while tightening pores. “Mandelic acid is a fantastic ingredient for treating acne in dehydrated skin and skin of colour, as it’s more gentle on the skin,” she adds. Only when you become confident in superficial peeling, should you move to deeper peels, the practitioners advise. “There are different types of trichloroacetic acids (TCAs) available, which will give you more or less peeling depending on what is suitable for the patient,” says Dr Vyas. Investing in a brand When choosing a brand to invest in, Dr Vyas recommends researching the clinical evidence each has and considering whether they would best treat your demographic’s concerns. She says it’s also worth investigating how much training and support is on offer from the provider. “Even with peels, it’s important you optimise the skin quality through skincare prior to treatment,” she says, adding, “Look for those brands offering the supportive preparatory skincare and you’ll then be able to create protocols alongside your peel treatments.” It is vital that practitioners also pay due consideration to treating skin of colour with

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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peels, as it can be more challenging. Dr Martín Hernández says, “You can cause more damage by worsening hyperpigmentation, for example. Do your research and ensure the products you invest in have been tested on darker skin types.” Dr Vyas uses the NeoStrata ProSystem as she appreciates the safety data of the range, and the fact that the peels have been tested on multiple skin types. “The retinol peels do result in some shedding, but this is relatively short-lived and results are equivalent to those I have seen with medium peels,” she says, adding that with the NeoStrata ProSystem peels, there is no shedding and patients can go straight back to work or to a special event. For deeper peeling, Dr Vyas recommends the Obagi Blue Peel that uses TCA to tackle acne scarring, deeper pigmentation, skin laxity and wrinkles. With downtime lasting up to two weeks, she says this is better for patients who don’t have work commitments or are happy to accommodate longer, more aggressive side effects. For Young, PCA Skin is her brand of choice. She says, “They offer peels for all skin conditions, so we can create bespoke treatment plans for all patients.” Young highlights that the NoPeel Peel is a good starting point, explaining, “It’s got a high level of lactic acids, which bind to arginine creating a slow release, rather than blasting the skin with a strong acid. It also contains gluconolactone, which increases cell turnover, and salicylic acid, which is great for acne and oily skin.” For more advanced peeling, Young recommends a Sensi Peel. “This is really good for patients with particularly sensitive skin,” she says, explaining, “It’s a 6% TCA blended peel, with lactic acid that helps to inhibit melanogenesis. Silymarin and emblica are also included, which are powerful antioxidants that help manage inflammation and discolouration.” Going deeper, Young notes that the Ultra Peel is a great option. With the same ingredients

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Intimate peeling Intimate peeling is also something Dr Martín Hernández offers at her clinic. “I use the Pink Intimate System, which my patients have found to be comfortable, with no downtime,” she says. The product contains modulated chloroacetic acid, urea peroxide, kojic acid, rucinol and glutathione, which have a lightening action, while papain, genistein, retinol, bisabolol and glycyrrhiza glabra root extract provide a regenerating, biostimulating and soothing effect.2 It can be used on the mons pubis, labia majora, perianal region, inguinal area, underarms and nipples (Figures 1 & 2). “Most patients are looking to improve hyperpigmentation in some of these areas, which is often related to hormonal changes, particularly after pregnancy and during menopause, excessive shaving, the use of certain deodorants or antiperspirants or even clothes that cause friction,” Dr Martín Hernández explains. Before a procedure, Dr Martín Hernández tells patients not to wax or shave for 48 hours and avoid sun exposure for a week. During treatment, Dr Martín Hernández says she continually checks in with the patient and, if they experience any intense pain, such as itchiness, increasing burning sensation or have an allergic reaction, it is removed immediately. She provides three to six sessions, seven to 10 days apart, for best results. Before

After

Figure 1: Before and after six weekly sessions with the Pink Intimate System. Images courtesy of Dr Beatriz Martín Hernández.

as the Sensi but double the strength, this peel can really tackle more advanced ageing concerns and scarring, she says. Prescription-only peels could also be an option, with Young highlighting that these are her favourite. “In the prescription range we have 4% and 6% pure retinol peels. Of course they are blended, so we can flood the skin with beneficial actives such as marigold, silymarin, olive fruit oil and vitamin E, as well as tackling skin concerns with this

“Optimised skin health is the absolute key component of any treatment within medical aesthetics” Susan Young

Before

After

Figure 2: Before and after five weekly sessions with the Pink Intimate System. Images courtesy of Dr Beatriz Martín Hernández.

high-strength protocol,” she explains. Dr Martín Hernández offers the V-Carbon Peel System to her patients. “I like it because of its unique properties,” she says, explaining, “It’s carbon activated, which purifies and detoxes the skin, while its active peeling ingredients – ferulic acid, mandelic acid and lactic acid – work to brighten, regenerate and reduce inflammation of the skin.” This enables the peel to treat open pores, acne and pigmentation, notes Dr Martín Hernández, highlighting that patients find it is almost like having a facial. She says, “This is a really nice thing to say about a peel because, yes, there will be flaking and a bit of dryness, but the immediate effects are brightened, detoxified skin that satisfies patients!”

Administering a peel Some practitioners recommend avoiding peeling in the summer months, however Young says, “We can use any of the peels,

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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Before

Figure 3: Before and after images showing an improvement in deep dermal pigmentation following a course of four Pure Retinol 6% peels. Images courtesy of Susan Young.

particularly the more gentle peels as long as patients are educated around the ‘non-negotiable’ use of SPF and keeping out of the sun as much as they can due to the possibility of pigmentation.” Before you administer a peel, the practitioners advise investigating your patient’s current skincare regime. Young says, “We will tell patients to avoid using actives such as retinols or AHAs prior to treatment, and may also get them on a redness-reducing serum or a really good cleanser such as Dual Action Redness Relief, which is high in niacinamide to help improve the barrier function and reduce transepidermal water loss, along with InflaShield, which is a patented ingredient that reduces sub-clinical inflammation. This product is great to help prep the skin for a peel,” she says. Dr Vyas also recommends finding out more about any cultural products or practices patients engage in, which is particularly common amongst those with skin of colour. Questions she suggests asking are, “Do you do a lot of exfoliation/scrubbing of your skin? Do you use lemon juice? Do you use any products that I may not be familiar with?” It’s also advisable to consider the use of hair dye and how often patients are dying their hair or using treatment on it, as the ingredients could negatively react with the peel. Dr Vyas says, “This is of course relevant for everyone, but we find that in patients with skin of colour there is a lot more usage.”

After

Figure 4: Before and after images showing an improvement in rosacea following a course of four Sensi peels. Images courtesy of Susan Young.

highlighting that she adds two weeks more for skin of colour patients, which she says can make a significant difference. “Putting your patients on products that contain poly hydroxy acids will help strengthen the skin barrier, ahead of adding stronger or more exfoliating ingredients, which is particularly important in darker skin as it’s more prone to dermatitis,” she adds. When it comes to performing the peel, the practitioners highlight how important it is to always follow the product’s protocol, no matter how many treatments you’ve performed with other brands. “Protocols from one brand won’t be the same as others, so do not mix them up,” says Dr Vyas, adding, “A patient’s skin may also have gone through a change since the last time they saw you, so it’s always important to start at the lowest strength and follow the protocol to avoid unwanted side effects.” So how often should you peel patients’ skin? “It depends on the type but, usually,

one superficial peel isn’t going to solve all of your patient’s skincare problems,” says Dr Vyas. Young agrees, emphasising that she would never recommend a singular peel unless it was deep, and will offer more treatments if a patient has significant ageing concerns, and fewer to those with sensitive skin. They agree that educating patients on what to expect is essential, as it isn’t an overnight treatment. The practitioners advise spacing superficial peels about one month apart and offering a course of between three and six, depending on the patient’s concern and budget, with a maintenance peel every three months. “You would normally start to see a glow and improved hydration after the first couple, but patients will need to wait approximately three months to see improvement in specific skin conditions such as hyperpigmentation or acne,” explains Dr Vyas, noting that this will, of course, be improved if patients stick to their home skincare routine.

“Irritation or inflammation in darker skin is the precursor to post-inflammatory hyperpigmentation” Dr Amiee Vyas

Skin should be prepped for a couple of weeks prior to the peel, with Dr Vyas

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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After

and, therefore, undesired side effects,” notes Dr Martín Hernández, while Young highlights that you could also see unwanted pigmentation changes. That being said, the practitioners agree that if the patient’s skin is prepped appropriately, they will have a more controlled response. As mentioned, explaining the side effects to patients is essential. “If patients aren’t informed correctly and look at themselves in a mirror straight after treatment, they may be shocked,” warns Dr Vyas, adding that if you think your patient may not be compliant with applying their sunscreen, then it may not be worth treating them. “They’re going to be more at risk of scarring and hyperpigmentation,” she says.

Figure 5: Before and immediately after the first session with the V-Carbon Peel. Images courtesy of Dr Beatriz Martín Hernández.

Post-procedure skincare Keeping on top of skincare is essential, with Young highlighting that by doing so patients are treating their skin 60 more times in a month. “With an effective morning and evening routine, we can help advance results effectively,” she says. Before patients leave clinic, Young says, “We hydrate and protect the skin, so patients are going home glowing rather than bright red and sore!” She recommends the Vitamin B3 Brightening Serum, a blend of peptides, antioxidants and a highly therapeutic dose of 6% niacinamide, which aims to help inhibit melanogenesis and boost barrier function. “We always finish our treatment protocols with an application of either PCA Skin Weightless Protection Broad Spectrum SPF 45 (with antioxidants) or PCA Skin Hydrator Plus Broad Spectrum SPF 30 with antioxidants and sodium hyaluronate. Patients leave with a post-procedure kit made up of calming hydrators and an SPF to ensure the best recovery possible,” she says. Dr Martín Hernández recommends the Medik8 post-treatment kit, which includes a cleanser, recovery cream and SPF 50. “Patients need to continue to hydrate the skin and protect it from the sun,” she says, advising that patients should avoid using retinol-based products for one to two weeks before and after treatment, as the skin will be

sensitive and it can lead to more irritation. Sunscreens are an essential part of any skincare routine, with Dr Vyas’ recommended products being the Epionce Ultra Shield, which she says has skin barrier conditioning ingredients and NeoStrata Sheer Hydration, which contains the patented Neoglucosamine – a potent tyrosinase inhibitor to help resurface and brighten skin. Young will finish off every treatment with an application of either Weightless Protection Broad Spectrum SPF 45 or the Hydrator Plus Broad Spectrum SPF 30. For darker skin types, Dr Vyas says tinted SPFs are valuable, noting that Obagi Sun Shield Tint Broad Spectrum SPF 50 Warm is an excellent choice for Asian patients, as is Intradermology SPF50 Synergy 6, while Oxygenetix and Ultra Violette have a huge range of shades to choose from.

Monitoring the patient throughout treatment is essential, agree the practitioners, highlighting it’s important to get their continued feedback to be able to react accordingly. Training is also imperative to any treatment. “Particularly with peels,” says Dr Vyas, who points out that what you think may be a complication is actually just the normal sequelae of the treatment. Knowing what’s meant to happen and when something may be wrong is imperative, the practitioners agree. As with all patients, the practitioners highlight that starting with low strength peeling is vital when treating any skin type, particularly skin of colour. “You don’t want to risk irritating skin with higher strength peels, as irritation or inflammation in darker skin is the precursor to post-inflammatory hyperpigmentation,” says Dr Vyas. Young concludes, “A progressive, not aggressive, approach is always best for every patient.” REFERENCES 1. Hannah Coates, Samantha Jones’s Disastrous Skin Peel was the Most Farfetched SATC Storyline of All (UK: Vogue, 2021) <https://www.vogue.co.uk/beauty/article/skin-peels> 2. SkinLaboratory UK, PromoItalia Pink Intimate System (UK: SkinLaboratory UK, 2022) <https://skinlaboratory.uk/product/ promoitalia-pink-intimate-system/>

Considerations In general, peels are safe to use to optimise your patients’ skin health. However, it is essential that the correct protocols are followed and patients are selected appropriately. Depending on the depth of the peel, the practitioners explain that the expected side effects can include redness, stinging and burning. “If you leave it on too long, it can be uncomfortable and the peel is able to travel to deeper layers of the skin causing damage

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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Case Study: Treating the Mid-Face and Perioral Area Independent nurse prescriber Susan Young discusses her treatment tips for the mid-face and perioral regions A 58-year-old patient presented to my clinic with concerns of looking old, having become aware of drooping and noticing a sunken mouth. She had no medical history of note and had received dermal fillers many years ago with no issues. During the consultation, I used ageing anatomy to explain to her the changes that she was experiencing and pointed out that her main concerns were due to bone reabsorption, mainly in the maxilla. When assessing her face, I noted that she had some characteristic enlargement of the piriform aperture leading to deepening of the nasolabial folds, and had signs of deflation and ptosis in the medial and lateral suborbicularis oculi fat (SOOF). Her most superficial middle cheek fat pad was also showing ptosis and this created a midcheek groove. Periorally, she had rhytids due to the loss of subcutaneous fat. We discussed these issues in depth and decided together that I would address her midface and perioral region with appropriate dermal filler.

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Finally, I treated the lips themselves. When injecting the superior perioral rhytids I always use RHA® 1 as it’s a really sophisticated blend of cross-linked and non-cross-linked filler. We don’t want to create any volume in the upper lip, so using a fine filler with a 25 gauge cannula can gently subsize the retinacula cutis fibres, particularly when using a fanning technique. The patient had one or two slightly deeper lines, so I also injected those very superficially using micro boluses intradermally, avoiding the philtral columns so that I didn’t risk going into the columella arteries.

Top tips for success The most important thing I recommend is getting to know your ATP – this stands for anatomy/ageing/ assessment, technique and products. When analysing your patient’s face, I always like to advise practitioners to follow a superior to inferior way of assessing, as well as lateral to medial.

Product selection and technique For treating the mid-face, I decided to use Teosyal® PureSense Ultra Deep (PS Ultra Deep) because of its strong lifting capacity. I injected into the periosteum in the region of the medial cheek fat, and placed a small amount in the medial and lateral SOOF. I used a 27 gauge needle, avoiding the infraorbital foramen and the transversal artery, which lies inferior to the zygoma. I used boluses so as to provide structural support, using a total of 1.2ml. I then fanned 2.4ml of RHA® 4 into the preauricular sulcus area using a 25 gauge cannula, concentrating on the mid-cheek groove. RHA® 4 is a powerful volumiser, and has a fantastic stretch capacity so it creates a lovely contour to the cheek, while also respecting natural facial expressions. To help support the cheek area, I injected another 0.6ml of PS Ultra Deep into the deep piriform aperture using a 27 gauge needle, deep to the periosteum. It’s important not to forget this area when treating the mid-face as I’ve found that it’s a really effective area to augment. To create support for the perioral area I injected 1.0ml of RHA® 3 into the nasolabial folds, superficially using a 25 gauge cannula. RHA® 3 has great strength and integrates beautifully into the skin. I also used 1ml of this filler to inject the marionette lines, the area medial to the mandibular ligament which is called the marionette compartment and then the mental crease, all using a fanning technique.

I also injected the vermillion border to give the lips more definition, shape and structure. I used a 4mm 30 gauge needle to introduce RHA Kiss® into the virtual canal, allowing it to travel through without having to use multiple injection points. Overall I injected 1.7ml into the lip area. The patient was delighted with her result because although we used quite a lot of filler, she got a nice subtle outcome, and she had no side effects to note. Susan Young is an independent nurse prescriber and owner of multi-centre aesthetic training group, Northern Institute for Facial Aesthetics. She is also a Teoxane Regional Expert and founder of Young Aesthetics. Qual: RGN, BSc, INP, MBACN

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Managing Psoriasis Dr Lola Meghoma outlines treatments for psoriasis and their efficacy Psoriasis is a multi-factorial chronic inflammatory skin disorder estimated to affect around 1.5% of the UK population.1 It is characterised by symmetrically distributed, well-demarcated plaques covered in a silvery scale. Plaques tend to appear pink-red in lighter skin types but can be violaceous or brown with associated post-inflammatory pigment changes in darker skin types.2 Psoriasis can have a profound effect on quality of life and has been associated with an increased risk of psychiatric comorbidities.3,4 The condition is also associated with a number of comorbidities, including psoriatic arthritis, cardiometabolic disease and inflammatory bowel disease.5 A holistic approach to management should therefore be adopted, taking into account lifestyle factors and the psychological and physical burden of the disease.

areas, whereas body sites with thicker lesions often require more potent corticosteroids such as betamethasone 0.05%.12 Frequent and prolonged use of topical corticosteroids may result in skin atrophy and striae.11 Rare systemic effects such as suppression of the hypothalamus, pituitary and adrenal gland axis can be minimised by limiting the long-term use of high-potency topical corticosteroids on large body surface areas.11 A number of comparative studies have demonstrated that the combination of potent corticosteroids with vitamin D analogues provide an advantage above other first-line combination topical therapies and monotherapy.13-15 In combination, these agents are also better tolerated and can be applied once a day at different times or in a fixed combination preparation.15

General approach

Topical vitamin D analogues Topical vitamin D analogues are also used as first-line agents. They exert their effect in psoriasis through inhibiting keratinocyte hyperproliferation and abnormal differentiation.16 Vitamin D analogues perform at least as well as topical corticosteroids and can be used long-term.11 However, they are more likely to cause local adverse events such as burning or irritation.11 Vitamin D analogues can be used as an alternative or as an adjunct to topical corticosteroids. There are three types of vitamin D analogues available for prescription in the UK: calcipotriol, calcitriol and tacalcitol.17 Calcitriol and tacalcitol are less irritating and therefore may be better suited to sensitive areas of the skin.17 Due to the risk of hypercalcaemia, topical vitamin D analogues are contraindicated in patients with calcium metabolism disorders, and severe liver and kidney disease.17

Management of psoriasis should address lifestyle factors that have been associated with the condition, such as smoking, alcohol intake, weight management and exercise.6 Disease severity can be established through using measures such as the Body Surface Area (BSA) score and the Psoriasis Area and Severity Index (PASI) score.7 The definition of mild, moderate and severe psoriasis varies worldwide. Mild skin disease can often be managed with topical therapy, whereas moderate-to-severe disease may require phototherapy or systemic agents. Patients suitable for systemic therapy include those with greater than 10% BSA involvement, involvement of special sites (e.g. scalp, genitals, palms, soles, face) and non-responders to topical therapy.8 Insight into the psychological impact of the disease and its effect on quality of life can be assessed with tools such as the Dermatology Life Quality Index (DLQI).7 Treatment goals should be established with the patient, and the treatment modalities chosen should be based on disease severity, efficacy, comorbidities and patient preference.

Topical therapies Topical therapies are the cornerstone of treatment in localised psoriasis. Emollients are valuable adjuncts in the management of all psoriasis patients and help minimise itching and keep the skin moisturised.9 Different formulations of topical therapies can be chosen according to the site being treated. Lotions, gels and foam are best for hair-bearing areas, creams for inflamed skin and ointments for dry, thickened skin.10 Topical corticosteroids Topical corticosteroids exert an anti-inflammatory, anti-proliferative and immunosuppressive effect and are used as a first-line agent.11 They are typically applied once or twice daily in the presence of thick, active plaques and can be applied intermittently, thereafter as maintenance (e.g. twice a week).12 Low-potency corticosteroids such as hydrocortisone 1% are suitable for the face and intertriginous

Topical calcineurin inhibitors Topical calcineurin inhibitors work by inhibiting the T cell activation of the pro-inflammatory cytokines IL-2 and IFN-γ.16 Topical tacrolimus 0.1% and pimecrolimus 1% are used off-label as second-line agents for difficult-to-treat sites such as flexural, facial or genital psoriasis.16,18 A randomised controlled trial of 57 patients with moderate-to-severe flexural psoriasis demonstrated that 71% of patients achieved clear or almost clear psoriasis after eight weeks of twice-daily treatment with pimecrolimus 1% cream.19 Topical calcineurin inhibitors are generally well tolerated and avoid the risk associated with chronic topical corticosteroid use.18 Common side effects include skin irritation such as burning, stinging and itching.18 Topical keratolytics Topical keratolytics used for psoriasis include tazarotene and salicylic acid. Tazarotene is a third-generation topical retinoid that downregulates keratinocyte proliferation, keratinocyte differentiation and the expression of pro-inflammatory genes.16 Topical tazarotene is suitable for patients with mild to moderate plaque psoriasis affecting up to 10% of the body surface area.20 Due to the risk of teratogenicity, it is contraindicated in pregnancy and an effective form of contraception is required during treatment.20 Common side effects include skin irritation such as erythema, burning and pruritus.

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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Coal tar Coal tar has been used in the management of psoriasis for several decades due to its anti-inflammatory and anti-proliferative effects. Its mechanism of action remains unknown, but is thought to involve aryl hydrocarbon receptors.21 Several coal tar preparations are available, including lotions, ointments, shampoos and bath additives.22 Tar preparations can be messy, stain and have an unpleasant odour.22 Due to this, more modern treatments have reduced its popularity. Dithranol Dithranol inhibits keratinocyte hyperproliferation and has been used for several decades as an effective treatment in psoriasis.23 Dithranol is available in cream, ointment and gel formulations.24 Due to the risk of skin irritation, it is applied as a short-contact regime that is gradually titrated.23 Its use is limited due to the risk of skin irritation and staining of skin, hair and fabrics.24

Phototherapy Phototherapy is an effective treatment option in moderate-to-severe psoriasis. UV radiation has demonstrated benefits in psoriasis through its anti-proliferative effects and immunosuppressive effect via inducing T cell apoptosis.25 The main types of phototherapy used for psoriasis include narrowband ultraviolet B (UVB) radiation, broadband UVB radiation, targeted phototherapy and psoralen ultraviolet A (PUVA).26 Adverse effects of phototherapy include skin burning, itching, blistering, photoageing and photocarcinogenesis.26 Initially, treatment is two to three times a week which may limit its use due to the required time commitment.26 Narrowband UVB phototherapy involves the delivery of 311 to 312 nm of UVB radiation.27 Broadband UVB radiation delivers between 290-320 nm of UVB radiation.27 In practice, narrowband UVB phototherapy is preferable to broadband UVB phototherapy due to its efficacy, quicker treatment response and lower rates of adverse effects.26 However, there is a lack of high-quality, randomised trials reviewing this.12,27 PUVA therapy involves the administration of psoralen followed by the delivery of 320-400 nm of ultraviolet A (UVA) radiation.27 Psoralen enhances the effects of UVA and is administered either orally or topically.27 Topical PUVA may be used for palmoplantar psoriasis, however there is a higher incidence of palmar hyperpigmentation when compared to narrowband UVB phototherapy.27 Oral PUVA therapy appears to lead to longer-lasting clearance with fewer treatments required when compared with narrowband UVB phototherapy, although current evidence is very heterogenous.27

Oral systemic therapy Oral systemic treatments have been used in moderate-to-severe psoriasis for many years prior to the advent of biologic agents. The most commonly used agents include methotrexate, ciclosporin, acitretin, apremilast and fumaric acid. Methotrexate Methotrexate is a folic acid antagonist that has been used in the management of psoriasis and psoriatic arthritis for more than half a century and is considered a first-line oral systemic agent.12,29 It has been suggested that methotrexate works through decreasing circulating cutaneous lymphocyte-associated antigen-positive T cells, therefore decreasing inflammatory infiltrate to the dermis and epidermis.29 Oral methotrexate is given once weekly. Patients taking methotrexate are at risk of hepatotoxicity and liver fibrosis.

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This incidence is increased in obesity, diabetes mellitus, excessive alcohol consumption and hyperlipidaemia.30 Liver function tests, serial serum procollagen III levels and transient elastography can be used as methods of surveillance for liver fibrosis.28 Subcutaneous methotrexate may confer greater efficacy and bioavailability.31 A multicentre, randomised controlled trial of 120 patients with moderate-to-severe plaque psoriasis demonstrated a PASI 75 response in 41% of patients receiving subcutaneous methotrexate and a favourable 52-week risk-benefit profile.31 It is typically used in patients that fail to respond to oral therapy or have gastrointestinal side effects with oral therapy. Ciclosporin Ciclosporin is a calcineurin inhibitor that suppresses T cells and the production of IL-2 and other pro-inflammatory cytokines.32 It is highly effective in psoriasis and rapid acting. In a multi-dose, randomised controlled trial of 85 patients with severe psoriasis, treatment with 3, 5 or 7.5mg/kg/day of ciclosporin resulted in clear or almost clear psoriasis in 36%, 65% and 80% of patients respectively.33 Although highly effective, ciclosporin has significant adverse effects including hypertension and irreversible nephrotoxicity with long-term use.28 Acitretin Acitretin is an oral synthetic retinoid that decreases keratinocyte hyperproliferation and pro-inflammatory cytokines including IL-6 and IFN-γ.28, 34 It is used in the management of severe plaque psoriasis, including pustular, erythrodermic and palmoplantar psoriasis.28 In a randomised, double blind dose ranging study of 61 patients with severe chronic plaque psoriasis, PASI 75 was achieved at week 12 in 47%, 69% and 53% of patients taking 25, 35 and 50 mg/day of acitretin respectively.34 Due to the risk of teratogenicity, it should be avoided in women of child-bearing age and pregnancy is contraindicated for three years after discontinuation of the drug.35 Apremilast Apremilast is a phosphodiesterase 4 inhibitor that leads to the downregulation of multiple cytokines including IL-2, IL-12, IL-17 and TNF-α and the upregulation of anti-inflammatory cytokines such as IL-10.36 It is used in the management of moderate-to-severe psoriasis and psoriatic arthritis with modest efficacy. A multicentre randomised controlled trial of 844 patients demonstrated 33% of patients with moderate-to-severe psoriasis taking apremilast 30mg twice daily achieved PASI 75 at week 16, compared to 5% in the placebo group.36 Adverse effects include nausea, diarrhoea, upper respiratory tract infection and weight loss. Apremilast should be used with caution in patients with a history of depression due to the association between apremilast and suicidal thoughts and behaviour.37 Fumaric acid esters Fumaric acid esters have been used to treat psoriasis for many years in some European countries. Dimethyl fumarate is licensed in the UK for moderate-to-severe plaque psoriasis.38 In a randomised double-blind controlled trial of 671 patients, 37.5% of patients with moderate-to-severe psoriasis treated with dimethyl fumarate achieved a PASI 75 at week 16 compared to 15.3% receiving placebo.38 Common adverse effects include flushing and gastrointestinal upset, which can occur in up to 40% of patients.28 Severe prolonged lymphopenia has been reported in patients taking dimethyl fumarate, increasing the risk of progressive multifocal leukoencephalopathy.39

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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Biologic agents Biologics have revolutionised the management of patients with moderate-to-severe psoriasis and psoriatic arthritis. They act at a cellular level, targeting specific inflammatory mediators in psoriasis. The four classes of biologics used in the treatment of psoriasis are TNF-α inhibitors, IL-12/23 inhibitors, IL-17 inhibitors and IL-23 inhibitors.40 A Cochrane network meta-analysis has demonstrated that a higher proportion of patients reach PASI 90 taking biologics compared to non-biological systemic agents.40 In particular, the most effective drugs for reaching PASI 90 when compared to placebo were infliximab, ixekizumab, bimekizumab and risankizumab.40 Eligibility for biologics under the National Institute for Health and Care Excellence (NICE) guidelines requires patients to be unsuitable for conventional oral systemic agents, a DLQI >10 and PASI ≥ 10, or have localised severe psoriasis associated with significant impairment.41 Prior to the initiation of a biologic agent, patients should be screened for tuberculosis, HIV and hepatitis B and C. TNF-α inhibitors This is the oldest class of approved biologics and includes adalimumab, certolizumab pegol, etanercept and infliximab. Certolizumab pegol is a pegylated humanised antibody fragment and unlike other biologics, it does not cross the placental barrier and can be used in pregnancy.28 Network meta-analysis of 60 clinical trials demonstrated that infliximab has the highest efficacy of this class, with 80% of patients achieving PASI 75 at week 10.16,42 Adverse effects of TNF-α inhibitors include risk of latent TB reactivation, upper respiratory tract infection and injection site reactions. TNF-α inhibitors should not be used in patients with demyelinating diseases, advanced heart failure or severe infection (e.g. active tuberculosis).16 IL-12/23 inhibitors Ustekinumab is a human monoclonal antibody that inhibits the common p40 subunit of IL-12 and IL-23 and is approved for treatment in psoriasis and psoriatic arthritis.28 Dosing is weight-dependent and is administered every three months. Common adverse effects include upper respiratory tract infection, headache, gastrointestinal upset and achiness around the time of injection. A five-year follow-up study that included 3,117 patients demonstrated no dose-related or cumulative signs of increased risk of severe infection or malignancy.43 IL-17 inhibitors The IL-17 inhibitors are approved for management of both psoriasis and psoriatic arthritis. This class has high efficacy and a fast onset of action.40,42 Secukinumab and ixekizumab inhibit the IL-17A ligand, bimekizumab inhibits IL-17A and IL17F ligands and brodalumab inhibits IL-17 receptor a.16 A phase III randomised trial of 149 patients suggests that moderate-to-severe genital psoriasis responds favourably to ixekizumab, with statistically significant reductions in genital itch and reduced limitation in sexual activity.44 IL-17 inhibitors should be avoided in patients with inflammatory bowel disease due to the risk of exacerbation. Due to the role of IL-17 in preventing candida infections, IL-17 inhibitors have been associated with mucocutaneous candidiasis.45 There has also been concern regarding the risk of suicidal ideation and completed suicide in patients being treated with brodalumab, but a causal relationship has not been confirmed.46

IL-23 inhibitors The IL-23 inhibitors target the p19 subunit of IL-23 and reduces the activity of the Th17 axis.28 Approved agents include guselkumab, risankizumab and tildrakizumab.40 This class has a less frequent dosing regime, making it more convenient for patients.16 The IL-23 inhibitors have an acceptable safety profile and demonstrate no increased rates of serious infections or malignancies.40 Adverse effects include upper respiratory infections and superficial fungal infections.16

A proactive approach Psoriasis is a chronic inflammatory disorder that is associated with significant morbidity and psychosocial burden. Topical agents, phototherapy and oral systemic agents remain an important component in treatment of the majority of patients. Advancements leading to the introduction of biologic agents has transformed the management of patients with moderate-to-severe psoriasis. A proactive approach to management is essential, with treatment choice taking consideration of disease severity, efficacy, relevant comorbidities and patient preference. Dr Lola Meghoma is an internal medicine trainee at East Surrey Hospital. She studied medicine at the University of Liverpool and completed her foundation training in London. Dr Meghoma will be starting as a clinical fellow in dermatology at Whittington Hospital. Qual: MBChB, MSc, MRCP(UK)

Test your knowledge!

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

Possible answers

1.

What is a contraindication to starting a topical vitamin D analogue?

a. b. c. d.

Generalised pustular psoriasis Breastfeeding Severe kidney disease A patient taking a thiazide diuretic

2.

What examination/investigation should be complete prior to starting ciclosporin?

a. b. c. d.

Eosinophil count Blood pressure Thyroid function test Pregnancy test

3.

Which investigation is not suitable for ongoing surveillance for hepatoxicity and liver fibrosis in patients taking methotrexate?

a. b. c. d.

Transient elastography Serial serum procollagen III levels Liver biopsy Liver function test

4.

What is the recommended maximum length of time ciclosporin should be used for?

a. b. c. d.

6 weeks 2 months 10 months 12 months

5.

Which biologic agent would be the best option for a patient with genital psoriasis?

a. b. c. d.

Ixekizumab Certolizumab Ustekinumab Adalimumab

Answers: C, B, C, D, A

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Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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ac t i vat e Skin r e n e wa l Sculptra stimulates natural collagen production to gradually restore firm skin1,2

Find out more about Sculptra by following @Galderma.AestheticsUK on Instagram

Adverse events should be reported. For the UK, Reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for Yellow Card in the Google Play or Apple App Store. For Ireland, Suspected adverse events can be reported via HPRA Pharmacovigilance, Website: www.hpra.ie; Adverse events should also be reported to Galderma (UK) Ltd, Email: Medinfo.uk@galderma.com Tel: +44 (0) 300 3035674 1. Goldberg D, et al. Dermatol Surg. 2013;39(6):915–922. 2. Hexsel D, et al. Dermatol Surg. 2020;46(8):1122–1124. UKI-RES-2200130 DOP March 2022


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Local anaesthetic Many skin surgeons use 1-2% lidocaine (10-20mg/ml) mixed with adrenaline 1:80,000-1:200,000. This works well and is freely available to medical practitioners from suppliers. The adrenaline causes vasoconstriction, helping to reduce bleeding.6

How are skin lesions removed?

Treating Skin Lesions Dr Keli Thorsteinsson outlines how to treat skin lesions safely and the common techniques Before you start treating skin blemishes, practitioners need to hone their lesion recognition skills. This is because they must minimise the risk of inappropriately removing or destroying a lesion which turns out to be cancerous.1 Incorrectly treating a blemish could lead to potential harm for the patient. In this article, I will consider how to avoid this, and outline common pitfalls in skin surgery.

Preparation Skin surgery is a regulated activity in the UK, so the premises must be registered and inspected by the relevant regulator in your country or region of the UK (CQC, CIW, HIS, RQIA). It will likely take a few months to set up a new skin surgery service to meet the regulatory demands and ensure that you have the appropriate equipment and safety protocols in place. Practitioners must have completed an approved training course in skin surgery which offers a certificate of completion, and have medical indemnity before starting.2 Infection control Practitioners will already be familiar with appropriate infection control measures. Infection risk is higher in skin surgery

than in aesthetics, so practitioners should pay attention to hand hygiene, choice of gloves, skin preparation, drapes, use of aprons and hats, as well as careful aseptic technique. Practitioners need written standard operating procedures for each element of the service and must train staff accordingly. This includes a written protocol on hand washing, opening a surgical pack, clearing up post-treatment, instrument counting and suture removal. Instruments need counting after surgery to minimise the risk of the patient leaving the premises with a needle or sharp object on their clothes or hair, leading to injury to them or others they meet.3 Practitioners must have a separate needle-stick policy and procedure in place.3 Consent As part of the Good Medical Practice guidelines, practitioners must obtain signed consent from patients, with details of the procedure, body site treated, side effects and possible complications. You also should assess the patient’s ability to give informed consent.4 The regulator will expect practitioners to have a consent and capacity policy and procedure detailing how capacity is assessed and what to do when capacity is in question.5

Cautery Cautery is the process of delivering electricity to the skin, causing heat and a controlled burn. Cautery machines have energy settings according to the area being treated. Many practitioners use a Hyfrecator device, which is easy to use and has a good safety record.7 Other reputable manufactures include Schuco. To cauterise a lesion, touch the lesion until it chars black. Wipe the blemish away with a swab and repeat until the lesion is gone and bleeding has stopped. Generally, two to three cycles are sufficient. Cautery on its own is suitable to treat spider naevi, small skin tags, cherry haemangiomas, syringoma, milia and sebaceous hyperplasia.3,8 Snip and cautery In my view, this is the best way to remove larger skin tags as they are easy to grab with a pair of forceps, allowing the practitioner to snip the base with surgical scissors. Place a small amount of anaesthetic at the base and cauterise to stop bleeding. Occasionally, this technique may result in a full thickness wound. If this happens and the bleeding does not stop with cautery, consider placing one to two haemostatic sutures on the skin and remove a week later.3,8 Curettage and cautery I use a 4 or 7mm ring curette according to lesion size. After numbing the area, scrape from the periphery towards the centre to remove tissue and cauterise to stop bleeding. Two to three cycles of scraping and cauterising may be required before the lesion is removed.3,8 In my experience, this technique works for superficial lesions such as seborrhoeic keratoses. It is also useful when treating larger cherry haemangiomas, syringoma, milia, sebaceous hyperplasia or removing remnants of lesions after snipping or shave excision. Curettage and cautery is a common treatment for low-risk skin cancers or precancer, such as actinic keratosis, Bowen’s disease and superficial basal cell carcinoma.9

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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High-risk sites To treat or not to treat? The safety of patients is paramount. It’s vital that practitioners only treat lesions if they are trained to do so and it’s within their scope of practice. To determine whether you should treat, or refer, consider: • Can I confidently give the lesion a name? If the answer is ‘yes’ (and it is harmless) you may consider treating the lesion without pathology analysis. • If you can’t give the lesion a name, give yourself three choices ONLY: 1. Remove with pathology analysis 2. Refer to a specialist 3. Observe and follow-up after three to six months (take photos)

When treating suspected skin cancer, you must follow guidelines from the National Institute for Health and Care Excellence (NICE).10 If it isn’t within your scope of practice to treat skin cancers, then refer your patient to a suitable practitioner who has experience in treating lesions. Shave excision Shave excision is where a lesion is removed by a blade or surgical knife, without breaching the deeper dermis or requiring sutures to repair the wound. With this technique you rock the device gently as you advance it under the lesion, heading down until reaching the centre of the lesion, then up and out the other side. If the lesion isn’t removed at once, practitioners may use a curette to finish the procedure and cauterise to stop bleeding. This is a preferred technique for removing exophytic lesions, such as dermal naevi and larger seborrhoeic keratoses.3,8 Punch biopsy This is a small ‘apple-corer’, used in the diagnosis of a lesion or rash. They can be used to remove small skin blemishes, such as melanocytic naevi. After placing the anaesthetic, push the tool against the skin while twisting it until the dermis is pierced. Use non-toothed forceps to lift the sample up and snip

Figure 1: Punch biopsy procedure

through the subcutaneous fat with surgical scissors. Practitioners should remove some fat to ensure full thickness removal and a sample for analysis. Interrupted stitches should be placed on the area to stop bleeding from a small wound as well as closing the defect. Stitches can be removed after seven days on the face and 12-14 days on the body.3,8 Surgical excision Surgical excision refers to the removal of a lesion by cutting around it through the skin and the tissue underneath the blemish. It is the appropriate way to remove larger and deeper lesions, such as moles, cysts and suspected or confirmed skin cancers. Practitioners should mark out the lesion and a margin of healthy skin and then an ellipse (‘boat shape’) where the length of the excision is three times the size of the lesion. This should result in a flat scar.3,8 After the skin is numbed, use a surgical blade to incise through the dermis and use forceps and scissors to cut through the subcutaneous fat until the sample is free. Cautery is usually sufficient to stop bleeding, but practitioners should know how to clamp and tie off a bleeding vessel. Once the wound is dry, deep dissolvable stitches are placed to oppose the edges, followed by interrupted non-dissolvable stitches to the surface. Sutures can be removed after seven days on the face and 12-14 days on the body.3,8 An important tip is to ensure no flammable fluids are used to sterilise the skin. This can risk causing a fire or burn to the patient’s skin during cautery. I would remove hazardous materials from your surgical suite. Safe options include 0.05% aqueous chlorhexidine (Unisept) or Clinisept+ Skin, with other brands available.

If practitioners are cutting through the skin, they need to know about high-risk areas. There are locations on the body where motor nerves run close to the skin. Injury to these will cause permanent weakness of the muscles served by the nerve. Examples include injury to the facial nerve over the zygoma, resulting in a weak frontalis muscle and brow drop, and injury to the accessory nerve in the lateral neck, resulting in a weak shoulder. Injury to a blood vessel not responding to cautery can be repaired by clamping the vessel and tying it with a suture. If bleeding is controlled, the patient will not come to any harm. These high-risk sites will be covered in detail on a competent training course in skin surgery.3,8

Pitfalls As with any area of medical practice, there are pitfalls in lesion treatment. To help avoid these issues, follow the advice given in the boxout. Wrong diagnosis Could a melanoma be ‘hiding’ amongst your patients’ solar lentigines, seborrhoeic keratoses and moles?1 Before treatment, ask yourself the questions in the box above. Wrong technique The most common ‘mistake’ is to carry out a shave excision of a ‘mole’, which turns out to be a melanoma. A shave excision may not get to the base of a melanoma, meaning that it cannot be ‘staged’ for treatment planning and prognosis. The way to remove any lesion which could be a melanoma is by complete excision with 2mm margin of healthy-looking skin.9 Recurrence A skin lesion may recur if it is incompletely removed. Incomplete removal of a skin cancer is detrimental for your patient, and therefore practitioners should be careful about treating a lesion without histological analysis (see steps in the boxout). Rare entities All organs of the skin can turn cancerous, and the resulting tumours can initially look innocuous, such as Merkel cell carcinoma. Another rare entity is the seborrheic keratosis-like melanoma – an almost impossible diagnostic challenge. It’s vital that practitioners consider the possibility of rare entities and refer to a specialist if they cannot treat themselves.

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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Being able to recognise common lesions and offer treatments is positive for your patients and may fit well into your practice

Aftercare For small wounds, a spot plaster will suffice, however for larger wounds use a breathable, absorbent dressing. Advise patients to change it every day from day two to three onwards, or use petroleum jelly or a antimicrobial product if they wish to leave the area undressed. The wound should not be soaked with water but cleaned gently every day. Patients should avoid physical activity for a few days or until stitches are removed. Encourage patients to contact the clinic if they have concerns, so any complications can be treated early.8

Complications Infection occurs in up to 10% of skin surgery procedures.11 The rate is low for procedures where no stitches are used, but highest for large excisions and in skin cancer surgery.11 Signs include redness, pain, swelling and oozing of pus. These symptoms are common in the first two to three days, and practitioners may reassure the patient if things are improving over time. However, if symptoms are worsening, review the patient in-clinic.8 When treating lesions, blood can be expected. If the wound oozes blood, advise the patient to press on the area for 20 minutes. If this doesn’t work, additional haemostatic sutures may be required.8 A fluctuant area with an overlying bruise suggests collection of blood in the wound. Advise the patient to cool the area, rest and use painkillers. Anti-inflammatory drugs can

aggravate bleeding and haematomas. Rarely, a haematoma may need lancing.8 Dehiscence (opening up of a stitched wound) is a sign of poor suture technique, infection, patient factors such as smoking or diabetes or not complying with aftercare instructions.12 Practitioners should dress the wound every two to three days and wait for it to heal from the bottom and sides. Skin lesion treatments may result in scar formation. A hypertrophic scar is a thick scar corresponding to the footprint of the procedure, whereas a keloid scar grows outside the confines of the procedure. The risk is highest in areas of skin tension, particularly the upper chest, back and shoulders, and is more common in Fitzpatrick skin types IV-VI.8 Treatment options include silicone gel, topical steroid under occlusion, steroid injections and laser. None are satisfactory and even when treatment is successful, the cosmetic outcome tends to be poor.8

Dr Keli Thorsteinsson is a specialist doctor in secondary care NHS dermatology and a cosmetic practitioner. He has more than a decade of experience in skin cancer diagnosis, reconstructive skin cancer surgery and medical aesthetics. Dr Thorsteinsson is the co-owner and director of Freyja Medical, a dermatology and aesthetic clinic in Wrexham and Nantwich. He also co-runs Clinic Courses, an academy teaching skin surgery and advanced aesthetic techniques to medical practitioners. Qual: MD, DPD REFERENCES 1. Thorsteinsson K, ‘Diagnosing Skin Lesions’, 2022, <https:// aestheticsjournal.com/feature/diagnosing-skin-lesions> 2. NHS, ‘Quality Standards for Dermatology’, 2022, <https://www. pcds.org.uk/files/gallery/dermatolog-standards-final.pdf> 3. British Society for Dermatological Surgery, 3’BSDS/BAD Guidelines’, 2011, <https://bsds.org.uk/resources/bsds-bad-guidelines/> 4. General Medical Council, ‘Good medical practice’, 2014, <https:// www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/ good-medical-practice> 5. Care Quality Commission, ‘Regulation 11: Need for consent’, 2022, <https://www.cqc.org.uk/guidance-providers/regulationsenforcement/regulation-11-need-consent> 6. Niemi G, ‘Advantages and disadvantages of adrenaline in regional anaesthesia’, Best Practice and Research in Clinical Anaesthesiology, 2005, p.229-45. 7. Weyer C, et al., ‘Investigation of hyfrecators and their in vitro interference with implantable cardiac devices’, Dermatologic Surgery, 2012, p.1843-8. 8. Cunliffe T, Chou C, ‘Primary Care Dermatology Society – Skin Surgery Guidelines’, 2007, <https://www.pcds.org.uk/files/ gallery/skin_surgery_guidelines.pdf> 9. Mazzoni D, Muir J, ‘A guide to curettage and cautery in the management of skin lesions’, Australian Journal of General Practice, 2021, p.893-897. 10. National Institute for Health and Clinical Excellence, ‘Improving outcomes for people with skin tumours including melanoma (update)’, 2010, <https://www.nice.org.uk/guidance/csg8/ evidence/2010-update-the-management-of-lowrisk-basal-cellcarcinomas-in-the-community-updated-recommendations-andevidence-on-this-topic-only-pdf-7022614429> 11. Dixon A, et al., ‘Prospective study of wound infections in dermatologic surgery in the absence of prophylactic antibiotics’, Dermatologic Surgery, 2006, p.819-26. 12. National Library of Medicine, ‘Wound Dehiscence’, 2022, <https://www.ncbi.nlm.nih.gov/books/NBK551712/> 13. JAMA Surgery, ‘Patient-Reported Outcomes and Factors Associated with Patient Satisfaction After Surgical Treatment of Facial Non-Melanoma Skin Cancer’, 2018, p.179-181.

Safely treat skin lesions Skin surgery is a fulfilling area of practice with high patient satisfaction.13 There are many training providers which offer courses in lesion diagnosis, dermoscopy and skin surgery. Being able to recognise common lesions and offer treatments is positive for your patients and may fit well into your practice. There are pitfalls, however, and you must ensure that you follow guidance by NICE and fulfil the requirements laid down by the medical regulator of the nation where you practice.

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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Dermal Fillers for Male Patients Dr Kishan Raichura discusses the rise in popularity in non-surgical treatments for male patients FOR HEALTHCARE PROFESSIONALS ONLY Dermal filler implants can be used for beautification/enhancement, transformation, correction, and eventually, with the progression of time, to effect positive ageing. In younger male patients who generally do not face the issues of skin laxity, fat pad deflation or ptosis, the objectives for treatment might solely be the enhancement of existing masculine features. The mature male face however, requires a different brief, requiring subtle re-support of the classic areas of ageing mentioned above.

Product selection As practitioners there are many considerations for choice of product in these patients. As well as the product performance and rheology, safety is a principal concern. For both of my cases here I used fillers from the Merz Aesthetics range. I have personally never had any complications using them, and furthermore the safety data with regards to the BELOTERO® and RADIESSE® range of fillers is robust. The UK incidence of complication such as delayed onset nodules

The mandible as a focus for treatment in a full-face approach Enhancement of the existing jaw anatomy is an often-requested target for this type of treatment. A generous mandibular dimension in the frontal plane conveys the look of masculinity and is an attractive secondary sexual characteristic. During puberty the male facial skeleton widens at the mandibular body, ramus, and the chin under the virilising influence of the potent androgenic hormone dihydrotestosterone. These bony changes herald the transition of a boyish face to a more mature masculine profile. Perhaps at an unconscious level it is this observation of developmental changes in puberty that highlight the relationship between androgenic hormones and male anatomy that makes this a desired facial feature. 48

The excellent tissue integration is a result of Merz Aesthetics CPM technology6

Aesthetics | September 2022

is significantly low.1,2 When using a higher G-prime hyaluronate filler to sculpt and add definition in the male face, it is also reassuring to use products that have proven ease of extrusion, consistent volumising effect3 and durability4 in the case of BELOTERO® Volume for up to 18 months. Patients treated at our clinic have been extremely happy with results from BELOTERO® fillers, which is reflected in the research with high patient satisfaction rates and in global aesthetic improvement scales,5 thanks not only to the rheology but also to the excellent tissue integration which is a result of Merz Aesthetics CPM technology.6 With my cases, in addition to using the BELOTERO® HA portfolio, I also used RADIESSE®, a calcium hydroxyapatite biostimulator injectable from Merz Aesthetics, which is my ideal product, over and above hyaluronate fillers to define contours in the lower face. While research studies have supported this observation and preference, in my practice, I generally reserve this for patients who have already experienced, and most importantly, happy with, enhancements of the lower face previously with a reversible hyaluronate treatment.7 In these patients, the bio-stimulating effect following placement of RADIESSE® results in formation of denser collagen and elastin fibre networks within nine months.8


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Case study 1 After a thorough consultation with my youthful-looking 30-year-old patient, we planned a course of treatment using BELOTERO® hyaluronate fillers and RADIESSE® biostimulator injections.

Patient goals for treatment To achieve a more handsome, masculine, alert and attractive appearance through widening the jaw and the lateral aspects of his cheekbones. He requested for a more ‘angular’ look rather than the softer contours he presented with. We also noted that his temporal region was somewhat concaved, and while in a male face a mild depression here or a flat surface can be attractive, we decided to target this area too.

Identified areas for enhancement • Temples – to lift concavity to a flatter, more youthful appearance. • Mandibular contour – to widen and define further the posterior body, angle and the ramus of the mandible. • Zygomatic arches – to create more definition and a slightly sharper, more defined look. • Apex of the nasolabial fold – while the depth of the parenthesis was mild, we took the opportunity to treat this at the same time.

Jawline: 4.5ml total of RADIESSE®. I used a cannula from the mid-point of the mandibular ramus, working my way backwards towards the angle, in the superficial subdermal plane delivering threads of 0.05ml of product with each pass with a total of 1.5ml for each side. I used a second entry point at the posterior mandible to work in an upwards direction to augment the ramus portion of the jaw, delivering 0.75ml of product each side.

waiting 10 seconds of aspiration, to lower the risk of intravascular injection.

Outcomes

Apex of the nasolabial fold: 0.6ml total of BELOTERO® Volume. I used a 27 gauge needle to place 0.3ml of product at the base of each of the nasolabial folds, injecting after

The patient was counselled and consented for the common and rarer side effects and complications of having treatment. Within one week, the immediate post treatment swelling after receiving a total of 7.5ml of product, had completely resolved and there had been no bruising or other issues. At the one month review appointment, the patient reported being very happy with the results.

Before

After

Before

After

Treatment Temples: 1ml total. 0.5ml BELOTERO® Volume per temple using a supraperiosteal injection with careful aspiration for 10 seconds prior to delivery of the product. In this area, the superficial artery should be located and injections directed away to avoid complications. Zygomatic arches: 1.4ml total. 0.7ml BELOTERO® Volume injected using a cannula in a horizontal vector, similar to the Frankfort plane, injecting product in line with lower aspect of the arch. This effects a more masculine look than using product in an upward vector or in the upper aspect of the arches which may be more appropriate when treating the female face.

Figure 1: 30-year-old patient before and after BELOTERO® hyaluronate fillers and RADIESSE® biostimulator injections

Aesthetics | September 2022

49


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Case study 2 The next patient is an already very good-looking 42-year-old-male who had never had dermal filler treatment before and decided to try some facial volumising for slightly different reasons.

Patient goals for treatment His chief areas for improvement were for his eyes to look less tired, to regain some firmness of the lower face and to improve his cheek contour, which was looking a little sunken. He also wished to look more masculine and handsome, however in his case we had to address some classical signs of facial ageing too.

Identified areas for enhancement • Temples – to lift the temporal concavity for a more youthful, less gaunt look. • Anterior cheek – to address volume loss in the anterior cheek and soften the emerging malar split and medial tear trough. • Mandibular contour (jawline) – to widen and define the posterior body, angle and the ramus of the mandible. • Nasolabial fold – parenthesis was visibly deeper in this patient’s face which is often associated with facial ageing.

from the angle moving anteriorly. I also used the same entry point to deliver product over the ascending ramus. Nasolabial fold: 1.2 ml total of BELOTERO® Volume. I used a 27 gauge needle to place 0.1ml of product at the base of each of the nasolabial folds, injecting after waiting 10 seconds of aspiration, to help lower the risk of intravascular injection. Subsequently, I placed 0.5ml of product along the nasolabial fold with a 25 gauge cannula to lift the fold further utilising the high G-prime rheology of BELOTERO® Volume to reduce the depth of this anatomical fold further.

Outcomes Our patient experienced little, if anything, in the way of post-treatment swelling6 or bruising after a total of 6ml of volumising filler, and, at the one month review appointment, the patient reported being very happy with the results. His post-treatment photography indicates an effective broadening of the jawline contour with durable restoration of volume in the key areas of facial ageing including the temples, cheeks and the nasolabial fold.

Before

After

Before

After

Treatment Temples: 1ml total. 0.5ml BELOTERO® Volume per temple using a supra-periosteal injection with aspiration for 10 seconds prior to delivery of the product. Anterior cheek: 1.8ml total. 0.9ml of BELOTERO® Volume injected with 27 gauge needle in the deep fat pads using aspiration prior to each bolus, along the tripod of the zygomatic body and a lesser amount along the arch of the complex to give indirect support to the tear trough, anterior cheek and the lateral portion of the cheek. Jawline: 2ml total. 1ml of BELOTERO® Volume each mandible border and angle. I used a 25 gauge cannula from the mid-point of the mandibular ramus, working my way backwards towards the angle, in the subdermal plane delivering threads of product in a retrograde injection,

50

Figure 2: 42-year-old patient before and after BELOTERO® hyaluronate fillers

Aesthetics | September 2022


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Conclusion @aestheticsjournaluk aestheticsjournal.com Both of my patients wereAesthetics seen at The @aestheticsgroup Lovely Clinic in Chelsea, London where we have seen an increase in the proportion of male patients over the last 5 years. This observation has been reflected in wider surveys in the US and in London, particularly with respect to the Conclusion increase of neuromodulator treatments in men. This report indicates how seen judicious ofClinic highinperformance Both of my patients were at The use Lovely Chelsea, dermalwhere fillerswe can beseen used enhance, London have an to increase in the masculinise proportion and restore male face is This a potential area of male patientsthe over the last fiveand years. observation hasfor 9 been reflected in wider surveys in the US and in London, treating discerning patients of different age groups . 9

. of neuromodulator particularly with respect to the increase treatments in men. This report indicates how judicious use of high performance dermal fillers can be used to enhance, masculinise and restore the male face and is a potential area for treating discerning patients of different age groups.9

“Indicates how judicious use of high performance dermal fillers can be used to enhance, These reports indicate masculinise and restore the how judicious use of high male face”

performance dermal fillers can be used to enhance, masculinise and restore the male face

Dr Kishan Raichura is a qualified doctor and dentist, with a passion for working in the field of medical aesthetics. He practises at The Lovely Clinic in London. Qual: MBBS (medicine), BDS (dentistry), BSc Pathology (pathology) Dermal filler implants can be used for beautification/enhancement, transformation, correction, and eventually, with the progression of younger male patients who generally do not face the issues of skin laxity, fat pad deflation or ptosis, the objectives for treatment might solely be the enhancement of existing masculine features. The mature male brief, requiring subtle re-support of the classic areas of ageing mentioned above.

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The mandible as a focus for treatment in a full face approach Enhancement of the existing jaw anatomy is an often-time requested target for this type of treatment. A generous mandibular dimension in the frontal plane conveys the look of masculinity and is an attractive secondary sexual characteristic. During puberty the male facial skeleton widens at the mandibular body, ramus, and the chin under the virilising influence of the potent androgenic hormone dihydrotestosterone. These bony changes herald the transition of a boyish face to a more mature masculine profile. Perhaps at an unconscious level it is this observation of developmental changes in puberty that highlight

the relationship between androgenic hormones and male anatomy that makes this a desired facial feature. Product selection As practitioners there are many considerations for choice of product in these patients. As well as the product performance and rheology, safety is a principal concern. For both of my cases here I used fillers from the Merz Aesthetics range. I have personally never had any complications using them, and furthermore the safety data with regards to the BELOTERO® and RADIESSE® range of fillers is robust. The UK incidence of complication such as delayed onset nodules is significantly low1,2. When using a higher G-prime hyaluronate filler to sculpt and add definition in the

male face, it is also reassuring to use products that have proven ease of extrusion, consistent volumising 3 and durability4 in the case of BELOTERO® Volume for up to 18 months. Patients treated at our clinic have been extremely happy with results from BELOTERO® fillers, which is reflected in the research with high patient satisfaction rates and in global aesthetic improvement scales5 thanks not only to the rheology but also to the excellent tissue integration which is a result of Merz Aesthetics CPM technology6.

24/7 ACCESS TO EXPERT-LED CLINICAL EDUCATION AT YOUR FINGERTIPS With my cases, in addition to using the BELOTERO® HA portfolio, I also used RADIESSE®, a calcium hydroxyapatite biostimulator injectable from Merz Aesthetics, which is my ideal product, over and above hyaluronate fillers to define contours in the lower face. While research studies have supported this observation and preference, in my practice, I generally reserve this for patients who have already experienced, and most importantly, been happy, with enhancement of the lower face previously with a reversible hyaluronate treatment7. In these patients, the bio-stimulating

References: 1. King, M., Bassett, S., Davies, E., & King, S. (2016). Management of Delayed Onset Nodules. The Journal of clinical and aesthetic dermatology, 9(11), E1–E5. Merz Aesthetics, “The excellent (n.d) Merz Data1.on FileM., (DOF) BEL-DOF-011_01 P, Vandeputte J,ofKravtsov Treatment of Age-related Mid-face Atrophy by Injection of Cohesive Polydensified References: King, Bassett, S., Davies,REF-0922. E., & King,2.S.Micheels (2016). Management DelayedM.Onset tissue Nodules. integration The Journal of clinical and aesthetic dermatology, 9(11), E1–E5. Merz Aesthetics, (n.d)Volumizer. Merz Data on File (DOF) BEL-DOF-011_01 REF-0922. 2. Micheels P, Vandeputte J, Kravtsov M. Treatment Age-related Mid-face Atrophy by Injection Matrix Hyaluronic Acid J Clin Aesthet Dermatol. 2015;8(3):28–34. 3. Prager W et al. Mid-Face With Hyaluronic Acid:ofInjection Technique and Safety Aspects from a whichVolumization is a result of Cohesive Polydensified Matrix Hyaluronic AcidJVolumizer. J Clin2017 Aesthet Dermatol. 2015;8(3):28–34. 3. Prager W et al.M,Mid-Face Hyaluronic Controlled, Randomized, Double-Blind Clinical Study. Drugs Dermatol. Apr 1;16(4):351-357. 4. of Kerscher M, Agsten K, Kravtsov Prager W.Volumization EffectivenessWith evaluation of two Acid: volumizing Merz Aesthetics Injection Technique Safety Aspects from a Controlled, Randomized, Double-Blind Study. J Drugs Dermatol. 2017 Apr 1;16(4):351-357. M, Agsten 6 ”Dermatol. technology hyaluronic acid dermaland fillers in a controlled, randomized, double-blind, split-face clinical study.Clinical Clin CPM Cosmet Investig 2017;10:239–247. 5. Micheels P4.etKerscher al. J Clin Aesth Derm. RADIESSE® results in formation of K, Kravtsov M, Prager W. Effectiveness evaluation of two volumizing hyaluronic acid dermal fillers in a controlled, randomized, double-blind, split-face clinical study. Clin denser and elastin 2015;8(3):28-34. 3. Gavard Molliard S, Albert S, Mondon K. J Med Behav Biomed Mater. 2016;61:290-8. 6. Micheels P, Besse S,collagen Sarazin D, fibre et al. Ultrasound and Histologic Examination Cosmet Investig Dermatol. 2017;10:239–247. 5. Micheels P et al. J Clin Aesth Derm. 2015;8(3):28-34. 3. Gavard Molliard Albert S, Mondon K. J Med Behav Biomed . networks within 9S, months after Subcutaneous Injection of Two Volumizing Acid Fillers: A Preliminary Study. PlastExamination Reconstr Surgafter GlobSubcutaneous Open. 2017;5(2):e1222. Sundaram H, et al. Comparison the Mater. 2016;61:290-8. 6. Micheels P, Besse S,Hyaluronic Sarazin D, et al. Ultrasound and Histologic Injection7.of Two Volumizing Hyaluronic of Acid Rheological PropertiesStudy. of Viscosity Elasticity in Two Categories of Soft Tissue Fillers: Calcium Hydroxylapatite and Hyaluronic Acid, Derm Surg 2010;1076-0512. 8. Yutskovskaya Fillers: A Preliminary Plastand Reconstr Surg Glob Open. 2017;5(2):e1222. 7. Sundaram H, et al. Comparison of the Rheological Properties of Viscosity and ElasticityY, et in Two CategoriesSplit-Face, of Soft Tissue Fillers: Calcium and Hyaluronic Acid, Derm Surg 2010;1076-0512. 8. Yutskovskaya Y, etJal. A Randomised, Split-Face, al. A Randomised, Histomorphologic StudyHydroxylapatite Comparing a Volumetric Calcium Hydroxylapatite and a Hyaluronic Acid-Based Dermal Filler, Drugs Dermatol. 2014; 13(9): 1047Histomorphologic Comparing a Volumetric Calcium and a Hyaluronic Dermal Drugs Dermatol. 13(9): 1047-1052. 1052. 9. NonsurgicalStudy Cosmetic Procedures For Men: Trends AndHydroxylapatite Technique Considerations, COREY Acid-Based S. FRUCHT, MD, PhD;Filler, ARISAJE. ORTIZ, MD Santa2014; Barbara Skin Care, Santa Barbara, 9. Nonsurgical Cosmetic Procedures For Men: Trends And Technique Considerations, COREY S. FRUCHT, MD, PhD; ARISA E. ORTIZ, MD Santa Barbara Skin Care, California; Department of Dermatology, University of California,San Diego, San Diego, California. Santa Barbara, California; Department of Dermatology, University of California,San Diego, San Diego, California. 8

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This advertorial is sponsored byJune Merz Aesthetics UK & Ireland M-MA-UKI-2256 Date of Preparation 2022 M-MA-UKI-2256 Date of Preparation June 2022

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Treating Folliculitis Dr Thuvarahan Amuthalingam discusses the treatment of folliculitis in SOC patients In the world of aesthetic practice, we are aware of the need to understand the differences in treating skin of colour (SOC) patients with various modalities. Physiological differences in skin and hair mean conditions present differently and adjustments to treatment may be required for better outcomes. Folliculitis is a common skin condition that many people experience throughout their lives. There are many different types of folliculitis, and each type is unique, depending on the cause, symptoms and appearance. Think of folliculitis as a generic term – it’s a family of conditions. Studies have suggested that different ethnicities have varying impacts to skin infections like folliculitis as well as a suspectability to them.1 In this article, we will discuss the different types of folliculitis and approaches to management in treating SOC.

Physiology The anatomical makeup of skin varies amongst different ethnicities.1 Afro-Caribbean hair is thought to be curlier to coiled with oval to elliptical hair follicles, Asian hair is more likely to be straight to wavy with round to slightly oval-shaped follicles, and Caucasian hair is more straight to curly with oval-shaped follicles.2,3 Afro-Caribbean skin has a thicker epidermis and a compact dermis leading it to have a higher skin barrier function.4 Subsequently, it is easily inflamed and more prone to pigmentation and scarring. Lowest ceramide levels correlate to the highest epidermal water loss seen in Afro-Caribbean skin.5 Afro-Caribbean skin has higher levels of sebaceous glands and three times more apocrine sweat glands. More compact collagen fibres, fibroblasts and less elastosis are common in SOC as they have a more compact dermis. As well as a very convoluted dermal-epidermal junction, this may explain the reduced signs of photoageing in Afro-Caribbeans.6

Folliculitis The main cause of folliculitis is a fungal or bacterial infection at the top of the hair follicle.7 In most cases, the main symptom of folliculitis is a red bump on the skin that looks like a pimple. These pus-filled bumps are usually riddled with ingrown hairs and are often surrounded by pink to red inflamed skin. Pimples may appear on the skin in groups or on large areas of the beard, arms, back, buttocks and legs. Irritation and excessive sweating can trigger folliculitis. Folliculitis begins with the introduction of skin pathogens into the hair follicles. The condition is contagious, and people can pass it on to others through close skin-to-skin contact. Folliculitis

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can develop into more serious skin conditions, such as cellulitis or abscesses if left unattended or not treated correctly.7 If practitioners are unsure about a skin condition or if it’s beyond the scope of their practice, then referral to a specialist should be considered. It is commonly caused by Staphylococcus aureus which naturally lives on our skin.8 The condition can also be caused by Pseudomonas from shared baths and contaminated water. The herpes simplex viruses from cold sores can also lead to herpetic folliculitis. Oil folliculitis is an inflammation of the hair follicles due to exposure of various oils and usually occurs on the forearms or thighs.8 Fungal folliculitis caused by Malassezia, previously known as pityrosporum folliculitis, can result in an itchy acne-like eruption affecting the upper body and face. Pimples can appear in areas including the forehead, down the hairline and on the upper back. As it is similar in appearance, pityrosporum folliculitis is often mistaken for acne vulgaris. Treatment failure or exacerbation should make you question the diagnosis and consider folliculitis as a potential differential. People are more likely to confuse guttate or pustular psoriasis with folliculitis because all these conditions cause patches to appear on the skin.9 Keratosis pilaris Also known as keratosis follicularis, lichen follicularis, or colloquially ‘chicken skin’, keratosis pilaris is a very common condition that is seen widely.10 It is characterised by small, rough bumps on the hair follicles, caused by an overproduction of keratin. The accumulation of keratin forms a ‘keratin plug’ that blocks the opening of the hair follicle. This causes the hair follicles to expand under the skin, creating bumps on the skin’s surface. It causes dry, rough patches and small bumps, often on the shoulders, thighs, cheeks or buttocks. Although follicular keratosis can appear on different parts of the body, the condition is easy to recognise due to its tiny size.10 Keratosis follicularis slightly resembles the rough skin of a chicken, hence the name. In Caucasian skin, keratosis follicularis is usually characterised by white or red bumps, while darker brown bumps may be seen in darker skin tones. Although keratosis follicularis is a benign disease, it is associated with significant aesthetic comorbidity, with 69% of patients reporting discomfort due to rash.11 This is of particular concern given that

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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keratosis follicularis most commonly occurs in adolescent women, with the potential to impact self-esteem and body image. Pseudo folliculitis As per the name, pseudo folliculitis is a mimic of true folliculitis. Known as pseudofolliculitis barbae when it affects the beard, it the most common form of folliculitis seen in adult males.2 An inflammatory response is triggered by irritation to the hair follicle through shaving, plucking, waxing, electrolysis or the way hair regrows. Shaving against the grain, thick hair, uncut beards or wearing clothing that rubs against the skin can be risk factors. The area may be itchy, and papules can appear with an ingrowing hair. It is most commonly seen in patients of colour due to the more tightly curved hairs, but can affect all ages and races.12 Folliculitis decalvans When hair follicles are damaged, they are more susceptible to infection. In most cases of folliculitis of the scalp, there is resolution without antibiotics or any lasting scarring, however, in folliculitis decalvans this is not the case.13 It can affect small patches or larger areas over time. More severe cases of folliculitis decalvans can lead to complications such as scarring, or permanent hair loss. The cause is not well understood, and it is suspected to be S. aureus alongside predisposing factors such as a weak immune system. It affects both sexes, but men can be affected from as early as adolescence whilst women tend not to be until their 40s.14 Though no published studies are available, African-American women are said to be disproportionality affected.3 Clinically, patients present with round patches of erythematous or cicatricial alopecia on the vertex or occipital areas. Pustules and crusting are usually seen as well as erosions.15 As the follicle is completely destroyed, the hair is shed, leaving a scar tissue behind. Scars on the scalp lead to permanent hair loss as new hair does not grow through the scar tissue without a hair follicle.4 This can lead to significant psychological stress. Acne keloidalis nuchae Also known as folliculitis keloidalis nuchae, the tell-tale sign is scarring at the nape of the neck. It is more common between 14 and 25 years of age and in men with curly hair.16 The condition is prevalent

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in Afro-Caribbeans and is rarely seen in Caucasians due to the anatomical differences in hair and skin. A chronic inflammatory process with follicular papules or pustules leads to hair loss in the affected areas. The hypertrophic scarring may fuse into a band or plaques just below the hairline. Close shaving of the neck can worsen the condition as curved hairs can get caught beneath the skin or attempt to re-enter the skin, triggering an inflammatory response. Shirt collars can also exacerbate the problem.17

Principles of management Lifestyle Patients should avoid shaving for three months or longer, as well as reducing how often they shave. It is advised for patients to use an electric razor or a single blade for a wet shave to reduce irritation. Patients should shave in the direction of the hair grain and avoid stretching the skin, as this can exacerbate the condition. They should aim to leave stubble of at least 1mm to avoid hair retracting into follicles or curling back to pierce the skin.18 I advise my patients to avoid anything rubbing around the beard or neck area such as high collars or helmets, as well as avoiding the use of greasy hair products or pomades until resolution.19 Topical therapy The use of topical antiseptics as a soap substitute can help with folliculitis and, when applied regularly, can regularly can reduce secondary infections as well as soothe irritation.18 Patients can apply a mild potency steroid immediately after shaving which can help the condition. Where a fungal infection may be suspected, I advise treatment with an anti-fungal cream and shampoo as frequently as possible until resolution, followed by once or twice weekly maintenance as fungal infections can often recur.18 Key ingredients in cosmeceuticals can also help folliculitis conditions. Azelaic acid has been shown to improve hyperkeratosis and roughness by 92%.20 Salicylic acid can help pigmentation and roughness by 52% and lactic acid can improve pigmentation and roughness by 66%.21 For hypertrophic scarring in acne keloidalis nuchae, super-potent topical steroid creams can be applied daily under observation.22 Steroid-impregnated plaster has been shown to be effective due to better adherence and controlled dosage.23

Oral treatment When there is no response to topical treatment or if the condition is severe, a three-month course of tetracycline antibiotic can be used acting as an anti-inflammatory. If there is still poor or no response, a swab may be necessary and escalation of antibiotic therapy. Conditions such as folliculitis decalvans may need dual antibiotic therapy with rifampicin 300mg BD with clindamycin 300mg BD.6 Procedures Laser hair removal can help address folliculitis in areas where hair may not be desired. In severe cases, this may even be considered on the scalp and face. Hypertrophic and keloid scarring can improve with steroid injections and laser every four-six weeks.25 If there has been no or little improvement, surgical excision can be considered with further steroid injections to minimise recurrence.7

Spreading awareness Different ethnicities are more pre-disposed to different forms of folliculitis, and SOC patients are predisposed to poorer cosmetic outcomes due to their tendency for pigmentation and scarring. The lack of concrete evidence in treating the cosmetic outcomes in SOC can only be overcome with more widespread advocacy and research by practitioners and patients alike. Dr Thuvarahan Amuthalingam is a GP with a special interest in dermatology, minor surgery and aesthetics. He is the founder of Dr.Derme Skin and aesthetic clinics in Harley Street, Solihull, Birmingham and Manchester. He continues his NHS practice in Modality Community Dermatology and is a national trainer for Derma Medical. He chairs the Black Country Skin Club. Qual: MBBS, BMedSci, MRCGP, PGDip, Derm

VIEW THE REFERENCES ONLINE! WWW.AESTHETICSJOURNAL.COM

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


Advertorial Prollenium

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A Revolution in Lip Treatment Introducing the latest new addition to the Revanesse® portfolio, OutlineTM

This month, pioneers of The Spherical Revolution, Prollenium®, add to its portfolio of next generation hyaluronic acid (HA) dermal fillers with the launch of Revanesse® OutlineTM. It’s the only dedicated tool in the range developed specifically for areas which require anatomical architecture or structure without creating rigidity. Prollenium® is renowned for its forward-thinking approach to manufacturing HA dermal fillers, creating projection and structure through the delicate tuning of additional linear HA. Revanesse® KissTM, UltraTM and ContourTM from the collection contain 10% additional linear HA which creates a mouldable product suitable for volumisation or reflation of lipoatrophic indications. For structure, projection and definition, rather than adding more 1,4-butanediol diglycidyl ether (BDDE), Prollenium® simply reduced the linear HA, thus keeping the safety profile of the collection favourable. OutlineTM contains 4%, and ShapeTM 0% making the gels higher in yield stress/shape retention – perfect for structure, definition and volumisation. The Revanesse® collection of HA gels contains three products which can be used in the perioral region. Award-winning plastic surgeon and global trainer Dr Arthur Swift utilises the algorithm as shown in Figure 1 for choosing the correct product for each patient lip indication. He often performs the same injection techniques, changing only the product per indication to create desired results. OutlineTM was launched in Canada just over two years ago. Currently, OutlineTM is one of the top selling products in the range, praised for its versatility. Launched primarily as a lip product, Outline’sTM versatility has since been harnessed by many to be used in combination treatments for the lips, cheek and chin or for areas that require structure and architecture.

Subtle reflation (ex. mature lips) Hydration / mild plumping Velvety appearance Enhancement Bar code treatment

Lip border definition

Volumisation + lip architecture

Augmentation Volumisation (with present architecture)

Figure 1: Dr Arthur Swift’s algorithm for lip injections using the Revanesse® dermal filler range

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Advertorial Prollenium

Ask the experts

Dr Zaki Taher Canadian-based board-certified dermatologist, national speaker, trainer and founder of Lucere Dermatology and Laser Clinics, Dr Zaki Taher, said, “OutlineTM has slowly become a product I reach for in my practice. I believe it’s appropriate for almost all patients with the right approach. The product is best used to achieve good structure without rigidity. Many other products meant for the lips don’t provide the structure needed for a mature lip, for example. The 4% linear HA and spherical particle allows for crisp results without lumps or bumps.”

Dr Arthur Swift Dr Swift said, “Outline is amazingly versatile for lip enhancement and restoration. It can be used structurally for creating beautiful architecture, more robustly for lip augmentation with smooth contours, or delicately to define the vermilion border by strengthening the white roll. I’ve been extremely impressed with the natural results obtained both in repose and with animation, and the minimal post-procedural swelling.” TM

Frances Turner Traill Independent nurse prescriber, board member of the British Association of Cosmetic Nurses (BACN) and founder of FTT Skin Clinics, Frances Turner Traill, said, “Lips are an incredibly popular treatment with all ages and genders in our clinics. We use Revanesse® KissTM for a subtle, hydrating, volumising treatment and lean towards Revanesse® UltraTM for a more projected, volumised look favoured by our younger patients. There has been a little gap in our tool kit for our patients. Particularly, our patients whose heritage and ethnicity benefit from greater volume yet still want a beautifully natural result. Our clinicians and patients have been thrilled with the results achieved. We trialed OutlineTM on our patients for whom regular HA didn’t give the longevity we all hope for, considerably increasing our patient satisfaction.”

Prollenium® | One of the fastest growing dermal filler companies Prollenium® Medical Technologies was founded in 2002 by Ario Khoshbin and later joined by childhood friend Khasha Ighanian. The entrepreneur’s decided to develop their own filler product out of their factory in Aurora – Toronto, Canada. The artisan manufacturing process creates Revanesse® in small batches to ensure homogenous consistent batches and the highest quality control.

Quickly outgrowing the first factory, today Prollenium® manufacture from two state-of-the art sites with the same small batch artisan approach. Each syringe is individually inspected for quality assurance before leaving the facility. Currently, Prollenium® remains the only manufacturer of HA dermal fillers in North America, and one of only five US FDA-approved dermal filler brands.

This advertorial was written and supplied by Prollenium

For more information about Prollenium® and Revanesse®, please contact: info@prollenium.co.uk

Aesthetics | September 2022

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Exploring Techniques for Filler Dissolving Independent nurse prescriber Alex Henderson outlines techniques for a safe and effective outcome when opting for elective and emergency use of hyaluronidase Hyaluronidases are endogenous enzymes (endoglycosidases) that can depolymerise hyaluronic acid (HA), leading to its degradation. These reduce viscosity of HA which improves tissue diffusion by hydrolysing the disaccharides at hexosaminidic b-1 through b-4 linkages.1,2,3 In the UK, hyaluronidase is licensed for enhancing permeation of subcutaneous and intramuscular injections ranging from local anaesthetics to infusions.3 The use of hyaluronidase has many factors that need to be considered when prescribing for the correction of dermal filler injections. Practitioners require sufficient understanding of the drug and its uses when applying it to aesthetic practice, for both elective and emergency situations.

Prior to treatment Storage Hyaluronidase (Hyalase) is available in 1500u of dry power in a glass vial. It is recommended by the Aesthetic Complications Expert (ACE) Group World that should be stored between 2-80C in the package container in which it is dispensed.4 However, if it is stored at room temperature (250C), the stability is only guaranteed for 12 months, and not the three years shelf-life as stated on the SmPC..4

Patch testing The ACE Group World recommends the use of a test patch (except when the indication is for vascular compromise, as a delay could result in further harm to the patient).11 An intradermal injection of 15-20 units of hyaluronidase in the forearm is advised, observing the results after 20-30 minutes.11

Elective use Volume In the event of elective reversal of HA-based dermal filler, guidelines combine studies of hyularonidase dosing relevant to HA dosing, and suggest the following algorithm for effective use of the drug in elective cases:4 Volume to inject (mls) = number of units required (units) X volume of diluent (mls) total number of units (1,500 units).4 Different brands of HA filler have differing physical properties that influence their degradation.3 Products which have a higher G-prime and more cross linking or HA concentration will require stronger doses, and HAs of the opposite rheology would require less. The Complications in Medical Aesthetics Collaborative (CMAC) suggests ‘treat to effect’ with concentrations no less than 1500u in 5ml.5

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Detection Ultrasound examination is a rapid technique for the detection of dermal filler and its position beneath the skin.6 With the correct training and experience, it can be an effective method because it provides the practitioner with a visual, while also reducing the likelihood of ‘guess work’ and unnecessary injury to the skin and tissue. In aesthetic practice, it is common for practitioners to have patients presenting with complications from another clinic or injector. In instances when records are not clear, or the patient’s previous clinician doesn’t provide medical records, techniques such as multilayering may be required to dilute dermal filler.7 For example, to correct the volume loss which affects the deep fat pads, a dermal filler with a high G-prime and HA concentrations is used deep on the periosteum which in turn requires deep placement of hyularonidase.8 For effective dissolution of HA product in this compartment, 3D anatomical knowledge is required as is knowledge in the reconstitution of hyularonidase, explained in the aforementioned ACE Group World guidelines algorithm.4 Instrument choice Some evidence suggests that mimetic muscles may displace or shift HA filler over time, in particular if products have been injected to modulate specific muscles for the improvement of their movement.9,10 To minimise trauma, a 25 gauge x 50mm cannula is recommended as a viable alternative to needles due to its association with fewer adverse effects.7 Gliding through soft tissue with ease, the cannula will achieve more precise placement and allow the practitioner to treat several different plains with minimal trauma.4

Emergency use Impending necrosis is a possible complication of all injectable HA. According to ACE Group World, vascular compromise as a result of HA filler injection should be treated immediately.4 Dilution Onset of immediate pain with a vascular occlusion can be possible even with small bolus injections of 0.1ml, so management and knowledge of this is essential in the patient journey to recovery.11 Lidocaine 2% is recommended as an adjunctive pain relief with additional properties of vasodilation.5,4 Because hyaluronidase is a dispersing agent, lidocaine will also perfuse nearby

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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The clinician should aim for soft tissue and intra-arterial placement with needle tissue, increasing the likelihood of good pain management and the uptake of hyaluronidase into nearby vessels. Both ACE Group World and CMAC guidance on emergency administration of hyaluronidase states that 1500u should be diluted in 1ml and infiltrated over the entire area including the course of the vessel.4,5 Multiple puncture Multiple puncture technique refers to repeated injections at the site of compromise in emergency reversal. Serial punctures should be used to inject hyaluronidase along the course of the vessel, and the needle should be perpendicular to the skin.4 Whilst a cannula is recommended in elective use of hyularonidase, this device is blunt and therefore the likelihood of intra-arterial placement is highly unlikely.12 In this instance, I instead use a 31 gauge needle with the aim of reducing tissue trauma and pain where possible. The clinician should aim for soft tissue and intra-arterial placement with a needle. As mentioned, ultrasound can help to guide a practitioner to the location of any embolism or compression and so should be considered as a potential aid.6

Considerations When considering hyaluronidase injection, the practitioner should take a full medical history to understand any allergies and medications that the patient might be on. A history of allergy to wasp or bee stings can indicate a contraindication to hyaluronidase as the venom of any of the hymenopteran order may contain hyaluronidase.13 In this case it is important to establish the allergy type and whether or not the patient has a history of anaphylaxis as intradermal patch testing would then be considered a risk and not advised. Instead, the patient would require a confirmed diagnosis from a specialist allergy testing centre.14 If the patient is considering dermal filler and has such a history, the practitioner would have to balance the decision making of treatment based on risk vs benefit. Considering the potential side effects of dermal filler with possible delayed onset

of complications, the clinician would not be able to safely reverse the HA filler, resulting in potential long-term issues for the patient.14 Hyaluronidase is also known to commonly react with benzodiazepines, phenytoin, dopamine and furosemide. Whilst these interactions are mildly significant, it’s always best to avoid if possible.7,4,15 The practitioner should also be aware of the antagonist effects of non-steroidal anti-inflammatory drugs, anti-histamines and mast cell stabilisers which include vitamin C.13 I would recommend discontinuing the use of any relevant medications for approximately 48-72 hours and taking into account the half-life of the medication. If the corrective treatment is not related to the clinician’s practice, then they should obtain a clear and concise history of the patient’s treatment journey by contacting the original clinic/practitioner.6

Topical hyaluronidase Topilase is a new topical treatment to adjust skin irregularities associated with dermal filler injections. It is suggested to be an effective way of safely shaping and reducing undesirable outcomes associated with injection. Whilst Topilase does not have to be prescribed as it is a natural formula, the clinician should still obtain the skill and knowledge to enable a skin diagnosis and justify their decision in the patient’s best interest.16

Safe practice Hyaluronidase is a diverse drug universally used in medicine as a dispersing agent. Its ability to permeate membranes, tissue and vessel walls makes for an effective reversal in emergency and elective presentations. Clinicians should treat safely by understanding the drug and how to effectively inject when reversing dermal filler.

Alex Henderson is an independent nurse prescriber with 12 years’ industry experience. She has successfully opened two award-winning clinics in the Southwest of England and has recently opened her third on Harley Street. Henderson has experience in training practitioners on foundation filler and toxin courses as well as foundation and advanced PDO threads on behalf of 4T Medical. Qual: BSc, INP REFERENCES 1. Buhren, B.A., Schrumpf, H., Hoff, N.P., Hilton, S., Gerber, P.A., (2016) Hyaluronidase: from clinical applications to molecular and cellular mechanisms. European Journal of Medical 2. Jones, D., Palm, M., Cox, S. E., McDermott, M., Sartor., M., Chawla, S. (2021). Safety and Effectiveness of Hyaluronic Acid Filler, VYC-20L, via Cannula for Cheek Augmentation: A Randomized, Single-Blind, Controlled Study. Dermatologic Surgery. 47:12. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8612896/pdf/ ds-47-1590.pdf> 3. Kartal, S. P (2018) Hyaluronidase in tear trough complication. [Accessed 12.8.22] Turkderm-Turk Arch Dermatol Venereology 2018;52:108-10 4. King. M., Convery, C., Davies, E. (2017) The Use of hyaluronidase in Aesthetic Practice. Aesthetic Complications Expert Group, The Use of Hyaluronidase in Aesthetic Practice v2.4 5. Murray, G., Convery, M., Walker, L., Davies. (2021). Guideline for the Safe Use of Hyaluronidase in Aesthetic Medicine, Including Midified High-dose Protocol. Journal of Clinical Aesthetic Dermatology. 2021 6. Munia, M. A., Munia, C. G., Parada, M. B., Parente, J. BH., Wolosker, N, Doppler Ultrasound in the Management of Vascular Complications associated with Hyaluronic Acid Dermal Filler. Journal of Clinical Aesthetic Dermatology, 2022 7. de Almeida Balassiano, L. K., Bravo, S., Hyaluronidase: a necessity for any dermatologist applying injectable hyaluronic acid, 2014 8. Rosales, T., Hoyt, K . S., Love, J. W., Guideline Implementation for Dermal Filler Administration Via Blunt-tip Cannula to Decrease Post-Procedure Hematoma Formation, 2017 9. DeLorenzi, C., New High Dose Pulsed Hyaluronidase Protocol for Hyaluronic Acid Filler Vascular Adverse Events. Cosmetic Medicine, 2017 <https://academic.oup.com/asj/ article/37/7/814/3074317> 10. De Maio, M, Myomodulation with Injectable Fillers: An Innovative Approach to Addressing Facial Muscle Movement. Aesthetic Plastic Surgery. 2018 11. Newton, D.J., McLeod, G. A., Khan, F., Belch. J. J. F., Mechanisms influencing the vasoactive effects of lidocaine in human skin. Anaesthesia, 2007 <https://associationofanaesthetistspublications.onlinelibrary.wiley.com/doi/epdf/10.1111 /j.1365-2044.2006.04901.x> 12. Goodman, G., Al-Niaimi, F., McDonald, C., Ciconte, A., Porter, C. (2020). Why we should be avoiding periorificial mimetic muscles when injecting tissue fillers. Journal of Clinical Dermatology, 2020 <https://onlinelibrary.wiley.com/doi/epdf/10.1111/jocd.13531> 13. Jones, D., Palm, M., Cox, S. E., McDermott, M., Sartor., M., Chawla, S., Safety and Effectiveness of Hyaluronic Acid Filler, VYC-20L, via Cannula for Cheek Augmentation: A Randomized, Single-Blind, Controlled Study. Dermatologic Surgery, 2021 <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8612896/pdf/ ds-47-1590.pdf.> 14. King. M., Convery, C., Davies, E., The Use of hyaluronidase in Aesthetic Practice (V2.4). Journal of Clinical Aesthetic Dermatology. 2018 15. Kim, J. H., Ahn, D. K., Jeong, H. S. and Suh, S.,Treatment Algorithm of complications after filler injection based on Wound Healing Process. Journal of Korean Medical Science. 2014 16. GMC, Good practice in prescribing and managing medicines and devices content. Prescribing Unlicensed Medicines, 2021, <https://www.gmc-uk.org/ethical-guidance/ethical-guidance-fordoctors/good-practice-in-prescribing-and-managing-medicinesand-devices/prescribing-unlicensed-medicines>

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022



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Advertorial SkinCeuticals

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The Pioneers Of Skin Health Discover the history of SkinCeuticals Since 1997, SkinCeuticals has led the way, integrating skincare into the aesthetic treatment space with its vast, potent range of active-rich skincare treatment products, making it the natural choice for aesthetic clinics globally. At SkinCeuticals, the mission is to improve skin health, centring its treatment products around three main pillars: Dr Ana Mansouri Prevent, Correct, Protect. The products work together to The Skin Clinic 3 Calthorpe Road, provide optimal results and now, specific protocols have Cropthorne Court, been developed to support the skin prep, healing and Edgbaston maintenance of results from in-clinic aesthetic treatments such as injectables, lasers and peels. Dr Ana Mansouri, aesthetic practitioner at Dr Ana The Skin Clinic, said, “I’m an advocate for the value of early integration of medical-grade skincare, particularly with my injectable cases. This is due to experiencing how this has transformed my practice, both from a business point of view, and by enhancing clinical outcomes.”

Integrated skincare benefits Combining clinical procedures with professional treatments and advanced home care delivers comprehensive results. • Professional pre-conditioning and recovery post-treatment helps to reduce downtime and feelings of discomfort • Advanced home care aids in prolonging and protecting results due to the additional benefits of antioxidants

Integrating SkinCeuticals into injectable treatments Dr Mansouri notes, “My approach to SkinCeuticals integrated skincare is based around a simple ‘ABC + targeted treatment’ routine where I utilise vitamin A, sunblock and vitamin C to prepare my patients’ skin for any rejuvenating treatments. This is carried out for four to eight weeks pre-procedure, as well as for ongoing maintenance of results by optimising neocollagenesis in the longer term.” “I also recommend adding targeted HA serums and ceramide-based moisturisers to support the maintenance process post-injectables in dry and mature skin types. My recommended product combination is the H.A Intensifier, as this has been shown to improve HA levels by up to 30% in just four weeks, paired with the Triple Lipid Restore 2:4:2 to support the barrier function of the skin,” she says.

A word from SkinCeuticals “Today’s patients are more educated than ever before, and they often research ingredients and products online before they see a skincare professional,” says Sinead Mayne, medical relations manager at SkinCeuticals. “For some in aesthetics, efficacious skincare has been at the core of the clinical setting for years, but for those practitioners slightly later to the party, the need for a comprehensive skincare offering has become more of a must-have than a niceto- have, and the choice of brands can be overwhelming.” “Offering products that are results driven with proven efficacy helps put the control of the patient treatment outcome firmly in the hands of the clinic. We believe that the combination of procedures and science-based skincare provides the apex of results for patient skin. SkinCeuticals heritage and grounding in science makes it the choice of many,” she says. Aesthetics | September 2022

25

25 years and counting...

• 1992: Dr Pinnell patents ‘the duke formulation parameters’ which outline the parameters for formulating a stable serum with l-ascorbic acid • 1996: Dr Pinnell published on topical vitamin C in ageing • 1997: SkinCeuticals was founded with Dr Pinnell as lead scientist • 2003: Dr Pinnell publishes on photoprotection of the skin by combination topical antioxidants vitamin C and vitamin E • 2004: SkinCeuticals introduces its Prevent, Correct, Protect philosophy along with integrated skincare, supported by a professional line to complement in-office procedures • 2014: SkinCeuticals publishes research on antioxidant protection against infrared-Agenerated free radicals photodermatology, photoimmunology and photomedicine • 2017: Research was published on C E Ferulic and Phloretin CF protection against ozone pollution and published a study on a multimodal facial serum to increase hyaluronic acid levels in skin • 2021: the brand formed an innovative commercial partnership with manufacturer Cutera to work together to produce a specific integrated protocol to get the best results from laser • 2021: Silymarin CF & Blemish & AGE Defense was published in the Journal of Cosmetic Dermatology, and within the April AAD Poster a topical antioxidant serum containing silymarin reducing sebum peroxidation was published • 2022: SkinCeuticals clinical studies took place investigating the role of topical skincare as an adjunct to aesthetic treatments with a presentation at IMCAS in June 2022

This advertorial was written and supplied by SkinCeuticals

Speak to your SkinCeuticals representative for more information about the range. Contact@SkinCeuticals.co.uk. https://www.skinceuticals.co.uk/

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Combining AAT and APRP In recent years, research into use of autologous products such as AAT and APRP has allowed us as clinicians to offer new ways to help women to restore thinning hair. The concept is not new, and has in fact been used for many years in other branches of medicine regarding improvement of joint function, wound healing, treatment of sport injuries7 and increasing the speed of healing of skin damage.4,7,8 The scientific rational behind all tissue regeneration is the same, namely the settling of inflammation and the increase in interstitial communications, resulting in better direction of the regenerative systems to support, regenerate and restore the tissues to a healthier state.4 This is achieved by introducing the platelet growth factors and activated autologous regenerative cells into the environment, and works the same in hair as it does other parts of the body. Interesting work conducted and published by Gentile and Cervelli et al. indicates the promising use of combined AAF and APRP.4 In terms of hair restoration, its benefits can range from the use of simple equipment Dr Sadequr Rahman and Dr Aamer Khan explore extracting growth factors from the patient’s APRP and adipose for treating female hair loss own blood to inject into the scalp, up to the more highly advanced autologous fat According to the NHS, eight million women experience hair loss in processes requiring greater levels of skill and clinical experience the UK.1 For women in particular, the presence of strong, healthy hair is to extract. These will require more advanced and complicated a societally recognised sign of beauty, youth, femininity and health; all (therefore expensive) equipment, as well as specialist expertise, to of which are signs of sexual attractiveness.1,2,3 offer such treatments.4 Here, we will discuss the use of direct injections of autologous products such as autologous adipose tissue (AAT) and autologous Our treatment method platelet-rich plasma (APRP) to stimulate and restore the hair for Firstly, we aim to restore the growth potential of the hair follicular unit female patients. While the treatments discussed here bring us closer which has usually moved into a longer dormant phase in which the to allowing women to stabilise hair loss and improve the overall follicular body is still present, but produces only smaller and weaker appearance, it should be clear that we are in the relatively early hair shafts that shed more quickly. Secondly, we aim to improve stages of the research and clinical use of these treatments, and we blood flow and therefore oxygenation to the follicle, and thus allow expect further advancements over the coming years. the follicle to thrive and return to its previous growth capability. APRP and stromal vascular fraction (SVF) cells derived from adipose tissue Alternatives to surgery increase the blood supply by enhancing the carrying capabilities of As with male patients, there may be an organic or medical cause for the vessels supplying to the follicular bodies.9 In the more advanced the hair loss that can be identified through examination by a medical treatments, we can encourage the formation of new blood vessels in practitioner. These may include dermatological causes such as a process known as angiogenesis. By creating a stronger network of psoriasis4 or fungal infections,5 or a biological cause such as anaemia.6 blood supply to the scalp, the follicle is encouraged to produce better, Once such causes have been excluded, we can consider how to best thicker and longer hair.9 help our patients. Unfortunately, many of the treatments available for The follicles that are arrested in prolonged catagen may also be men are unsuitable for women. For example, topical minoxidil can be stimulated into anagen, and so improve the density of hair covering difficult to apply in long hair and may give a greasy appearance, and the scalp with the appearance of new hair growth over six to 12 oral finasteride or dutasteride is untested in women and may result in months.9 As part of the natural ageing process there is atrophy of the 5 unexpected adverse effects. More evidence is required for the use subcutaneous fat layer of the scalp. This results in the reduction of the of these drugs, and their side effects in female patients. For a small regenerative cells, including stem cells that are found in this layer. By number of women, transplantation may be considered, however grafting autologous fat nano grafts to this area we can replenish the the nature of the hair loss in women usually means that locating stock of regenerative cells, and so improve follicular and scalp health.8 suitable donor sites is challenging, and the resulting grafts may not be The amount of blood required to produce the APRP will vary effective, resulting in false or artificial results similar to early attempts depending on the area treated. For APRP, we use the Angel treatment with male transplantation. system, which we find is a good system because it produces

Treating Female Hair Loss with APRP

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


Your patients with excess weight have the will. You can offer them the way. Patients achieved significant and sustained weight loss, in conjunction with reduced calorie intake and increased physical activity, in 1-year and 3-year trials vs placebo1,2* Similar to natural glucagon-like peptide-1, Saxenda® works to decrease appetite and thereby reduce food intake3†

This is not a real patient but only an illustration.

This material relates to the adult indication only. Please refer to SmPC for full indication. Adults: Saxenda® is indicated as an adjunct to a reduced-calorie diet and increased physical activity for weight management in adult patients with an initial Body Mass Index (BMI) of ≥ 30 kg/m2 (obesity) or ≥ 27 kg/m2 to < 30 kg/m2 (overweight) in the presence of at least one weight-related comorbidity such as dysglycaemia (pre-diabetes or type 2 diabetes mellitus), hypertension, dyslipidaemia or obstructive sleep apnoea. Treatment with Saxenda® should be discontinued after 12 weeks on the 3.0 mg/day dose if patients have not lost at least 5% of their initial body weight.

If you would like to request a visit from a representative please contact us on obesityuk@novonordisk.com For all product related enquiries please contact Novo Nordisk Customer Care Centre on 0800 023 2573.

The exact mechanism of action of liraglutide is not entirely clear.

* In the 1 year trial patients taking Saxenda® (n=2487) had a baseline body weight of 106.2 kg. Completers’ (n=2437) mean weight loss at week 56 of treatment was 8.4 kg. Patients taking placebo (n=1244) had a baseline body weight of 106.2 kg. Completers’ (n=1225) mean weight loss at week 56 of treatment was 2.8 kg1, p<0.001. In the 3 year trial Patients taking Saxenda® (n=1505) had a baseline body weight of 107.5 kg. Completers’ (n=1472) mean weight loss at week 160 of treatment was 6.5 kg. Patients taking placebo (n=749) had a baseline body weight of 107.9 kg. Completers’ (n=738) mean weight loss at week 160 of treatment was 2.0kg2, p<0.0001. References: 1. Pi-Sunyer X, Astrup A, Fujioka K, et al; for the SCALE Obesity and Prediabetes NN8022-1839 Study Group. A randomised, controlled trial of 3.0 mg of liraglutide in weight management. N Engl J Med. 2015;373(1):11-22. 2. le Roux CW, Astrup A, Fujioka K, et al; for the SCALE Obesity and Prediabetes NN8022-1839 Study Group. 3 years of liraglutide versus placebo for type 2 diabetes risk reduction and weight management in individuals with prediabetes: a randomised, double-blind trial. Lancet. 2017;389(10077):1399-1409. 3. Saxenda® Summary of product characteristics, NI&GB. Bagsvard, Denmark: Novo Nordisk A/S.

Prescribing Information Please refer to the Saxenda® summary of product characteristics for full information. Saxenda® Liraglutide injection 3 mg. Saxenda® 6 mg/mL solution for injection in a pre-filled pen. One pre-filled pen contains 18mg liraglutide in 3mL. Indication: Adults: Saxenda® is indicated as an adjunct to a reduced-calorie diet and increased physical activity for weight management in adult patients with an initial Body Mass Index (BMI) of ≥ 30 kg/m2 (obesity) or ≥ 27 kg/m2 to < 30 kg/m2 (overweight) in the presence of at least one weight-related comorbidity such as dysglycaemia (pre-diabetes or type 2 diabetes mellitus), hypertension, dyslipidaemia or obstructive sleep apnoea. Adolescents (≥12 years): Saxenda® can be used as an adjunct to a healthy nutrition and increased physical activity for weight management in adolescent patients from the age of 12 years and above with obesity (BMI corresponding to ≥30 kg/m2 for adults by international cut-off points) and body weight above 60 kg. Posology and administration: Saxenda® is for once daily subcutaneous use only. Is administered once daily at any time, independent of meals. It is preferable that Saxenda® is injected around the same time of the day. Recommended starting dose is 0.6 mg once daily. Dose should be increased to 3.0 mg once daily in increments of 0.6 mg with at least one week intervals to improve gastro-intestinal (GI) tolerability. Treatment with Saxenda® in adults should be discontinued after 12 weeks on the 3.0 mg/day dose if patients have not lost at least 5% of their initial body weight. Daily doses higher than 3.0 mg are not recommended. No dose adjustment is required based on age but therapeutic experience in patients ≥75 years is limited and not recommended. No dose adjustment required for patients with mild or moderate renal impairment or mild or moderate hepatic impairment but it should be used with caution. Saxenda® for adolescents from the age of 12 to below 18 years old a similar dose escalation schedule as for adults should be applied. Treatment with Saxenda® in adolescents should be discontinued and re-evaluated if patients have not lost at least 4% of their BMI or BMI z score after 12 weeks on the 3.0mg/day or maximum tolerated dose. Saxenda® is not recommended for use in patients with severe renal impairment including endstage renal disease, or severe hepatic impairment or children below 12 years of age. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Special warnings and precautions for use: There is no clinical experience in patients with congestive heart failure New York Heart Association (NYHA) class IV and Saxenda® is not recommended for use in these patients. It is also not recommended in patients with eating disorders or treatment with medicinal products that may cause weight gain. Use of Saxenda® is not recommended in patients with inflammatory bowel disease and diabetic gastroparesis since it is associated with transient GI adverse reactions including nausea, diarrhoea and vomiting. Acute pancreatitis has been observed with the use of GLP-1 receptor agonists, patients should be informed of the characteristic symptoms. If pancreatitis is suspected, Saxenda® should be discontinued. If acute pancreatitis is confirmed, Saxenda® should not be restarted. In weight management clinical trials, a higher rate of cholelithiasis and cholecystitis was observed in patients on Saxenda® than those

Saxenda® is a trademark owned by Novo Nordisk A/S. 2021 © Novo Nordisk A/S, Novo Allé, DK-2880, Bagsvæd, Denmark

on placebo, therefore patients should be informed of characteristic symptoms. Thyroid adverse events such as goitre have been reported in particular in patients with pre-existing thyroid disease. Saxenda® should be used with caution in patients with thyroid disease. An increase in heart rate was observed in clinical trials. For patients who experience a clinically relevant sustained increase in resting heart rate, treatment with Saxenda® should be discontinued. There is a risk of dehydration in relation to GI side effects associated with GLP-1 receptor agonists. Precautions should be taken to avoid fluid depletion. Patients with type 2 diabetes mellitus receiving Saxenda® in combination with insulin and/or sulfonylurea may have an increased risk of hypoglycaemia. Episodes of clinically significant hypoglycaemia have been reported in adolescents (≥12 years) treated with liraglutide. Adolescents should be informed about the characteristic symptoms of hypoglycaemia and the appropriate actions. Fertility, pregnancy and lactation: Saxenda® should not be used during pregnancy. If a patient wishes to become pregnant, or pregnancy occurs, treatment with Saxenda® should be discontinued. It should not be used during breast-feeding. Undesirable effects: Very common (≥1/10); nausea, vomiting, diarrhoea, constipation, headache. Common (≥1/100 to <1/10); hypoglycaemia, insomnia, dizziness, dysgeusia, dry mouth, dyspepsia, gastritis, gastro-oesophageal reflux disease, abdominal pain upper, flatulence, eructation, abdominal distension, cholelithiasis, injection site reactions, asthenia, fatigue, increased lipase, increased amylase. Uncommon (≥1/1,000 to <1/100); dehydration, tachycardia, pancreatitis, cholecystitis, urticaria, malaise, delayed gastric emptying Rare (≥1/10,000 to <1/1,000); anaphylactic reaction, acute renal failure, renal impairment. The Summary of Product Characteristics should be consulted for a full list of side effects. MA numbers and Basic NHS Price: NI: EU/1/15/992/003. 5 x 3 ml pre-filled pens £196.20. GB: PLGB 04668/0409. 5 x 3 ml pre-filled pens £196.20. 3 x 3 ml pre-filled pens £117.72. Legal category: POM. Full prescribing information can be obtained from: Novo Nordisk Limited, 3 City Place, Beehive Ring Road, Gatwick, West Sussex, RH6 0PA. Marketing Authorisation Holder: Novo Nordisk A/S, Novo Allé, DK-2880 Bagsværd, Denmark. Date last revised: March 2022

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store. Adverse events should also be reported to Novo Nordisk Limited (Telephone Novo Nordisk Customer Care Centre 0800 023 2573). Calls may be monitored for training purposes. Saxenda® is a trademark owned by Novo Nordisk A/S.

UK22SX00040. Date of preparation: March 2022


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Before

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After

Managing expectations In our experience, most patients will not see visible improvements for at least three months, with most starting to see results at four to six months. This will continue to improve over the subsequent 12 months and while treatment courses can be repeated at any interval, we generally recommend repeating treatment at between 12-18 months depending on the results. We will normally advise that with this form of treatment we should expect stabilisation of hair loss in 90% of treatment subjects, and more than 80% should expect visible improvement in the treatment areas. These are our own observations, which have been supported by a randomised double blind study.11

Figure 1: Patient before and after treatment using AAT and APRP

predictable and measurable APRP. Using this treatment system, we draw 60-120ml of venous blood from the patient. This will then be processed and separated using the Angel PRP device to provide a highly concentrated solution of APRP, as well as a volume of platelet-poor plasma (PPP) which can still be used as part of the procedure because it will also contain cells that will be helpful in the process, albeit not as effective.10 The main components of PPP are fibrinogen, fibronectin and thrombin. PPP is involved with haemostasis and coagulation, and acts as a cell attachment vector. It also promotes mitosis of fibroblasts and epithelial cells.8 PPP has been shown to sustain cell growth and survival.8 Our APRP device will typically produce 3ml of APRP and 20ml of PPP from a 60ml blood sample (i.e. APRP makes up 5% of the whole blood sample). Most clinicians will have their first exposure to APRP through training courses that will demonstrate venipuncture and separation, usually with simple centrifuges. This is an inexpensive way of introducing providers to the concepts of autologous blood products for aesthetic use. The main problem we find with this is the quality and consistency of the final ‘product’ that can be extracted in this manner, as this will be manually aspirated from the test tube using syringe and needle in most cases. Extracting a high concentration of platelets in this manner is difficult to achieve, even in experienced hands, and will usually result in most of the product having low levels of platelet (as in the PPP mentioned previously) or indeed no platelets at all.6 In our protocol, when using APRP alone, we draw the product in 0.9ml ‘doses’ into 1ml syringes. To this we add 0.1ml of calcium gluconate to activate the product and increase its efficacy. The product is then deposited sub-dermally using approximately 0.05ml doses at a 2cm spacing into the scalp using 30-32 gauge mesotherapy needles. To complete the procedure, we use our PPP fraction in the same way, to either the same area or other areas that may be less affected. This has the potential for improvement through the wound repair mechanism following needle trauma and the formation of fibrin complex that is involved in the healing of wounds after tissue injury. The procedure can cause considerable discomfort and our protocol is to apply topical anaesthesia (EMLA or similar) at least 30 minutes beforehand. We also recommend codeine pre- and post-treatment as long as the patient has no allergy issue. The use of ibuprofen or other non-steroidal anti-inflammatory drugs may also be of benefit and we have not found this to cause significant issues of post-treatment bruising or bleeding. In our hair protocol, this treatment is repeated at four weeks.

The younger the patient, the better the outcome of any regenerative treatment, especially when using cell enriched autologous fat grafting to follicular niche.5 With this in mind, we advise that these treatments have the best results in younger patients (35-45 years) as a standalone treatment, but can benefit older patients (over the age of 45) in combination with hair transplantation. This is because the quality of the scalp into which the hair follicular units are transplanted can be improved, which will support the transplanted follicles after surgery. Patients who are not suitable for APRP treatment include those with a platelet or other bleeding disorder, liver conditions and acute or chronic infections, or those that are taking platelet function inhibitors.12 Women who are pregnant or breast feeding should be excluded, as should patients who are being treated for auto-immune or malignant conditions, until their treatments have been completed.

Going forward The use of autologous fat and APRP is gaining popularity as a modality in the treatment of androgenic alopecia in men, and we are starting to see its use extend to our female patients who have historically been underserved regarding this issue. We believe the market for hair restoration treatment using autologous products is still in its infancy, yet has potential for significant growth in the future. What are now needed are large-scale studies and standardised protocols for preparation of the autologous materials and their application. Dr Aamer Khan is an aesthetic practitioner specialising in non-invasive treatments of the face and neck. He has spent the past 15 years performing aesthetic treatments. He is also co-founder of The Harley Street Skin Clinic. Qual: MB, ChB, MBCAM. Dr Sadequr Rahman is a GP and aesthetic practitioner with clinics in Harley Street, London and Newport, South Wales. Dr Rahman regularly offers mentorship to new practitioners. Qual: MB, BS, MRCGP, BSc (Hons)

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Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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the production of over-regulatory T cells, leading to the development of autoimmune disorders and reduction in the protection against inflammatory disorders including arthritis. They also evidenced how gut microbiome dysbiosis had a stimulating effect on metabolic neurodegenerative neoplastic disease.5

Gut microbiome and skin health

Understanding the Microbiome Nurse prescriber Piroska Cavell investigates the relationship between the gut and skin health The connection between the skin and the gut microbiome is a relatively new discovery, but it has a substantial impact on treating the skin to improve quality, treat disease or reduce the effects of ageing, including photoageing and environmental damage.1 In my experience, patients are also becoming increasingly aware of this and are actively looking for a more holistic approach to their skincare and aesthetic treatments. It is important for practitioners to keep up to date with not only medical advances, but also the increased awareness patients have with regards to their knowledge of treatments and their health.

very often used interchangeably. There are millions of diverse organisms within a microbiome that co-exist with the host (in this case humans) without harming it. These include microbes, fungi and protozoa. The microbiome contains more than 10 times the amount of host cells with 150 times more genetic material. Their functions include the secretion of p40 protein to supress cytokine-mediated apoptosis and epithelial cell interference, and they have been shown to have both immune and neurotransmitter properties.4 The microbiota is capable of actively killing pathogens, reinforcing the epithelial barrier and skin, induction of fibroblasts and epithelial cell migration and function.4

What is the microbiome? The microbiome is the collective term used to describe the entire environment surrounding the variety of diverse micro-organisms that create a particular habitat, including within the gut and on the skin.3 Microbiota refers specifically to a group of elements that are biota only – live bacteria that have a positive effect on the body and can be introduced to the body without causing harm, such as the microbe Lactobacillus.3 It can be confusing as the terms microbiome and microbiota are

What can affect the gut microbiome? The delicate balance of the gut microbiome is suspectable to disruption by medication such as antibiotics, malnutrition, stress, disease, dehydration, high alcohol and caffeine intake, a diet high in processed food, processed carbohydrates and a lack of fibre.5 Research, such as that conducted by Kim et al. clearly demonstrates the effect of a disruption in the gut flora.6 The disruption triggered

The microbiome of the gut has a far-reaching effect beyond the gastro-intestinal system, influencing other organs including the skin. Both the skin and the gut have a unique microbiome crucial to the maintenance of the health of each independently, moderating and monitoring what is taken into and absorbed through them. Both have vital immunological functions related not just to themselves but to systemic function, and are essential to the continuation of physiologic homeostasis.6 It is now widely accepted that the skin and gut microbiomes communicate with each other, influencing inflammatory and immune responses within the body. Together, they form the skin-gut axis.6 The gut and skin floras’ constant bi-directional communication is through mediation and modulation of adaptive and innate immunity, mainly by the gut microbiota which contains 70% of the body’s immune cells.6 This is how these respective systems collaboratively rectify and preserve allostasis, as well as maintain homeostasis of the skin and the gut, and thus the health and optimum function of the whole body too. The skin microbiome also performs an immune function as part of maintaining skin homeostasis, but not to the same extent as the gut. Like the gut, the skin has a dense colonisation of bacteria, an overgrowth of which is commonly found in several skin diseases.6 Current research Early evidence that the gut microbiome has an influence on the skin was reported by a pivotal study in which mice were given drinking water enhanced with the addition of Lactobacillus reuteri.2 The mice developed a thickened epidermis, as well as an increase in acidity of the epidermis, follicular genesis and sebocyte production. This led to thicker, shinier and healthier fur. These changes were found to be linked to an immune system response triggered by the added bacteria. Later, a randomised control double-blind placebo-controlled trial study on two sets of groups of 32 humans showed reduced skin sensitivity and reduced transepidermaltrans epidermal water loss

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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The skin and gut microbiomes communicate with each other, influencing inflammatory and immune responses from the skin, after patients were given Lactobacillus paracasei NCC2461. In addition, Kosiewicz et al. identified that racteroides fragilis, faecalibacterium prausnitzii and clostridium cluster IV and XI bacteria produce retinoic acid and polysaccharide, which stimulates the anti-inflammatory response with the accumulation of regulatory T cells.7 O’Neil et al. discovered that disrupted intestinal barriers allow gut metabolites and microbiota to access the circulatory system in the skin and disrupt cutaneous homeostasis.2 This disruption can be treated with the ingestion of oral probiotics to modulate the gut microbiota, triggering the anti-inflammatory response at the cutaneous level.4 In 2006 Baba, Masuyama and Takana published their experiments with Lactobacillus helveticus fermented milk and its effects on normal human epidermal keratinocyte differentiation.8 Results showed the fermented milk stimulated keratinocyte differentiation, promoting the expression of profilaggrin at mRNA level which in turn becomes filaggrin – a natural moisturiser in skin. In dry skin it is at negligeable levels or in conditions such as itchthyosis vulgaris and contact dermatitis absent. They concluded that Lactobacillus helveticus fermented milk was expected to be a useful moisturising agent for treating dry skin by boosting filaggrin production. They also demonstrated how Lactobacillus helveticus had a positive effect on the reduction of the severity of sodium dodecyl sulphate induced dermatitis.8 In their open label trial with 101 female participants, Mori et al. showed that Lactobacillus paracasei can reduce skin inflammation, with certain conditions all showing significant improvement, if not total resolution, when patients are treated with pre-and probiotics.9

Gut health and skin conditions The pathophysiology of acne vulgaris is influenced by the bi-directional crosscommunication between the gut and skin microbiota. This condition is more prevalent

in western societies, and is linked to a diet high in carbohydrates.10 This high intake of carbohydrates stimulates insulin/insulinlike growth factors, leading to a process ultimately triggering the target for rapamycin factor 1 – a controller of metabolism and proliferation of cells. It mediates lipogenesis, hyperproliferation of sebaceous glands and hyperplasia of acroinfundibular keratinocyte, therefore playing a role in the development of acne. Gastrointestinal disorders and disruption of the gut membrane, triggering malabsorption of minerals such as chromium, zinc and selenium, have been shown to further influence the psychological state of patients, and with oxidative stress, have been linked to acne vulgaris.10 Likewise, hypochondria has been linked to acne due to reduced acidity allowing the migration of colonic bacteria to the small intestine, causing small intestine bacterial overgrowth and triggering gut dysbiosis. This ultimately leads to systemic inflammation.10 Psoriasis is often linked with inflammatory bowel disease, with 11% of patients suffering from both conditions. It is known that psoriasis is linked to gastrointestinal inflammation and inflammatory conditions of other organs. Patients with psoriasis have had intestinal bacteria DNA isolated in their blood plasma.10 There are also strong connections between gut health and eczema and rosacea, but detail on this is outside the scope of the article.

Treatment As discussed here, there are marked similarities between the gut and the skin. In light of the above, my ethos has always been to take a holistic approach with patients. I talk a lot about the mind, body connection, the interaction of all the organs and the effects of diet and nutrition on skin health, ageing and appearance. Included in the consultation is a discussion about the patient’s diet. I explain the link between what patients put into their body and the condition of their skin. During this discussion, it is easy to enable patients to relate to the

connection between their diet and their skin by asking simple questions such as: Have they ever had a breakout when they have eaten a lot of junk food? Had a little too much alcohol? Or when taking certain types of medication, especially antibiotic therapy? We also discuss stress levels and their emotional state and explore how their nutrition can influence their mood with a move to a more natural, low-sugar diet. In addition, I recommend adding supplements such as lactobacillus and fermented foods which support gut health and rebalance the microbiome, helping to maintain homeostasis and the control of inflammation. This contributes to healthy, optimum functioning skin.9 Alongside this, the right skincare is essential. I recommend using skincare that is formulated with ingredients from the local coast such as bio kelp or marine algae, and including probiotic serums for the face and body. These products work with the skin, rather than disrupting the skin’s natural microbiota, rebalancing the skin microbiome.11

A holistic approach In recent years, a greater understanding of the importance of the microbiome in the gut and its systemic influence on the body is being recognised in medicine and is more widely acknowledged as a target for treating a variety of conditions, including several relating to the skin. With ongoing research into what is viewed as a new area of medicine, and in light of the increase in antibiotic resistance, this is being seen as a potential significant alternative. Practitioners should take a holistic approach to treating patients, establishing whether their diet and nutrition is affecting their skin health and recommending solutions accordingly. Piroska Cavell is a qualified nurse prescriber who specialises in weight management and obesity. She retrained in aesthetics in 2015 and has gone on to open her holistically focused Aesthetics clinic, Clinic Sese, in Whitstable in 2019. Qual: Bsc, PgDip, Pgcert, NIP

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Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


Advertorial Silkann

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Injecting With Cannulas Mrs Sabrina Shah-Desai outlines her tips for successful cannula use Aesthetic medicine is constantly evolving with new techniques, products and innovations being brought to the fore. With emerging evidence highlighting the benefits of cannulas for enhanced safety and results, it may be time to delve into the world of cannulas. Mrs Sabrina Shah-Desai from Perfect Eyes Ltd in London, trains aesthetic practitioners on how to use cannulas under ultrasound guidance. Here, she details her top tips for cannula use…

Tip 1: Choose an ultra-thin-walled blunt tip cannula An ultra-thin-walled cannula creates a larger inner lumen diameter, facilitating an increase in bolus size and therefore reducing the injection forces required to inject into the skin. Using a cannula with a blunt tip reduces the friction on the skin and helps the cannula to glide through the dermal tissue. As the cannula is blunt, the risk of causing a vascular occlusion is reduced, but not impossible. However, the blunt tip causes less trauma when it is ‘fanned’ under the skin. Whether you are using a needle or cannula, it is still pivotal to remain cautious and practise techniques to reduce the risk of any complications arising.

Tip 2: Use a cannula with an indicator By having a porthole position indicator on the hub, practitioners can orientate the port of the cannula to deliver the product correctly. This ensures that practitioners are dispersing the filler product into the correct treatment area, leading to beautiful aesthetic outcomes.

Tip 5: Buy your cannulas from a recognised company

same position relative to the tip, making it smooth, with no sharp edges which could compromise your procedure.

Tip 4: Change the cannula When navigating through fibrotic tissue, and to help reduce acne scarring, the Grooved Tipped Injection (GTI) cannula from the Silkann® range allows for the microsubcision of fibrous strands. This cannula is designed to treat surface defects and small scars. The cannula removes the need for the use of sharp instruments and provides a highly successful and safe treatment. For that reason, it is important to change your cannula based on the area you are treating, as some cannulas are better suited to different areas of the body or for helping aid different aesthetic concerns.

There are many poorly made and uncertified cannulas being sold on the internet. Practitioners should be certain that they are using CE or UKCA-marked products, which will replace the CE marking in December. This ensures that it has been manufactured to the highest-quality standards of the UK and EU market. Some fake and counterfeit products can even pretend they have the relevant approvals, which can put your patients at risk and could potentially lead to poor aesthetic outcomes. Therefore, it is important to buy your cannulas from a recognised vendor/distributor.

Creating high-quality medical devices for 30+ years With more than 30 years’ experience of designing single-use surgical products, Sterimedix is now a world leader in the development of ophthalmic and aesthetic cannulas and handpieces. In the last 10 years, the company has made more than 100 million devices, which have been designed and manufactured in the UK in line with strict European and global quality standards.

This advertorial was supplied by Sterimedix

Tip 3: Consider the size of the porthole Some cannulas have larger portholes, which can help facilitate an increase in bolus size. Make sure the location of the port is in the 66

For more information, head to sterimedix.com or contact info@sterimedix.com

Aesthetics | September 2022


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A summary of the latest clinical studies Title: Botulinum Toxin A Alleviates Persistent Erythema and Flushing in Patients with Erythema Telangiectasia Rosacea Authors: Yang R, et al. Published: Dermatology and Therapy, August 2022 Keywords: Botulinum Toxin, Erythema, Rosacea Abstract: The persistent erythema and flushing seen in some cases of rosacea do not respond effectively to, or may easily relapse after, oral medication or light-based therapies (laser or intense pulsed light). Intradermal botulinum toxin A (BTX-A) injection can be used to treat intractable erythema and flushing, but studies with large samples and long-term observation have not been conducted to determine its effectiveness and safety. The aim of this study is thus to investigate the effective duration and safety of intradermal BTX-A injection for intractable erythema and flushing. 16 patients with rosacea with erythema telangiectasia were injected with BTX-A at 1cm intervals between each point. Clinician Erythema Assessment (CEA) scores were obtained at baseline and one month after injection. Flushing assessment and survey using the Dermatological Quality of Life Index (DLQI) questionnaire were conducted at baseline and at one, three and six months after injection. At one month after injection, CEA scores revealed significant improvements in erythema and flushing; the results of the questionnaire on flushing and DLQI indicated that the improvement of flushing usually lasted for three-six months, but the effect decreased significantly at six months, and individual patients needed another treatment. BTX-A significantly improves the symptoms and quality of life of patients with refractory rosacea with few adverse effects. Title: Comparison of Oral Minoxidil, Finasteride and Dutasteride for Treating Androgenetic Alopecia Authors: Gapta A K, Talukder M, Williams G Published: Journal of Dermatological Treatment, August 2022 Keywords: Alopecia, Hair Loss, Oral Medication Abstract: Androgenetic alopecia (AGA) is the most common cause of hair loss, and is often challenging to treat. While oral finasteride (1 mg/day) is an FDA-approved treatment for male AGA, oral minoxidil and oral dutasteride are not approved yet. However, Japan and South Korea have recently approved oral dutasteride (0.5 mg/day) for male AGA. A probable efficacy ranking, in decreasing order, is: dutasteride 0.5 mg/day, finasteride 5 mg/day, minoxidil 5 mg/day, finasteride 1 mg/day, followed by minoxidil 0.25 mg/day. Oral minoxidil predominantly causes hypertrichosis and cardiovascular system symptoms/signs in a dose-dependent manner, whereas oral finasteride and dutasteride are associated with sexual dysfunction and neuropsychiatric side effects. The average plasma half-lives of minoxidil, finasteride and dutasteride are 4 hours, 4.5 hours and 5 weeks, respectively. Minoxidil acts through multiple pathways to promote hair growth. It has been shown as a vasodilator, an anti-inflammatory agent, a Wnt/β-catenin signalling inducer and an antiandrogen. Finasteride inhibits 5 α-reductase (5AR) type II isoenzyme, while dutasteride inhibits both type I and type II. Thus, dutasteride suppresses DHT levels more than finasteride in the serum and scalp.

Title: Age and Breast Reconstruction Authors: Chang-Azancot L, et al. Published: Aesthetic Plastic Surgery, August 2022 Keywords: Ageing, Breast Reconstruction, Mastectomy Abstract: Breast reconstruction is frequently offered to cancer patients who undergo mastectomy. Older women tend to have lower rates of reconstruction, mostly due to an age-based discretion. We aimed to assess the safety of this surgery in this population. We conducted a single-centre retrospective analysis of patients who underwent breast reconstruction following mastectomy between 2015 and 2020 at Complejo Hospitalario Universitario de Albacete in Spain. Patients were classified according to age when the reconstruction process began (group A: < 65 years-group B: > 65 years). Multivariable logistic regression models were used to estimate odds ratio (OR) and confidence intervals (CIs) for surgical complications according to age. We included 304 women (266: group A-38: group B). Complete reconstruction was achieved in 48.1% of patients in group A vs 10.5% in group B. After adjusting for potential confounders, age was not associated with an increased risk of surgical complications, neither overall (OR 0.88, 95%CI 0.40-1.95), early (OR 1.35, 95%CI 0.58-3.13) nor late (OR 1.05, 95%CI 0.40-2.81). Radiotherapy and smoking history were significant predictors for complications in every setting. In our cohort, age at breast reconstruction is not associated with a higher risk of surgical complications, in contrast to radiotherapy and smoking history. Therefore, age should not be a limiting factor when considering breast reconstruction. Title: Effects of Blue Light on the Skin and Its Therapeutic Uses: Photodynamic Therapy and Beyond Authors: Pieper C, et al. Published: Dermatologic Surgery, August 2022 Keywords: Blue Light, Light Therapy, Skin Treatment Abstract: Blue light is the most energetic portion of the visible light spectrum. Recent awareness of its ubiquity and potential has led to greater developments in therapeutic uses. This study aims to provide up-to-date information on the effects of blue light on the skin, and its place in therapeutic modalities within dermatology. A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for articles related to blue light’s effect on the skin and therapeutic modalities using blue light. This search resulted in 223 unique results with 60 articles selected for review. Therapeutic modalities using blue light have been proven to be effective as a monotherapy or component of a comprehensive treatment plan for common dermatologic diseases such as actinic keratosis, acne, cutaneous infections and psoriasis, and early reports support its use in disseminated superficial actinic porokeratosis and actinic cheilitis. The benefits and treatment applications of blue light have proven effective in multiple forms and uses. In the correct setting, blue light can be a useful tool for many common and sometimes refractory skin diseases while remaining low-risk and convenient. Further standardisation and monitoring should be pursued to determine the most appropriate use.

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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Managing pricing occurs through a combination of three things: mindset, preparation and communication. You will need to tackle these in this order, and the first part is the most challenging.

Create a growth mindset

Increasing Pricing in Your Clinic Entrepreneur and business coach Richard Crawford-Small details why you might want to consider a pricing increase, and how implementing a strategy can help you achieve this ‘Numbers are the language of business.’ These are wise words from the father of modern investing, Warren Buffett, and are just as relevant now as they ever have been.1 It is a challenging time in the global economy, with rising inflation fueling an increase in prices and the cost of living. The Retail Price Index (RPI) has been averaging a rise of around 3% per year, and if you haven’t been keeping your prices in line with this, you may have been losing money.2 In 2021, it increased to 7.1%, and now it’s more than 10%.2 Your suppliers may have increased their costs, and right now, you are probably looking at your business and thinking that you should do the same. And you would be right… but how? Increasingly, I’m finding that many aesthetic business owners are not paying themselves appropriately due to a lack of profit in their businesses, yet they haven’t implemented a price increase in years. However, this changes today – you are about to learn how you can put your prices up by implementing a strategy to be deployed on a bi-monthly basis. This article will help you use the data of your business to achieve this.

The Retail Price Index (RPI) has been averaging a rise of around 3% per year, and if you haven’t been keeping your prices in line with this, you may have been losing money

Many of us shy away from increasing our prices because of fear – pure and simple. You may think to yourself, “What happens if we raise our prices, become competitive and lose patients?” The truth is that you probably will lose some patients if you increase your prices, but this can be a good thing. Turning over your patient base is a natural part of the growth and evolution of a business, and you need to become comfortable with this. You are a business owner; you provide excellent services, and you deserve to be rewarded. You are in a market sector that is booming, and you have a right to make money and be successful. You may think, “What happens if patients say I’m too expensive?” The UK aesthetics sector has been undervaluing itself for years due to a lack of understanding on pricing strategies and it’s time for that to change. Not everyone will come on this journey with you, but you can use the data you collect to help you manage the fear. If you properly understand the key issues and challenges your patients have, either through patient surveys or effective questioning in the consultation process, you can create new and exciting solutions for them at a higher price. Firstly, you will need to summon the courage to have those uncomfortable conversations, but if you have done the preparation, it will become much easier.

Find the numbers In this exercise, you should write down four sets of numbers that you can extract from your business: 1. What is your current average monthly revenue? 2. What revenue do you need to generate monthly to run your business (break-even point)? 3. What revenue do you need to generate monthly to run your business and pay yourself a meaningful salary? 4. What revenue do you need to generate monthly to run your business, pay yourself a meaningful salary AND an additional 30% in savings? This will be your target revenue.

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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Turning over your patient base is a natural part of the growth and evolution of a business, and you need to become comfortable with this Spend some time on this, and allow yourself to dream – remember, 500 patients spending £2,000 per year with you is £1 million in business revenue, which is achievable. What would you do with that extra revenue? After you have a general idea of these figures based on RPI, you will have a vision of where you want to get to. The gap between number one and number four on this list might be quite wide, but that’s okay – this is a marathon, not a sprint.

Prior preparation prevents poor performance The next step is creating the environment you need to achieve your goals, and again, numbers are key. By the way, I’d like to point out that I hate numbers. I’m not a natural mathematician and I’m far happier in the world of sales and marketing. However, I’ve learnt the hard way that not having a handle on the figures is just abdicating responsibility for your business, and that is not what successful people do. There are two ways to fill the gap between your current monthly revenue and your target, and that is either to get more patients, or increase the average spend of your existing ones. You should always look to your current patient base first. This exercise almost never fails to unlock potential, and it will give you a super clear strategy on how to communicate your price rise to your patient base in the next step. As I said, not everyone is going to come on this journey with you, but you can use a method called quintiling to find out who might.

Find the tribe Quintiling is the process of dividing your patient base into 20% segments so you can more effectively target them. This method can be quite complicated the first time you complete it, but if you have a customer relationship management (CRM) system, you should be able to output this.

1. Export all of your patients’ names and their total spend with you over the last 12 months into a spreadsheet. 2. Sort the names so that the highest spend revenue is at the top (sort descending). 3. Add a row at the bottom with the total revenue generated. 4. Divide the total revenue by five. All you need to do now is identify all the patients in each segment, for example, quintile one is the top 20% of your patients, quintile two the next 20% and so on; you could divide these by using a colour-coding system. Eventually, you will have mapped your entire patient base dependent on the amount they invest into your business, and can now analyse these results.

Firstly, you need to find the language to use in communicating the changes, and you must position it from the patient’s perspective. They want to know how your changes will benefit them, not your business. Here are a few ideas of how you can pitch this to them: • Quintile 1-2: Create a bespoke treatment plan for each of your Q1 and Q2 patients, then call them and inform them that you will be giving them a free review at their next appointment. Position the plan and communicate the benefits. • Quintile 3: Analyse and spot any fast-moving patients who might be new but are spending higher amounts, and add to your Q1/2 plan. For the remainder, send a message telling them that at the next appointment you will be giving them a free review. • Quintile 4-5: Analyse and spot any fast-moving patients who might be new but are spending higher amounts, and add to your Q3 plan. For the remainder, send an email notifying them of the price rise. Put yourself in their shoes and sell the benefits.

It’s time to increase your prices! Look at quintile one (the top 20%) – what is the commonality? Are there combinations of treatments that show up frequently? Could you combine these into a treatment package and brand it as your own ‘special sauce’? Are there individual plans you could create? What treatments could you raise the price on while maintaining their popularity? I would highly recommend treating quintile one as your VIP group. You might want to isolate them from price increases, or you might want to create a plan just for them – there are so many opportunities to explore working with them more closely. Do this for each quintile, focusing on the first three – that’s where your upsell will be. If you were to increase average sales by 30%, what impact would that have on your bottom line? My guess is that it would be significant, and you won’t have spent a single penny on marketing.

With the right combination of mindset, preparation and communication, a change in pricing or commercial strategy shouldn’t be something to be feared. It can bring you closer to you target patients and create stronger relationships, while building a better business for you and improving outcomes for them. Remember, numbers are the truth, and as Buffett said, they are the key language you will need to learn. Richard Crawford-Small is an entrepreneur, best-selling author and founder of the Aesthetic Entrepreneurs. From small independent clinics right through to multi-million-dollar chains, he presents a methodology to grow businesses, and has helped hundreds of clinics across the world. REFERENCES 1. Zwieg P, ‘Numbers are the language of business’, Talk Business, 2020, <https://talkbusiness.net/2020/10/numbers-are-thelanguage-of-business/> 2. Gooding P, ‘RPI: Percentage change over 12 months – all items excluding housing’, Census 2021, 2022, <https://www.ons.gov.uk/ economy/inflationandpriceindices/timeseries/czbi>

Concrete communication The final step in this process is to communicate the changes in your business, which you can do by using your quintile data as your basis.

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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Entering a Mentorship Scheme Dr Emma Arjemandfar looks at the benefits and challenges of joining a mentorship scheme Having graduated in July 2021 as a recently qualified dentist, I understand what it means to be a mentee within the NHS, receiving guidance, support and training over an extended period of time. Since starting my undergraduate training I have always been interested in facial aesthetics, and have been fascinated by the growth it has seen over recent years. Despite the fundamental importance of facial and dental aesthetics to my clinical practice, there was little to no aesthetic teaching within my dentistry course, and I know the same to be true for medicine and nursing courses at undergraduate level. Here, I will outline key considerations I had when choosing a mentorship scheme and discuss the benefits that entering a scheme can provide anyone who is starting out in their aesthetic careers.

What is mentorship? Mentorship may be defined as, ‘the activity of giving a less experienced person help and advice over a period of time, especially at work or school’. The mentor is the more experienced individual, while the mentee is the less experienced.1 Mentorship has moved to the forefront of aesthetic training and education in recent years, with recognition of the need for a framework of support for healthcare professionals moving into the industry. Mentorship exists in all other areas of clinical practice, and in just about every established profession and trade across all sectors of the economy and market. A key way in which mentorship contrasts with a standard one- or two-day training course is the continued transfer of skills and experience from the more experienced individual (mentor) to the less experienced (mentee). It is less transactional and requires significant time-investment from both sides, that continues way past the time period of the scheme.

Choosing a mentorship scheme As an aesthetic patient myself, I had experienced both the good and not so good that the industry has had to offer over the years. I was curious about the variety of training pathways available to me after graduating but couldn’t find a clear answer from online searches. Courses ranged from hours, to a day, to months, with no clear guidance on regulations or what was considered ‘gold standard’.

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Like many healthcare professionals, I had sacrificed years to spending long days and late nights studying and was already proud of where I was. So, as my career was about to begin, I felt strongly about not rushing to associate myself with just any brand or organisation. Importantly, as a still-to-graduate dental student, only schemes or courses open to undergraduates were open to me, and this meant that a mentorship scheme over a longer time frame was necessary to guide me onto post-graduate training once I eventually graduated. It has been noted that features of a good mentorship include a transfer of expertise and knowledge, provision of support and guidance (both professional and personal), the establishment of excellent rapport and a relationship based on trust, as well as clear expectation setting and regular progress reviews.4 I kept this in mind, creating a list for researching possible providers. 1. Is it regulated? As healthcare professionals, we have a professional statutory regulatory body, whether it’s the General Dental Council, General Medical Council, Nursing and Midwifery Council or others. Everything we do both in our private and professional lives can have a bearing on our registration and continued ability to practise. Facial aesthetics is no different, and therefore I was especially interested in a scheme which incorporated regulated and academically accredited qualifications such as the Level 7 Diploma,5 which has been in the spotlight in recent parliamentary reports.6 The Level 7 Diploma in Injectables for Aesthetic Medicine (PGDip) is Ofqual-regulated and approved by the Joint Council for Cosmetic Practitioners (JCCP).7 The JCCP aims to create a safer environment for the public undergoing non-surgical treatments with mandated qualifications, premises criteria and insurance. These were the qualities I wanted to convey to my patients in the future, and for this reason I looked for a mentorship within an organisation that was offering the Level 7 Diploma. 2. Who are the faculty of trainers? Training is made by the trainers, especially where this is experiential or practical in nature. As a dental student, I wanted a faculty that was representative in all forms, both professionally and personally. The credentials of the faculty come first and foremost, and I wanted a scheme that had

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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a mix of medical and dental professionals; I researched where they trained, what courses they’ve undertaken themselves and what their educational and teaching qualifications are. For example, I knew that being part of a scheme which also aligned with regulated qualifications such as the Level 7 Diploma meant that trainers would all possess recognised qualifications in teaching itself. Beyond the qualifications, I also wanted a faculty that reflected me as a person, with experiences that I could share in and learn from. I found a scheme that was led by a team of trainee NHS maxillofacial surgeons with dual medical and dental qualifications and an array of surgical and non-surgical experience. This meant they had a greater understanding of my dental background. In addition, I had already followed the scheme and lead trainer for some time and was reassured by the team’s contributions to academic journals (including this very one!) and also speaking at educational conferences such as ACE and CCR, as this really solidified their dedication to the field. 3. What training do they offer? As well as the above, it’s important to look into whether the training on offer will be valuable and will teach you what you want to learn. The inclusion of face-to-face training was the non-negotiable point for me, and this indeed turned out to be the most valuable aspect of the mentorship scheme I chose, allowing for consolidation of theory, assessing and marking up patients myself, and gaining invaluable knowledge around consultation skills, consent and post-procedure care. Given the lack of undergraduate teaching in the area, and the still largely unregulated industry, I found the teaching on education and regulation (including an entire webinar on regulation and laws in aesthetics) highly valuable to me. The ability for more than a single face-to-face meeting, building on previous training, makes the experience even more worthwhile, allowing a mentee to reflect on previous experiences, come up with more questions and have these answered by the team of mentors. Going beyond an event-based model of learning was of immense value to me.

Key benefits of entering a mentorship scheme Learning techniques Having had no prior experience in facial aesthetics, the mentorship allowed me to

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learn techniques from some of the industry’s top injectors. Gaining their feedback and having the ability to continually practise under their eyes allowed me to refine my technique until it reached a stage where they were happy with it. This not only related to the actual physical injections, but also the consultation, assessment and marking up of faces. The diversity of patients seen really pushed home how important facial assessment skills are, taking into account patient desires, ageing, ethnicity and gender identity, among many other things. As a dentist, I particularly enjoyed the focus on facial geometrics as a first step in assessment, being able to draw on my undergraduate training in orthodontics and smile aesthetics to put this into action in facial aesthetics. Only through a mentorship scheme would this continued contact, teaching and support be possible, and even now I am able to contact my mentor to ask about challenging cases, or discuss a complication or unforeseen event. Building a community The relationship you build with the team leading the mentorship scheme is central to getting the most out of it. As a soon-tograduate dentist, on my scheme I was reassured and encouraged by the faculty of trainers each with their own successful aesthetic practices who were therefore able to share clinical and non-clinical advice and guidance with me. Being in a small group learning environment was also incredibly useful, and it is easy to underestimate the benefits of networking and building support networks with colleagues in person. Aesthetics and dentistry are similar in many ways, and one such way is the potential for lone-working, or within a small team. Building a network as a mentee can thus reap huge rewards when going out into practice in the community and treating patients. This is especially important for complication management. Setting you up for the future Importantly, beyond the clinical experience and theoretical training, being on a mentorship scheme introduced me to the ideal training pathway in the field, giving me an unparalleled insight into my own future pathway. Understanding the training steps, recognising a regulated and accredited endpoint for basic training, and embracing the mentorship model of professional development has given me motivation and reassurance in this exciting, yet still underregulated area of practice.

Challenges and considerations Time constraints and the location of training were key considerations, especially given the busy schedule of undergraduate healthcare professionals balancing exams, study and clinical placements. The mentorship days I attended were in London, so as long as adequate preparation and travel plans were made, this should not present too much difficulty for most. Finding a scheme with a face-to-face component locally would be fantastic, but it is also important to be taught by an expert faculty, and this commonly means travelling to centres outside your local area. Being able to access the theory remotely and on-demand is something I recommend people considering, as it was this that helped me to factor the scheme into my already hectic professional life.

Advancing your career Getting the balance right between facial aesthetics training and having sufficient understanding of the regulatory, safety and training aspects of the field, is not an easy thing to do. I had previously felt cautious about commencing training by the aforementioned ‘horror stories’ in the media and the confusing training information found when doing my own research. Undertaking a mentorship scheme, allowed me to experience a foundation on which I can make a critical and informed decision about my future training. I’m pleased to say that I have already undertaken the foundation course, and I am now in the early stages of the Level 7 Diploma in Aesthetics. Dr Emma Arjemandfar is a recently graduated dentist from the University of Manchester with a previous degree in education. Throughout her time at university as a mature student, she has worked in both NHS and private clinics assisting dentists who perform aesthetic medicine in harmony with their daily practice. Dr Arjemandfar undertook the Junior Trainee Mentorship Scheme (JTMS) run by Mr James Olding. Qual: MBChB (Hons), BDS (Hons), MRCS (England), BSc (Hons), Pg Dip (Aes)

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Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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Integrating Psychology into Business Psychologist Kimberley Cairns explores the benefits of implementing a psychological business model into your practice, and gives some insights on how to go about it Psychology is fundamental to aesthetic business, and many may argue that it underpins the commercial value of the entire aesthetic and non-surgical cosmetic sector. The practice of applying psychological theory to business models dates back to the early 1900s, when efforts to combine advanced business practices with the study of human behaviour offered insight into how individuals and groups behave.1 When applied throughout our industry, we can track the emergence of trends and accomplishments in our field, encouraging an inclusive stakeholder engagement approach beyond the clinic that extends to pharmaceuticals, research and development, manufacturing, advertising, marketing and personal relations, as well as training and education. By definition, the psychology of aesthetics involves the study of interactions and reactions, and how relationships form to create interpretations of preferences and dislikes in the everyday material world around us, including experiences of beauty.2 Aesthetics are ubiquitous in our lives, and are intrinsic to each patient and their individual needs, which is uniquely nuanced by the implicit and explicit aesthetic consumer experience.3 Therefore, we can expect to expand the notion of psychology to aesthetic business further into the design of clinics and workplace environments, recruitment processes and the retention of talent, performance and appraisal, as well as continuous personal and professional development. Collectively, these organisational constructs work to protect mental health and foster substantiated health-promoting behaviours.

Why create a business model for psychology? The business case for implementing psychology into your practice should not be regarded as a fleeting concept. It is a vital evidence-based component to identify the needs, gaps, barriers, responsibilities and ambitions of any healthy contribution to the aesthetic specialty. This has well-informed potential for preventing absence among employees and targeting poor mental health or stress-related symptoms at work, which can lead to increased staff turnover, reduced

engagement, high presenteeism and poor business continuity – all negative business implications.4,5 Aesthetic practitioners who own their own clinics are most likely to be regarded as small business owners (SBOs). Research by Mental Health UK compared the mental health of SBOs at the beginning of the pandemic to January 2021. They found that of the 984 SBOs surveyed, 80% of them reported experiencing symptoms of poor mental health at least ‘a few times’ per year.6 Of female SBOs, 86% reportedly experienced poor mental health compared to 77% of males.6 An inability to focus was most commonly reported (66%), followed by anxiety (64%) and disrupted sleep (63%).6 It was further reported that SBOs experienced more acute symptoms such as panic attacks (24%), and that symptoms of depression were more frequent since the pandemic began (37%).6 This is alarming given the need for our aesthetic SBOs to perform at a high level, and to execute superior decision-making to avoid faulty, distracted or unnecessary risk taking, especially when managing complications. Decision-making and business strategy are equally influenced by cognitive and social processes which are fundamental to safe aesthetic practice. A reduced ability to focus can be a catalyst for debilitated practice, affecting patient outcomes and practitioner health. Numerous studies, anecdotal reports, patient testimonials, recent surveys and the latest Health and Social Care Committee Report into the impact of body image on mental and physical health (see p.16) all make the strong case that aesthetic practitioners are in an unenviable position whereby they must navigate daily psychological threats and emotional liabilities in themselves, their peers and patients.7-10 Practitioners risk being psychologically compromised due to the unique demands and invisible cyclical burdens in-clinic and at home.11,12 Constantly striving to fulfil ‘realistic expectations’, overcome financial changes or constraints due to the current economic living crisis, endure the societal pressure to ‘look good’, manage time and diversify from competition, explore new product innovation and stay informed on industry developments such as licensing, as well as managing complication anxieties and fear of litigation, all create conflicts with maintaining good health. Simply put, these conditions demand necessary protection of psychological health in aesthetic practice.

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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Why is psychological support important? Developing healthy psychological ownership of the products and services offered within the sector must reflect empowered consumers’ preferences, as opposed to exposing vulnerabilities or (unintentionally) exploiting them.10 Consumers must feel qualified to make a decision which begins at the first touchpoint of connection. Decision-making is a loaded psychological theoretical construct which is influential in achieving an empowered product demand exchange. If the patient doesn’t feel qualified to make a decision, the ‘empowerment-product demand’ effect diminishes, and adverse consequences to patient satisfaction, practitioner confidence and business growth will endure.13

What are the ethical considerations? Many of the problems affecting the aesthetic industry are driven by cultures and behaviours. Industry taboos and bad practice endanger the value, integrity and respect of the great work being done in the industry. Without a shift in mindset towards compassion and unity, integral psychological collaboration can never fully deliver its commercial and ethical benefits, and the industry will continue to underperform. A psychological business model provides a pillar to safely ‘put the patient to work’, allowing both the patient and practitioner to thrive through decision-making, which is synonymous with the consultation processes, informed consent, risk management and the commitment to undertake treatment. To demonstrate this, let’s consider the contentious free consultation. For some, this may be common practice, while for others it’s just not the right fit. Either way, free consultations themselves are not the problem when implementing them – psychological business solution boundaries around them often are. A free consultation allows for signposting in a more comprehensive way. When the correct processes are in place, you can look a prospective patient in the eye and tell them why another service is better suited for them, or why another colleague or practitioner is a better fit. These messages are more likely to be taken on board if a patient is not ‘out of pocket’ and you are not in an ‘upsell’ or ‘conversion’ mindset. If a prospective patient attends a free consultation, there is no direct monetary exchange, but they are making an invaluable

Without a shift in mindset towards compassion and unity, integral psychological collaboration can never fully deliver its commercial and ethical benefits, and the industry will continue to underperform commitment to you. If a patient does not attend a free consultation and they ‘ghost’ you, this can be excruciating, yet also immensely beneficial. This early business transaction allows you to make a judgement on whether a patient has the readiness, motivation and psychological flexibility required to break their normal routine and make time to see you on your terms.14 This practice sets the tone to ensure the right patient gets access to the right treatment by the right professional at the right time. Once you can collate imperative data about a patient’s readiness to engage with you, you can expect a positive business and psychological shift. Assessing for ‘goodness of fit’ is a condition for every consultation, and can be conflicted by a fee-paying or redeemable model. It should be expected that not all enquiries will convert, and that you will not be the right practitioner for everyone. Undoubtedly, as you work to strengthen your relationships with your patients, elements of your personality will be brought into your patient interactions. Laughter has been considered a holistic care approach due to its specific health benefits, and you may be familiar with the phrase ‘laughter is the best medicine’. Researchers have explored the acceptability and functions of humour and laughter in patients with prolonged incurable cancer, and reported that nearly all specialists reported using humour (97%) and all reported sometimes laughing during consultations, with 83% experiencing positive effects from this.15 The opportunity to showcase who you are and the way you work should be sensitively encouraged in the scope of professional practice, and this will include elements of

your authentic personality. When you achieve this, you will become more equipped and confident in managing that feeling when you just ‘click’ with a prospective patient, or equally, when you know that you are not the right fit for them. Conversely, it is important to recognise factors that may destabilise the consultation space for correct patient selection. Including a consent form in any onboarding paperwork prior to a face-to-face consultation can undermine your specialist judgement of that patient’s psychological wellbeing. Informed consent is a teaching opportunity and should be formulated in person and with good signposting opportunities. This is of paramount importance given the reported findings that those affected by poor body image often do not get adequate access to support services. Of these, 64% felt that their experience of accessing services was either negative or strongly negative, with only 14% saying their experience was positive or strongly positive.17 Perhaps most worryingly, 55% of respondents felt that they had been stigmatised when they accessed or tried to access these services.17 There is a possibility that those provided with poor access to first line services will seek other aesthetic providers who offer more support. To demonstrate this further, recall the earlier use of the term ‘empowerment-product demand’ as we explore skincare.13 Skincare is often regarded as the foundation on which to build all other aesthetic interventions, and is considered a labour of love by many. Correctly understood and informed decisions can increase the perceived value of a product or service, but there are limitations and strict conditions to consider.18 Who do your patients blame if their skincare is not delivering the

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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A psychologically sound business model will be ethically aligned and well-purposed. This will not lead to more patients, but will lead to the right ones

intended results? You! It is unlikely that a patient will offer their non-compliance as a cause, even if you know this to be the case. You may argue skincare isn’t for those who want a ‘quick fix’, in which case I invite you to re-read the last paragraph.

Return on investment A psychologically sound business model will be ethically aligned and well-purposed. This will not lead to more patients, but will lead to the right ones. ‘Closing the sale’ gives no opportunity to recruit new patients. Talking about money can be uncomfortable, which will lie within personal mindset issues. It is essential to learn about the short-term blindsides of costs associated with psychology, as well as the longer-term longevity and financial gains to be made and preserved. Empowering your pricing decisions for a psychologically informed business model must be implemented with clear boundaries. It is well known that lawyers, accountants, private GPs or hairdressers do not offer free consultations, for example. It is therefore of paramount importance to give clarity as to why seeking an aesthetic opinion is different to other professions, and that paying for any subsequent time in treatment along the patient journey is transparent and upfront, thus avoiding setting a precedent that time is not worth money. Using proper, accurate and explicit pricing will bring prosperity with no danger of questioning a patient’s affordability. There are many ways to showcase pricing structures so that the financial conversation has already taken place, even if you were not directly part of it. This offers a compassionate space for the practitioner and the patient to separately

construct future planning and investment. Finding out after a skilful consultation has taken place that they are a ‘good fit’ for you and are a suitable patient for treatment, but they cannot afford you, is a threat to potential income and drains credibility. Increased offerings of heavily reduced prices, competitive marketing strategies, cumulative discounts and reward schemes all seem to be on the rise in an attempt to neutralise the industry’s complex psychological needs. Unintentionally, this can be extremely damaging to the mental health of the patient and practitioner. Flexing treatment prices to suit perceived financial affordability can be regarded as coercive and predatory, and risks silencing actual patient needs. Especially during the current widespread economic hardship, reducing prices or offering free treatments to oblige patients who can’t afford it helps no one, and a patient may be more likely to discredit you publicly if you are not protected with a positive psychological business model. This may be a good time to question whether your fees actually pay you. Having unmet personal needs does not make for a good professional aesthetic provider, and you will not be able to deliver quality standards of care and service to the vulnerable groups who need you. Your pricing structure may need to be reworked if you are one of the many practitioners on the edge of burnout who are earning less than minimum wage or persistently work through signs of exhaustion, exposing you to increased risk of malpractice allegations and the onset of chronic health conditions.20 A psychological business model may result in a slower schedule, but it will give you an opportunity to reflect, practise self-care

and potentially charge more for your quality services, which can act as a buffer against the increasing economic uncertainty. Considering your strength as a medical professional may touch on some deep internal work. This is encouraged and lends to the acceptance of mental health and psychological wellness in aesthetic practice.

The future of psychology in aesthetics Moving forward, it will be a requirement of aesthetic practice to be responsible for how we qualify patients for treatments at a much deeper level of emotional understanding within the scope of licensing.10 For an industry regarded as having a high rate of innovation and specialism, it is promising that as we enter the consultation phase for licensing, psychology is firmly on the agenda.10,24 Through integration, aesthetic practitioners can become prepared to explore, strengthen and contribute to the knowledge, education, skills and safeguarding requirements which deliver harm reduction approaches for an accessible, future-proofed psychological business model in the interest of public health. If you experience a decline in your mental wellbeing, notice an unexpected change in a colleague you work with or think your patients could benefit from psychological services, say something. You may be the voice they need at that moment – someone to trust. Praise their courage and seek further support from agencies like the Mental Health Foundation to promote good mental health for all.25 Kimberley Cairns provides specialist evidence-based psychological solutions across the international wellness and medical aesthetic industry as director of The Integrated Practitioners of Aesthetic Wellness. She is also a trustee to the board of the JCCP and faculty member at The City of London Dental School. She is the founder of the non-for-profit Aesthetic Wellness Foundation, which offers psychological support for the prevention and intervention of maladaptive aesthetics.

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Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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In The Life Of Dr Wassim Taktouk Dr Wassim Taktouk provides an insight into his working and training days, as well as his role as a key opinion leader binge. I am currently working my way through Stranger Things, however the TV is off by 11pm to ensure I don’t fall down a rabbit hole of box sets – I believe a good night’s sleep is the key to success.

A typical working day… I wake up at around 6:30am every morning, which is usually without choice as I seem to have some sort of alarm in my head which wakes me up no matter what and I can’t go back to sleep. I immediately check my phone, partly due to a social media addiction but also to check through messages. I am trying to reduce my time spent on social media platforms as it can be a time thief, but it has a positive side. It can be used to help educate people about aesthetics as well as the treatments I specialise in. I try and exercise most mornings, either on the Peloton at home or with my personal trainer. Then I shower and get dressed. I like to think my breakfast is an acai bowl with fresh fruit, granola and almond butter, but is usually an almond croissant. I live just 15 minutes from my clinic – Taktouk Clinic in Knightsbridge – so I walk to work, arriving at 8.30am. My working day begins with a video call with the faculty of my training academy, London Academy of Aesthetic Medicine (LAAM), where we discuss updates, pressing issues, how the last training weekend went and what we could improve on. The call usually lasts one hour. If I don’t have this call, then I have a team meeting at the clinic. The team greatly values this as it’s a platform to discuss the day ahead and plan for any potential issues. I have found this proactive approach works well to maintain a cohesive team. It’s important to me that all members of my team feel appreciated and that they have the opportunity to share any concerns. During a clinic day, I will see around 20 patients for a mixture of botulinum toxin and dermal filler injections – this is what I enjoy performing the most! I have a fantastic team of specialists working at the clinic. Any injectables, energy-based treatments using lasers, microneedling or skin tightening are in the hands of the experts. We pride ourselves in always having the right member of the team for every patient concern. I have lunch at 1pm, when I’m allowed to look at social media again, and my phone is handed to me by the manager for 15 minutes.

Other work commitments…

Something people don’t know about you… I nearly failed a practical exam as a student doctor because I wouldn’t touch the patient’s feet – I hate feet!

Favourite TV show… American Horror Story

Most challenging aspect of your day… Trying to switch off and wind down

The afternoon runs from 2pm-6pm when I will conduct virtual follow-up appointments with patients and perform more injectable treatments. At the end of day, I will have a quick team debrief to ensure the day has run smoothly. I will leave the clinic at 6:30pm and head home, stopping off at the supermarket to pick some dinner up. My evenings vary depending on commitments. I may have webinars or Instagram Lives to prepare for. I mostly unwind by cooking and catching up with friends for a quick mid-week dinner. After dinner I treat myself to a little box set

I’m an international key opinion leader (KOL) for aesthetic manufacturer Teoxane, so this takes up a lot of my time. During the week, I have Teoxane training days, so I sometimes travel abroad for these. I might go to clinics to show treatment techniques to practitioners who want a hands-on experience, discuss the products and how to best utilise them in practice. I might also get asked to speak at a conference – I believe that patient education is pivotal, so it was great to recently speak at the first Beauty Uncovered LIVE event. As well as being a lot of fun, it was a great opportunity to speak to consumers directly. When I’m not doing KOL duties, I will also be doing educational days at LAAM. During these days, the clinic gets restructured to become three training rooms, and the models wait in the waiting room, ready to be called in. These days usually happen every few weeks. The days can be manic, but we have a good team who runs it well and the feedback has been excellent. We have the academy online too, so I’m also busy filming and doing sound recordings for this.

Most memorable day… My most memorable day was when I opened my clinic. It had been a year in the making and it had been very stressful. We officially opened the clinic the day we came out of the third lockdown in April 2021, so the decorators were still laying the carpet down when the first patients were coming in. The night before the opening, we were decorating the shelves, so it was very last minute. Another memorable moment was when my parents came to see the clinic for the first time. This was a very special moment and one that I won’t forget.

Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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is currently being proposed is not sufficient for the Scottish aesthetic sector to see significant improvement in the health and safety of our patients.

Going forward

The Last Word Independent nurse prescriber Frances Turner Traill debates the effectiveness of the proposed new Scottish regulation for aesthetics In July, it was announced that the Scottish Government is to consider implementing new regulations on non-surgical cosmetic procedures after overwhelming backing from public consultation.1 The consultation stated that it was now a ‘priority’ to consider the regulation of dermal filler procedures, with a view to ensure all non-surgical cosmetic procedures carried out in Scotland are delivered from hygienic premises by appropriately trained practitioners, applying recognised standards and using legitimate products.1,2 This followed the English Government’s announcement that it would introduce a new licensing scheme for all individuals carrying out cosmetic procedures.3 While some have celebrated the response as a step in the right direction, I believe it still does not directly tackle the problem of non-medics performing aesthetic injectable treatments, nor affect the direct impact this has on patient safety.

Previous landscape While previously unregulated, in April 2016, legislation was introduced which meant that independent Scottish aesthetic clinics run by a doctor, dentist, nurse, midwife or dental technician had to register with Healthcare Improvement Scotland before they could legally provide cosmetic procedures.3 While I appreciate this improved the industry somewhat by implementing a universal standard for all clinics, it was essentially regulating the already regulated. There remained a vacuum of untrained injectors, and the standards here continued to be woeful. Indeed, other medical practitioners have referred to Scottish aesthetics as ‘the joke of aesthetic medicine globally’.4

Proposed changes Six years later, the outcome of the new consultation is that the Scottish Government will start to ‘consider’ new measures, including that anyone administering dermal fillers will have to meet hygiene and clinical standards. The Government has also noted that the Health and Care Act 2022 will introduce a licensing scheme for non-surgical cosmetic providers in England, and has committed to working with the other UK nations as they develop Scottish proposals in this area.1 Of course, it is positive that there is a conversation happening around aesthetics and its regulation (or lack thereof), and this will provide some sort of standard for those who are performing injectable procedures. However, this proposed regulation is still allowing non-medical persons to practise, even though they might have to be licensed. An obligatory annual inspection is akin to the rules currently in place for non-medical environments like premises for tattooists, semi-permanent makeup and ear piercing, rather than for clinical environments. In addition, environmental health officers don’t know the ins and outs of aesthetics or dermal fillers, and may not understand the true dangers or what really needs to be in place as it is not in their remit of expertise. I also haven’t seen any of them welcoming this new regulation because they don’t see it as being in their territory. To me, it seems like a tick box exercise rather than really looking after patient safety and ensuring that injectables become a private medical procedure. Therefore, I believe that what

Currently, I believe the fundamental issue is that adverse events are not being measured because complications are not reported. Non-Medical persons have no system to report to and medical practitioners under report, resulting in a lack of real data about the potential dangers of aesthetic treatments. Indeed, last year it was revealed that only 188 adverse reactions were reported to the Medicines and Healthcare products Regulatory Agency (MHRA) over the past 29 years, equating to fewer than 10 adverse events a year across the UK, which a study evidenced to be majorly incorrect.5 One in every six botulinum toxin procedures was identified to cause a complication, according to the study.5 Likewise, in 2019, Hamilton Fraser Cosmetic Insurance revealed that more than half of aesthetic practitioners in the UK did not report their complications that year.5 It is of paramount importance that all aesthetic practitioners report adverse events of dermal filler procedures to the MHRA using the Yellow Card reporting scheme,6 as well as to the medical device manufacturer, their regulatory body or the JCCP if they are a member.7 Together, we need to collect this data in order to put it to the Government as evidence of the danger of unregulated aesthetic treatments, and bring about real change in our industry. Finally, I also believe that associations such as BCAM and BACN need to lobby together alongside stakeholder groups and vehicles such as Save Face and the JCCP in order to move the Government to take more drastic legal action. Frances Turner Traill is clinical director of FTT Skin Clinics in Hamilton and Inverness Scotland. She is an active board member of the British Association of Cosmetic Nurses (BACN) and continues to lead the Scottish Regional Group’s educational meetings. Qual: RGN, RMN, MA Hons, NIP, BSc, PG Cert

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Reproduced from Aesthetics | Volume 9/Issue 10 - September 2022


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Aesthetics


EVOLUS. WHO WE ARE

• Evolus (Nasdaq: EOLS) is an emerging global performance beauty company with a customer-centric approach to delivering breakthrough products. • The company’s purpose is to bring innovation and forward-thinking technology to the aesthetic market by eliminating the barriers existing for customers today, making the beauty experience delightful and achievable. • Evolus, headquartered in Newport Beach, California, is launching in the United Kingdom.

OUR STORY

‘After more than two decades working with aesthetics practices, I’m excited to be building something different. I believe there is a gap in the market for a radically different type of company – one that is designed around our customers,’ says Dan Stewart, Vice President and General Manager for Evolus International. ‘We invite you to evolve the future of beauty with us.’

The beauty sector is great at capturing trends, understanding what consumers want, reacting quickly and creating desirable brands. And we also know that you need products that really perform. Just as your practices have evolved over the last 15 to 20 years, so has the mindset and desires of consumers. Today, this category is booming. Many people, across the generations, view beauty treatments as a part of daily life. This can be especially true for those with a millennial mindset who are visiting clinics and fuelling the boom.

WHAT MAKES US STAND OUT? Since our foundation, we have focused exclusively on aesthetics. This means we live and breathe beauty whilst also being a pharmaceutical company.

WHAT DO WE STAND FOR? We are a small start-up with a big vision. Our culture is designed around these three ideas.

Fun

If you love what you do, you’ll never work a day in your life. This is a mantra we live and breathe.

Transparent

At Evolus, we’re clear, open and honest - with each other and with our customers.

Impact

As a team, we move quickly but also have enough time and space to listen and create broad, innovative ideas. Dan Stewart, VP & GM, Evolus International From the get-go, we wanted Evolus to be different. We describe ourselves as a performance beauty company, taking learnings from the beauty sector and applying this within aesthetics.

DOP AUGUST 2022 | UK-UNB-2200009

We want our work to disrupt the status quo. We want to make an impact. Yet most importantly, we want to be customer-centric – always. (PS. Please remind us if we aren’t!)

HEADQUARTERED IN CALIFORNIA


evolve

We invite you to the future of beauty with us. HEADQUARTERED IN CALIFORNIA From our global corporate headquarters in Newport Beach, we have been growing since 2012. We have more than 170 associates with some amazing skills – from R&D experts to digital engineers and sales and marketing guru’s, one thing unites us - we love being disruptive!

SOME OF OUR NEWEST RECRUITS ARE IN THE UK We are super excited to introduce our shiny new team. Headed up by industry pioneer, Dan Stewart, we have assembled a stellar cast of Evolusionaries. Introducing the Evolus UK team (drum roll, please)

Suse Alexander, Jean Johnston, our UK General Scotland and the Manager, and North, Wearer of all-round superstar Killer Heels

Holly McDonald, London and the South East, also known as Hollywood

Hilary Gates, Southern and West England, Equestrian Queen

Amy Wood, Manchester and the North West, our Peloton junkie

Nichola Smith, Central and Eastern-ish England, outdoor enthusiast

Samuel Oladiran, Medical Science Liaison, and community champion

EVOLVE WITH US. EXPANDING AROUND THE WORLD As a company, we are flourishing. In 2021, over 1,400 new practices joined Evolus, bringing the total number of customers we support to more than 7,500 in the US alone. Now, we are excited to expand our operations outside of North America, starting with Great Britain, Germany and Austria. For us, this is another significant step in our strategy to become a leading, global, multi-product performance beauty company.

In the last three years, we’ve had a lot of conversations and learned a lot from our North American customers about what works, and what doesn’t work. We’re taking these lessons, and evolving what we do in Europe and beyond to meet your needs. Yet there is one thing that comes across clearly. Our North American customers are delighted to have choices. Now, we want to hear from the aesthetics community in the UK about the trends you are seeing and how your business is evolving. Visit www.hello-evolus.com to find out more.

Come and join us at our CCR symposium on Thursday October 13 at 1230 – 1330, with Dr Steve Fagien and guests.

We look forward to partnering with you as we launch a different type of company.

Don’t stand still, evolve with us


evolve with us To find out more visit hello-evolus.com DOP July 2022 UK-UNB-2200001


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