S ! D IC ET S LE H RD E A ST A EV AE AW S R ER N

VOLUME 8/ISSUE 7 - JUNE 2021

THEIR LOOK

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

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

Produced and Funded by Juvéderm®. UK-JUV-2150259 May 2021 ©2021 Allergan. All rights reserved. Model treated with Juvéderm®. Individual patient results may vary. Adverse events should be reported. Reporting forms and information can be found at https://yellowcard.mhra.gov.uk/. Adverse events should also be reported to Allergan Ltd. UK_Medinfo@allergan.com or 01628 494026.

CPD: Skin Layers and Injectables Dr Catrin Wigley provides an overview of the skin’s function and anatomy

Treating the Under-Eye

Practitioners share their approaches for ageing concerns in male patients

Transgender Patients

Dr Vincent Wong addresses the needs of patients that are gender transitioning

Consulting Male Patients How to ensure male patients are comfortable having treatments

LIGHT UP

YOUR LOOK

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Contents • June 2021 08 News The latest product and industry news 18 No More Stiff Upper Lips Julie Redmond discusses the growing popularity of lip enhancement 21 Defining a Medical Procedure Aesthetics looks at the new JCCP definitions of what constitutes a ‘medical’,

‘medically-related’ or ‘cosmetic’ procedure

CLINICAL PRACTICE 23 Special Feature: Injecting the Male Periorbital Area Practitioners share their methods for treating the aged under-eye area 29 CPD: Understanding Skin Layers and Injectables Three practitioners provide an overview of the skin’s function and anatomy 32 Treating the Male Jawline Dr David Jack outlines tips for treating the lower face and jawline 34 Considering Rosacea as a Systemic Disease Dr Firas Al-Niaimi discusses how rosacea can be linked to organ systems 36 Aesthetics Awards: The Winners Discover our deserving 2021 winners 42 Defining Male Beauty Mr Daniel Ezra and Mr Mohammad Dehabadi explore the attractiveness of

men and considerations for successful results

44 Treating the Male Mid-Face Dr Xavier Goodarzian restores male mid-face volume 48 Understanding Asian Men Dr Souphiyeh Samizadeh outlines East Asian male facial features 51 Case Study: Transgender Patients Dr Vincent Wong addresses the needs of patients gender transitioning 54 Considering Radiofrequency for Body Contouring Dr Yannis Alexandrides presents advice for contouring the body 55 Abstracts A round-up and summary of useful clinical papers

IN PRACTICE 57 Consulting Male Patients Dr Teuta Berisha and Mr Benji Dhillon outline how to ensure male patients

are comfortable when seeking aesthetic treatments

61 Creating a Positive Culture for Success Business consultant Stuart Rose shares advice on setting goals 65 Joining a Franchise Franchising professional Mark Lemmon explains the benefits of becoming

part of a franchise

69 In Profile: Mandy Cameron Mandy Cameron discusses becoming the winner of the Outstanding

Achievement Award

70 The Last Word: NHS Training & Aesthetics Mr James Olding argues why trainees should not be deterred from aesthetics NEXT MONTH IN FOCUS: COMPLICATIONS • Bruises vs Vascular Occlusions • Non-surgical Rhinoplasty

Special Feature: Injecting the Male Periorbital Area Page 23

Clinical Contributors Miss Priyanka Chadha currently works as a plastic surgery registrar in London and is co-director of Acquisition Aesthetics training academy. Her academic CV comprises national and international prizes and presentations. Miss Chadha is a KOL for Galderma. Miss Lara Watson is dual-qualified in medicine and dentistry and works as a registrar in oral and maxillofacial surgery. She is a faculty member for Galderma and is also a co-founding director of Acquisition Aesthetics with a background in anatomy and scientific research. Dr Catrin Wigley is a plastic surgical trainee in Central London. She was previously an academic trainee in the West Midlands and has held several lecturing roles. Dr Wigley practises aesthetics alongside her training and research interests. Dr Firas Al-Niaimi is an award-winning consultant dermatologist, as well as Mohs and laser surgeon. Dr Al-Niaimi has participated in more than 200 publications and his own book on preparation for dermatology specialist examination. Dr Daniel Ezra is a consultant at Moorfields Eye Hospital in central London, where he is also director of oculoplastic surgery. He runs a private practice based at 152 Harley Street and at Moorfields focusing on periocular and facial aesthetics. Mr Mohammad Dehabadi is currently an accident and emergency, and adnexal and oculoplastics Fellow at Moorfields Eye Hospital in London. He has a keen interest in both the functional and aesthetic aspects of oculoplastics and facial rejuvenation. Dr Xavier Goodarzian is the medical director and co-owner of the national award-winning Xavier G. Clinic in Southampton. Dr Goodarzian is a member of the Royal College of General Practitioners. Dr Souphiyeh Samizadeh is a visiting associate professor, the founder of the Great British Academy of Aesthetic Medicine, and the clinical director of Revivify London clinic. Dr Vincent Wong is an aesthetic practitioner and founder of VinDoc Aesthetics. He has a Bachelor of Science in Medicine from the University of St Andrews and a Bachelor of Medicine and Surgery from the University of Aberdeen.

Editor’s letter As we have all been locked away for so long, most of you will not have noticed the slight change in my appearance over the past months. Yes, I am expecting my first child! So, while I embark on Chloé Gronow this new and exciting journey, it Editor & Content is with pride I announce that our Manager current Deputy Editor Shannon @chloe_aestheticseditor Kilgariff will be stepping in as Acting Editor and Content Manager at Aesthetics Media. Shannon has been an excellent ambassador for the aesthetics specialty and I’m confident she will continue to enhance the Aesthetics brand in my absence, continuing our strong ethos of enhancing education. Finally, a huge congratulations to all Aesthetics Awards winners! The past year has been such a challenge for many of us, and the ceremony was a beautiful way to celebrate our brilliant specialty before my departure. See you all in 2022!

It is a huge honour to take over the editorship of Aesthetics as well as our new patient publication Beyond Beauty while Chloé is enjoying her maternity leave. I have worked with Chloé for almost six years and have learnt so much from her, as well as our previous editor and mentor Amanda Cameron – who I am delighted has just won this year’s Shannon Kilgariff Aesthetics Award for Outstanding Achievement in Medical Acting Editor & Aesthetics (read more about her fascinating career on p.69). Content Manager A huge congratulations, of course to all other deserving @shannonkilgariff winners – announced on p.36! Since I joined the team, I have learnt so much about the wonderful world of aesthetic medicine and met many inspiring practitioners, KOLs, contributors, clients and readers. Each and every one of you has helped drive my passion for high-quality education and industry progression, which myself and the team will continue to focus on. As the world reopens, I am looking forward to seeing you all again, and meeting more of you in future – perhaps at the upcoming CCR conference in London on October 14-15. If you see me at any conferences or events, then please do say hello or get in touch – shannon@aestheticsjournal.com or 07557 359257. I hope you enjoy our June issue, which has a large focus on treating male patients!

Clinical Advisory Board

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

WE WANT TO HEAR FROM YOU!

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

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

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

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

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

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

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

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

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

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

ARTICLE PDFs AND REPRO

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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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Regulation

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

#BeyondBeauty Mr Adrian Richards @mradrian.richards It was an honour to be featured in the Spring issue of @beyondbeauty_mag. We discuss some of the common misconceptions in aesthetics! #patientpublication

#Aestheticsjournal Update Aesthetics @updateaesthetics Delighted to share Nurse Nina’s article on Artistic Appreciation that was recently published in @aestheticsjournaluk alongside consultant plastic surgeon @paulbanwell. #cpd #Workshop Lee Walker @leewalker_academy Proud to be part of such an incredible line up and thankful to participate in a phenomenal educational event at the Global Anatomy Workshop @ascd.org.au! #virtual #Training Dr Raj Acquilla @rajacquilla I’m so proud of our brand new Summit platform and the opportunity it provides me to share my knowledge with our global aesthetic community #knowledge #MentalHealth BCAM @britishcollegeofaestheticmed Many thanks to @sleeparrish for delivering a session for our members during #mentalhealthawarenessweek as part of BCAM’s 20th Anniversary Mindfulness Initiative #wellbeing

Industry associations celebrate under-18 cosmetic fillers law Industry associations have voiced their support of the Botulinum Toxin and Cosmetic Fillers (Children) Bill which passed its third reading in the House of Lords on April 28. The Bill has the support from the British College of Aesthetic Medicine (BCAM), the British Association of Cosmetic Nurses (BACN) and the Joint Council for Cosmetic Practitioners (JCCP), which have all released statements applauding the announcement. The JCCP has provided advice to government departments as part of the formulation of this new legislation and has campaigned for its legal enforcement. Chair of the JCCP Professor David Sines said, “Whilst welcoming the new Bill, the JCCP is mindful that more needs to be done to ensure that the Advertising Standards Authority (ASA) and the Committee for Advertising Practice (CAP) are committed to the responsible advertising of aesthetic products and services, which do not mislead customers with regard to risk, benefits and outcomes.” BCAM president Dr Uliana Gout commented that the new law furthers BCAM’s aim of aesthetic medicine being recognised as a specialty in its own right. Dr Gout said, “Most people assumed that these treatments were already outlawed for under-18s, BCAM is proud to support the Bill and to collaborate with the Department of Health and Social Care on national data collection which helps to inform and influence government decision-making.” On behalf of the BACN, chair and Aesthetics Clinical Advisory Board member Sharon Bennett, commented, “Legislation in cosmetic medical practice is long overdue. We have legislation in place to prevent under-18s from having a tattoo or a sunbed session, so it is astonishing that legislation has not been in place for this age group. Children should be prevented access to these treatments to protect them from themselves, unscrupulous practitioners and from those without a medical qualification. The Bill is therefore a welcome step and, as chair of the BACN, I fully support it.” Education

Cynosure opens new centre Laser manufacturer Cynosure has opened a new experience centre located in Chiswick, London. The company explains that the centre will have research and training facilities, treatment demonstration rooms and operational commercial spaces, which will serve as a collaborative workspace for Cynosure and its customers, partners and employees. According to Cynosure, the workspace will showcase the company’s technology and device portfolio, including TempSure, FlexSure, Potenza, PicoSure and StimSure. Todd Tillemans, chief executive officer of Cynosure, said, “As a global leader in aesthetics, Cynosure is not only committed to the relentless pursuit of innovation, but also to the success and advancement of our customers as they strive to bring out the beautiful energy in each and every one of their patients. The new centre provides a truly unique space for collaboration with our partners where we can facilitate unparalleled educational, training and research opportunities. It’s another example of how we are committed to the overall success of our partners and our pioneering spirit in the aesthetic space.”

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

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Event

CCR to host ACE Group World conference

Vital Statistics 59% of 2,000 women said they find men with hair more attractive than those who are bald (GetHair, 2021)

For the first time the Aesthetic Complications Expert (ACE) Group World conference will be taking place at CCR on October 14. At CCR the ACE Group World will be discussing the latest industry developments on the prevention and management of complications occurring in practice. Aesthetic practitioner and ACE Group World founder Dr Martyn King commented, “We are very excited to be teaming up with CCR to make our 2021 conference possible and will have a packed agenda of renowned key speakers from our expert faculty. We welcome new and existing members to attend, to learn more about the latest evidence and guidelines on the management of non-surgical aesthetic complications.” Aesthetics and CCR event manager Courtney Baldwin said, “We are honoured to welcome the ACE Group World conference to CCR this year and are exceptionally excited by this new partnership. The ACE Group World are leaders in complications education and by co-locating their meeting at CCR we are providing our delegates with the very best opportunity to enhance their knowledge and skillset. CCR will be the first educational meeting this year to unite all specialties, and we can’t wait!” Tickets to attend the conference will be £125. Registration for CCR and the ACE Group World conference will open towards the end of June. Tickets will be on a firstcome first-serve basis.

In a survey of 1,935 internet users, 30% of smokers are smoking more regularly since the start of the pandemic (Mintel, 2021)

56% of 1,543 consumers say the way a business responds to reviews has changed their perspective on the business (Podium, 2021)

In a survey of 2,000 Americans, 62% prioritise the needs of others and neglect their own mental health (Mederma, 2021)

Education

Learna and JCCP introduces Fast Track Assessment platform Online learning platform Learna has developed the Fast Track Assessment (FTA), in collaboration with the Joint Council for Cosmetic Practitioners (JCCP). According to the platform, the course will streamline the qualifications process, enabling more cosmetic practitioners to be eligible to join the JCCP Government Professional Standards Authority (PSA) approved register. Learna explains that the FTA consists of two components: a three-hour theoretical exam, and an Objective Structured Clinical Exam (OSCE). The FTA results in a formally recognised equivalent verification standard that equates to the JCCP Level 7 education and training standard for the injection of toxins and insertion of dermal fillers. Founding director of Learna and chairman of the Welsh Aesthetic and Cosmetic Society Professor Steve Davies commented, “The new Fast Track Assessment provides an alternative option for practitioners who may have years of experience under their belts, and who are looking to demonstrate their experience within the cosmetics/ aesthetics sector and be recognised as a JCCP registered practitioner.” The first assessment dates for the FTA will be taking place at the end of June.

In a survey of 250 parents of teenagers with cystic acne, 93% worry that severe acne will leave their child’s faces scarred (American Acne and Rosacea Society, 2021)

74% of 300 leaders from retail organisations had allocated at least one third of their marketing budget to social media advertising (Global Social Advertising Trends, 2021)

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

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Events Diary 4 -5 September 2021 th

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

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

14 & 15 October, ExCeL www.ccrlondon.com

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Body treatment

BodiFirm added to Revision Skincare range Skincare brand Revision Skincare has introduced BodiFirm to its portfolio. Distributor of Revision Skincare AestheticSource explains the body contouring lotion aims to help firm, tighten, and lift the appearance of skin for a sculpted look. It also helps to improve the appearance of sun damage and is ideal for use before and after aesthetic procedures to complement overall results, according to the company. AestheticSource explains that the lotion includes patent-pending iFirm technology which has a blend of peptides, antioxidants, and a prebiotic to help the body’s natural production of dermal-epidermal junction proteins, collagen, and elastin. Aesthetic practitioner Dr Preema Vig stated, “As the skin on the body is different than the skin on the face, neck and décolletage, we are delighted to offer our patients Revision BodiFirm for use alongside any aesthetic body treatments or as a stand-alone homecare regime to optimise clinic treatment results.” Radiofrequency

Education

Croma-Pharma releases e-learning series Aesthetics manufacturer Croma-Pharma has released a new e-learning series for healthcare professionals. The company states that the interactive platform ‘Croma is More’ is aimed at healthcare professionals in the field of minimallyinvasive aesthetics and offers a variety of topics. These include social media and online marketing, facial anatomy workshops, aesthetic start-up academy and aesthetic excellence. According to Croma-Pharma, the topics are presented by industry professionals and all content has a lifetime access so healthcare professionals can learn at their own schedule and pace. When purchasing a course, practitioners will be added to an exclusive online community where they can ask the course instructor questions and receive support and tips, from fellow participants. Marketing support manager Matt Soares, said, “It’s the perfect resource for healthcare professionals to dive into the world of Croma-Pharma, divided into categories such as the virtual academy, medical training and business support. The Croma Hub will showcase the product portfolio, allow you to review clinical studies, download marketing materials and register for events.”

Cutera launches new skin rejuvenation device Aesthetic technology manufacturer Cutera has announced the new radiofrequency microneedling device Secret PRO into its portfolio. The company explains that the Secret PRO will offer practitioners a ‘multi-layered’ approach to skin rejuvenation, using CO2 skin resurfacing application ‘Ultra Light’ to target the epidermis, whilst simultaneously utilising the Secret RF microneedling technology to reach the subdermal layers of the skin. According to Cutera, the Secret PRO aims to prevent unnecessary damage to the skin tissue and reduce the associated downtime to between three and four days. Michael Karavitis, chief technology officer at Cutera, said, “The Secret PRO enables users to treat the full thickness of the epidermis and dermis to stimulate neocollagenesis and increase hyaluronic acid production, providing patients with the radiant skin they demand.” Technology

New patient booking app introduced Software provider e-clinic has launched its new patient-focused booking app called BookmyClinic. The platform enables patients to search for relevant clinics, book treatments, manage payments and schedule follow-up appointments. The company explains that the app can help practitioners to reach more patients through a location-based search tool which allows users to find clinics in their vicinity. Product director at e-clinic Mark Lainchbury stated, “The launch of BookmyClinic is an exciting step forward for e-clinic, and the healthcare industry more broadly. Ahead of an easing of lockdown and a return to relative normality, there is an expectation that aesthetic treatments will see a boom post-lockdown, and medical practices will be managing an increased number of patient bookings.” The app is available now for e-clinic customers and will be accessible to wider clinics later in the year.

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

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Dentistry

Allergan Spark launches new educational series Spark by Allergan Aesthetics has introduced an educational series for dental professionals. Participants in the discussions are maxillofacial surgery registrar and Interface Aesthetics director Dr James Olding, aesthetic practitioner and owner of Chelsea Dental Clinic Dr Rhona Eskander, aesthetic practitioner and dentist at Harrow On The Hill Dental and Beauty Spa Dr Zainab Al Mukhtar, and lead associate dentist at Dental Perfection Advanced Dental Clinic Dr Yasmin Shakarchy. According to Allergan Spark, each practitioner focuses on a specific area of expertise from social media to training. All discussions are available via the Allergan Spark Hub. Cosmeceuticals

VIVACY UK introduces Dermo-Cosmetics skincare French manufacturer Laboratories VIVACY has created a new skincare range for patients to use following aesthetic treatments. The company explains that the Dermo-Cosmetics range contains active ingredients treignac mineral water, sorbitol, hyaluronic acid and vitamin C. These ingredients are encapsulated in liposomes using VIVASOME technology to facilitate their penetration into the deeper layers of the skin. The range includes six products designed to adapt to a patient’s individual skin concerns. These include: EYE ULTIM LIFT, which aims to smooth wrinkles and fine lines; MIST mineral water for hydration; CELL SHOT serum to provide nourishment and hydration; HYALU CALM to soothe skin that has been weakened by superficial aesthetic procedures; HYDRA TOUCH hydration cream; and AGE REBOOST, an antiageing reconstructing cream that aims to improve skin texture and radiance. Boosters

HydraFacial partners with Murad Aesthetic manufacturer HydraFacial has partnered with skincare brand Murad to unveil the Murad Retinol Booster. According to HydraFacial, the booster provides practitioners with a combination treatment that accelerates the skin’s surface renewal in order to minimise the appearance of fine lines and wrinkles. The company explains that the new booster features patented Retinol Tri-Active Technology formulated to work with the HydraFacial protocol. The product is designed to deliver visible results at four weeks, following two booster treatments and the daily application of Murad’s Retinol Youth Renewal system. Dr Howard Murad, founder of Murad skincare, commented, “After years of research and development, I’m proud to say we have finally perfected a retinol for all skin types with Retinol Tri-Active Technology found in the Retinol Booster for HydraFacial and the Retinol Youth Renewal homecare products.”

Preparing

for Your Photo Shoot Photographer Hannah McClune’s monthly tips on the top three things to be ready for your brand shoot. By booking your brand shoot a few months ahead and following these steps your resulting gallery will give you so much more versatility.

1. The brief

The most important part of the whole planning stage – the questions are to fully understand you, your business and your customers. Consider the questions in depth. If you work with a marketing agency, their insights are valuable for upcoming communications, and they need supporting images too. I’ll turn your brief answers into a detailed shoot plan with locations, outfit ideas, shot lists, props and more.

2. Get pin happy!

Having a shared Pinterest board with your photographer not only checks you’re both on the same wavelength, but also gives some inspiration and ideas for outfits, location and general ‘feel’ for the type of images. We never copy a shot (how dull!), instead use visual mood boards as a prompt to what works for you.

3. Pamper

Lastly, ahead of the day, enjoy some pampering to be the best possible version of you. Book hair appointments the week before, your manicure (hands always feature!), and check if you need a hair and make-up artist recommendation. As a photographer and marketing professional, my approach is to understand your marketing needs and how you are positioning yourself. This then leads to how I can support you with photography.⁣ This column is written and supported by Hannah McClune, owner of brand photography company Visible by Hannah www.visiblebyhannah.com

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

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

MAY ROUND-UP In May, the BACN worked directly with Allergan Aesthetics, an AbbVie company, to focus on the importance of consultation and optimised treatment outcomes. The InFocus webinar was well attended, led by nurse prescriber Rosey Drewitt-Staples, and emphasised consultation and assessment processes as the cornerstone for any aesthetic nurses. The webinar was interactive and engaged nurses at different stages of their aesthetic journey. BACN members can access the webinar in the member’s area of the BACN website along with all previous recorded webinars.

#BACN1000 At the end of May, the BACN hit a milestone in its membership targets – reaching 1,000 members. This large growth in membership throughout 2020/2021 has shown that nurses working within the speciality of aesthetics have turned to their professional association for advice, networking, and support during what has been a difficult time for many. The BACN has come a long way from its humble beginnings and is now the leading association for aesthetic nurses in the UK, as well as supporting many members worldwide. Throughout June, the BACN will be celebrating via social media, and a social event will be hosted for members to look back at the BACN and discuss what can be done in the future.

JUNE UPDATES The BACN is excited to be partnering with Merz Aesthetics for the month of June looking at Belotero Revive, a new treatment for early onset photodamage. The BACN and Merz will be delivering a number of digital events that are available for members to book onto: • In Conversation with Julie Redmond – 15th June 6.00pm • InFocus Live Webinar – How to Introduce Belotero Revive into your Clinic from a Clinical and Marketing Perspective sponsored by Merz Aesthetics – 22nd June 6.00pm • Peer Review and Social with 15 Minute Takeover from Merz Aesthetics –24th June 6.00pm For full agendas and information on how to book please go to the BACN events page of the website. This column is written and supported by the BACN

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Skincare

GetHarley hosts first sales masterclass Skincare platform GetHarley has teamed up with aesthetic practitioner Dr Nina Bal for its first virtual sales masterclass. At the masterclass, Dr Bal will discuss how attendees can learn how to change their mindset when it comes to ‘selling’, how to incorporate GetHarley into their practice, and to best convert consultations into product sales. Dr Bal commented, “I was too busy to focus on skincare in my practice and was afraid to ‘sell’, believing that this wasn’t in the best interest of my patients. However, I quickly realised that skincare should be part of every treatment I deliver. Once I changed my mindset, I worked out some good ways of making it slot into my busy schedule.” The masterclass will be taking place on June 10 at 8pm GMT. Contact GetHarley to book your place. Conference

5CC World Congress goes virtual The 13th 5CC World Congress will take place this year on September 4 and 5 in a virtual format. The 5CC board of directors explains that the decision to keep the event digital was informed by advice from the World Health Organization, as well as leading global and local health authorities. The congress will feature an interactive exhibition as well as brand new side events tailored to all kinds of specific interests in the form of roundtables and workshops, as well as having networking opportunities. Dr Michael Gold, 5CC Congress president, commented, “We are all really excited about this new format and know you will be too. Our 13th edition aims to be our biggest, most inclusive, and forward-thinking gathering of the leading minds and game-changers in dermatology and aesthetics, and we can’t wait for you to experience it. In 2022, we will return to holding our annual 5CC World Congress as a physical in-person experience at the CCIB in Barcelona.” Gut health

Research suggests link between fasting and psoriasis Research investigating the impact of modified intermittent fasting (MIF) on the skin of people suffering with psoriasis has indicated a link between the gut and skin health. A study presented at the European Academy of Dermatology and Venereology Spring Symposium 2021 found a reduction in thickness of the skin in patients with mild psoriasis following a MIF 5:2 diet (eating normally for five days and restricting calorie intake on two non-consecutive days). 24 participants were enrolled in the study, with one group of 12 instructed to modify their diet with MIF for 12 weeks, and the remaining 12 to continue their regular diet. The fasting group were instructed to consume a total of 500kcal twice per week on two non-consecutive days but free to consume their usual daily calorie intake for the remaining five days of the week. The Psoriasis Area and Severity Index (PASI), and Body Surface Area (BSA), did not differ significantly between fasting and regular diet, although PASI reduced in the fasting group. Furthermore, the fasting participants reported significant improvement to psoriasis during weeks six and 12. The study will be completed at the end of June.

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

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Ceremony

Specialty celebrates Awards On May 28, the annual Aesthetics Awards took place, and it was a fantastic evening celebrating the achievements of clinics, practitioners, and products over the past year. Despite being held virtually this year, the ceremony was as glamourous and prestigious as the usual in-person event. Our host for the event Cherry Healey made sure to get the party started, a mixology masterclass took place in which everyone made our signature Aesthetics Awards cocktails and live reactions were shown to add to the excitement and celebrations of the evening. Congratulations to all of our winners and thank you to all finalists for joining in the celebrations! We can’t wait to see you all again at the Aesthetics Awards in 2022 taking place on March 12 after the Aesthetics Conference & Exhibition. To find out who our winners were, turn to p.36. Sun protection

iS Clinical introduces new SPF Powder Skincare brand iS Clinical has launched the new PerfectTint Powder SPF 40. According to iS Clinical distributor Harpar Grace, the SPF aims to provide broad-spectrum UVA/UVB sunscreen in a light formula with a matte finish. The product has been designed with a built-in application brush and supplied with two 3.5g refill cartridges. It is available in five shades and suitable for a range of skin tones. Key ingredients in the SPF include zinc oxide to provide a physical barrier to reflect UV radiation; hydroxyapatite to provide defence against wrinkles and photoageing; lycopodium clavatum to improve skin hydration; and imperata cylindrica root extract to optimise collagen in the skin. The product will be available from July 1. Laser

Lynton unveils SmartXide Punto to UK market Laser and IPL manufacturer Lynton has released SmartXide Punto to the UK market. The laser combines directly observed therapy (DOT) with a radiofrequency (RF) CO2 laser source to offer maximum versatility for dermatology and aesthetic procedures, according to Lynton. Lynton states the DOT is an effective technique for skin resurfacing. The CO2 laser emission takes place by DOT, generating microareas of thermal damage alternating with healthy tissue. This technique aims to generate new collagen, repair tissue, as well as a reduction in recovery times and post-treatment erythema. Lynton states that the DOT is ideal for rejuvenation treatments, including scar treatment, improving skin tone, and texture. The RF CO2 source allows practitioners to select the optimal pulse shape for any required treatment, including level and depth of ablation, power, duration, and thermal control via pulse type, allowing patients with deeper skin concerns to benefit from more stronger treatment settings available, according to the company.

Dr Sanjay Panasar, consultant plastic surgeon at Cocoona Centre for Aesthetics Transformation in Dubai, and chairman scientific, Emirates Plastic Surgery Society What’s your main focus at Cocoona Centre for Aesthetic Transformation? Cocoona is a leading all-in-one clinic for plastic surgery, skin and cosmetic procedures, dental, orthopedic, weight loss, and wellness solutions, based out of Dubai. We are respected and valued for the variety of treatments and technology we have on offer. One of our recent additions is the green EMERALD LASER™ by Erchonia, which is FDA cleared for full body circumference up to 40 BMI. We are the first clinic in the UAE to offer this treatment. Tell us about the EMERALD LASER™ The EMERALD LASER™ is an excellent addition to the non-surgical weight loss solutions at Cocoona. It’s super convenient, contactless and effective. The technology is still new at Cocoona, but very promising. We have recorded 2.5kg of fat loss in just three sessions for one patient. We are combining it with lymphatic drainage sessions and the results are amazing. Not only are patients happy, but the therapists are excited. It’s a must try for people who are looking to lose fat with nonsurgical solutions. How does the device work? The EMERALD LASER™ is a non-thermal laser that works by electromagnetic energy transfer empowering the body to repair, rejuvenate and restore itself by harnessing the body’s ability to function at a higher level through cellular activity. This in turn leads to an ability to reduce fat by not harming the fat cell itself, and collagen reprofiling, thus improving the appearance of cellulite. The process causes our fat cells to release their fatty content for removal from the body by the lymphatic system. These fat cells now begin to act and function like healthy lean fat cells again, releasing the correct messages to your brain and, even more exciting, they begin a communication cascade throughout the fat organ, causing other fat cells to react the same way, releasing their content and returning their hormone responses back to the positive! This column is written and supported by

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

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Suncare

Lynton unveils Focus Dual Laser and IPL manufacturer Lynton has introduced a new radiofrequency (RF) microneedling and high-intensity focused ultrasound (HIFU) device called Focus Dual. Lynton explains that the device delivers heat into the deeper layers of the skin to effectively remodel collagen, rejuvenate the skin’s appearance, tighten skin laxity, and address scarring whilst leaving the skin’s surface intact. According to the company, practitioners can adjust the RF microneedles and HIFU focal depths to improve the skin at every layer to address patients’ skin concerns. Sales and marketing director at Lynton Hayley Jones commented, “We are delighted to unveil the new Focus Dual device to our portfolio. We have devised an exclusive launch programme to help within your business with new technology this year, draw in new patients and convert existing ones. We will guide you through an effective strategy to launch a new product so that you can make maximum return on your investment.” Association

BACN reaches 1,000 members

The British Association of Cosmetic Nurses (BACN) has reached the milestone of 1,000 members. The BACN explains that after freezing membership payments, moving its events digital, and with the Nursing and Midwifery Council (NMC) there was an increase of existing members returning along with an influx of new members for networking, support and advice. BACN chair Sharon Bennett commented, “Reaching our 2020/2021 goal of 1,000 members is wonderful, especially at a time of hardship for nurses in aesthetic practice during the past year. A great achievement and credit to our amazing management board and head office team who have ensured this milestone is celebrated.” The BACN will be celebrating this achievement throughout June with a social media campaign and a social event looking back at the BACN and where it began. More information can be found on the BACN website.

skinbetter science reveals new sunscreen stick Distributor AestheticSource has launched skinbetter science’s new sunbetter Advanced Mineral Protection SPF 50 Sunscreen Stick. The product is designed in a travel-friendly stick which can be applied on the skin before sun exposure, explains the company. According to skinbetter science, the stick is water resistant for up to 80 minutes, has a sheer, mattifying formula with no chalky residue or discolouration regardless of skin type, whilst containing a high level of UVB and broad spectrum protection. Vikki Baker, marketing manager at AestheticSource, said, “AestheticSource is delighted to offer its partners the new sunbetter Advanced Mineral Protection – a great addition to the sunbetter range which will be expanding further in 2022. The product is suitable for all skin types and provides broad spectrum UVA/UVB, pollution, blue light and infrared protection.” Skin

Study indicates tralokinumab is effective for dermatitis A study presented at the American Academy of Dermatology Association Virtual Meeting Experience 2021 suggests that long-term use of the human antibody tralokinumab is safe and effective in the treatment of atopic dermatitis (AD). The phase 3 ECZTRA 3 study included 380 patients with atopic dermatitis assigned 2:1 to receive subcutaneous tralokinumab 300mg every two weeks, plus topical corticosteroids as needed or a placebo every two weeks and topical corticosteroids as needed for 16 weeks. The trial took place over two years. Data showed that those treated with tralokinumab 300mg every other week, in addition to optional topical steroids, experienced improvements in sleep, itching and AD symptoms at week 56. President of the Oregon Medical Research Center and dermatologist, Dr Andrew Blauvelt, explained, “The results are critical in reassuring both dermatologists and patients that the long-term use of their medication for their chronic disease is safe and effective for up to two years of use.”

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

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Recruitment

CCR 2021 accepting abstract submissions

CCR 2021, as part of events company Easyfairs, is accepting abstracts from practitioners interested in presenting content or speaking at the conference, which will take place on October 14 and 15. Abstracts which will be considered for the teaching lectures at CCR include a focus on the breast and body, non-surgical procedures covering technique, innovation and trends, advice and guidance for achieving the best business results and a clinical skin topic. Aesthetics and CCR event manager Courtney Baldwin, said, “We are delighted to be able to host our first in-person event at CCR this year. The aesthetic sector is constantly evolving, with the development of new products, devices, techniques, and changes to regulation occurring. We want to ensure that CCR is the ideal place for medical practitioners and professionals to enhance their knowledge and discuss these changes across two days with leading experts in the aesthetics specialty.” If you are interested in presenting at the event, go to ccrlondon.com/conference/ speaker-enquiry. Please note that speaker slots are limited and sales pitches will not be accepted. Due to the high volume of submissions, not every abstract submitted will be chosen and those successful will be contacted by the CCR team. Education

LABthetics introduces online CPD courses Skincare company LABthetics is now offering CPD-verified training on its website for medical professionals. According to LABthetics, its website now offers CPD training courses/ workshops on topics such as dermaplaning, skin rejuvenation with chemical skin peeling and professional skincare and cosmeceutical ingredients. Founder of LABthetics Emma Caine explained, “We are always looking for new ways to adapt in the current challenges we face. We pride ourselves on the quality of our training, cosmeceutical products, and ongoing aftercare support we provide to all our professionals.”

Dr Jane Leonard joins Interface Aesthetics Aesthetic training provider Interface Aesthetics has recruited Dr Jane Leonard to its academy. Aesthetic practitioner and NHS GP Dr Leonard will join maxillofacial surgery registrar and Interface Aesthetics director Mr James Olding and aesthetic practitioner, GP and Interface trainer, Dr Davina Wilson as part of the injectables clinical team. Dr Leonard has spent more than nine years as an aesthetic practitioner. She has spent much of the past year working on the NHS frontline alongside Dr Wilson. Mr Olding said, “Dr Leonard shares our core belief regarding the importance of healthcare-delivered injectable treatments, with an emphasis on greater regulation in both training and practice.” Social media

Dr Tim Pearce launches new marketing course Online aesthetic training provider Dr Tim Pearce eLearning has introduced a new web-based marketing course for aesthetic clinicians. The Dream Customer Attraction Method (DCAM) course was designed by marketing advisor Miranda Pearce. She explains that DCAM is ideal for clinicians who are worried about what to post on social media every day, wonder if they are posting the correct items on their channels or cannot understand why their social media posts are not converting into bookings. According to the company, DCAM is set over three core principles with 25 modules to complete. The course package includes downloadable MP4 and PDF materials with a marketing essentials tool kit, advertising regulation guidance, sales conversion scripts, access to a closed Facebook group, and more. Business

Laser Lipo creates clinic support initiative UK laser manufacturer Laser Lipo has launched a new initiative called ‘Bounce Back Britain’ to help its Strawberry Laser clients postlockdown. Laser Lipo explains that it will allow deposits, low monthly payment schemes and rental options for Strawberry Laser practitioners. The ‘Bounce Back Britain’ initiative will also include marketing tools and social media support for customers to help streamline their clinics, as well as additional training to help achieve good non-surgical treatment results for their patients. The initiative will last until June 30. CEO of Laser Lipo Ian Cobley stated, “We hope practitioners are able to feel supported coming out of lockdown by our ‘Bounce Back Britain’ initiative. The Laser Lipo Strawberry devices are made in the UK and today, there are very few British manufacturers of laser/beauty aesthetic equipment. By being one of the few, there are many advantages with support, and repairs, allowing customers to invest safely.”

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

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Publication

New memoir released by Dr Patrick Treacy Aesthetic practitioner Dr Patrick Treacy has published a new book called The Needle and the Damage Done. Dr Treacy explains that the book is an updated version of his previous memoir ‘Behind the Mask’. The first half of the book focuses on his adventurous journey into the world of medicine, whilst the latter half is related to what he has achieved since reaching his success. The book gives an insight into Dr Treacy’s research on the influence of botulinum toxin on the brain, and protocols for addressing dermal filler complications. Dr Treacy commented, “I love writing and the COVID-19 pandemic gave me a chance to put pen to paper! The new book covers the years 2012 to 2021, incorporating the Irish recession and the background to my international awards.” Industry

Déesse PRO expands globally Cosmeceutical distributor Harpar Grace has appointed business consultants William Hough and Thomas Gordan to lead the expansion of the Déesse PRO brand. Gordan and Hough will be working with director of Harpar Grace International Alana Marie Chalmers to identify and recruit new global distribution partners for the Déesse PRO and Express models, explains the company. Déesse PRO are currently in conversation with 25 countries. Chalmers commented, “The Déesse PRO brand offers a unique proposition that not only recognise the benefits of offering LED light therapy within their portfolio, but are looking for a total business solution across consumer, clinical, and spa sectors. To have a beauty tech brand that has clinical credibility is rare and that’s an exciting opportunity within this rapidly growing market.” On the Scene

CoolSculpting Elite global launch On May 6 Allergan Aesthetics, an AbbVie company, hosted its global launch event for the new body sculpting device CoolSculpting Elite. The event was opened by executive director for international body contouring division at Allergan Aesthetics, Jocelyn Isambert, who provided an introduction to CoolSculpting and its history. Clive Heke, senior director for design engineering at Allergan, then introduced the new Elite system and displayed a video which showed the new features and benefits of the device. Plastic surgeon and Allergan KOL Dr Farid Kazem provided an overview of the science behind the machine, as well as sharing his own personal experience being one of the first to use the new system in his clinic. This was followed by Matthew Hickling, executive director, global aesthetics medical affairs at Allergan Aesthetics, who discussed the current ongoing studies using CoolSculpting Elite. Certified CoolSculpting practice owner, US-based Jessica Stellwagen, also spoke on her experience being one of the first in the world to use the new device.

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News in Brief Nimue Skin Technology unveils two new products Skincare brand Nimue Skin Technology has launched the ThermoFlash Peel and the Biodegradable Active Resurfacing Wipes to help patients care for their skin at home. The company explains that the ThermoFlash Peel is a resurfacing treatment which should be applied when an enhanced skin radiance or exfoliation boost is needed. The treatment aims to remove dead skin cells, soothe, and repair the skin’s barrier and deliver visible results in ten minutes. The Resurfacing Wipes aim to reduce oiliness on the skin, promote an even skin tone and delay the appearance of skin ageing. InMode appoints new KOL Nurse prescriber Khatra Paterson is the new key opinion leader (KOL) for aesthetic manufacturer InMode UK. Paterson is the owner and director of KP Aesthetics and is a member of the BACN and the Aesthetic Complications Expert (ACE) Group World. As a newly appointed KOL, Paterson will focus on radiofrequency devices such as the FormaV device for stress urinary incontinence, laxity and dryness, commonly associated with menopause and childbirth, as well as cosmetic procedures such as the radiofrequency microneedling device Morpheus8 and Forma aimed at facial rejuvenation. New book on aesthetics for male patients published Aesthetic practitioner Dr David Jack and lifestyle columnist Jeremy Langmead have released a new book aimed to educate male patients about aesthetics. Dr Jack explains that Vain Glorious – A shameless guide for men who want to look their best outlines all the antiageing and aesthetic options available for men, from dermal fillers to hair loss treatments. Dr Jack provides the medical knowledge, whilst Langmead tries the procedures and products available. Acquisition Aesthetics expands Aesthetic training provider Acquisition Aesthetics has launched two new training sites. The training sites based in Cardiff and Glasgow are expected to launch in the latter half of 2021 and early 2022. The new sites will join the existing locations of London, Manchester, and Newcastle. Acquisition Aesthetics believes this expansion will allow them to reach a broader cohort of aesthetic delegates whilst facilitating greater convenience for its learners.

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

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NO MORE STIFF UPPER LIPS

Aesthetic nurse prescriber Julie Redmond on the growing popularity of lip enhancement, particularly with younger patients Lips have become one of the most prevalent aesthetic enhancement procedures over recent years, particularly among younger patients, and their popularity has continued to grow throughout 2020, despite the introduction of masks into our daily lives. We have never lived in such an image-conscious world. The pandemic has meant that our first interactions with people are usually over some form of digital media but, even before COVID-19, most of us were on social media sharing pictures of our lives. Pictures have become an important factor in our social interactions and are often how we make an initial judgement about someone, whether it’s picking a potential partner on a dating site or choosing a future employee, as nearly all job applications now require a photo. As a result of all these things, what we look like has never been more apparent to us, and this may have particularly 18

contributed to the rise in the popularity of lip fillers among the young. Another reason lip treatments are favoured by young people is because, more than any other filler treatment, they are about beauty enhancement and not just antiageing. In 2017, I made a documentary on why young people want to get lip fillers. I interviewed 10 young women who had had lip treatments and among the comments I got were, “everyone is doing it”, “it is readily available”, “I have small lips and want bigger ones”. Social media and their peers are the factors that most motivated them to have their lips done. Figures released by the British Association of Aesthetic Plastic Surgeons that year supported this growing interest, with 70% of 18 to 24-year-olds saying they would consider having a cosmetic procedure. Since then demand for lip fillers has increased exponentially and the only

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The triumvirate of eyes-nose-lips are the features that characterise our faces and give them their individuality, something we want to celebrate and enhance real change is that there are now more practitioners and a wider choice of treatment options, some good, some bad. In fact, while lip enhancement performed on the right patient, with the right product and by the right practitioner can offer beautiful results, there is a dark side to the lip filler sector that has seen an increase in complications go hand-in-hand with the rising demand for treatment. Lip fillers were the number one cause of complaints and complications, according to a consumer complaints audit report by industry watchdog Save Face and more than half of respondents (59%) said they viewed having lip fillers as comparable to getting a haircut or having a manicure.1 It is for these reasons that standards, safety, education and product selection are so key when it comes to fillers, particularly in the lip.

Natural-looking results are key As Brits we are often said to have a “stiff upper-lip”, meaning that we display fortitude and stoicism in the face of adversity, and this year has certainly been one for facing adversity. In aesthetics, however, the last thing we want is a “stiff upper lip”. What we are looking to achieve with lip injections is natural, soft and balanced looking lips that give strength and confidence to their owner from within. The triumvirate of eyes-nose-lips are the features that characterise our faces and give them their individuality, something we want to celebrate and enhance, not erase. In my practice I find that, while some patients will come in with a picture of what they want, others simply say they want something to “balance their features” or “enhance their attractiveness” when it comes to lips. The Merz motto: “A natural look is an exact science”, perfectly sums up the philosophy that I believe should be at the core of lip treatments for the future. This is also why I stick to the golden ratio as much as possible with the ideal height ratio of the upper to the lower lip being 1:1.6 in Caucasian patients. You also need to evaluate lip fullness by looking at all areas of the lip: the philtrum, vermillion border, Cupid’s bow and the body. The

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Merz Aesthetics scales are fantastic for this. In my practice, I use BELOTERO® Lips Contour2 and BELOTERO® Lips Shape.3 As a practitioner, having two products with different qualities and bespoke injection techniques means you can tailor “tweakments” to individual needs rather than taking a one-size-fits-all approach. This is something that no other brand can give you. BELOTERO® Lips Contour2 is ideal for creating definition as it is very cohesive. This makes it excellent for highly mobile areas such as the vermillion border. It also has low viscosity so it offers great tissue integration and allows for superficial and even blanching injection technique.

BELOTERO® Lips Shape3 is designed for volumising. By injecting it into the body of the lip you can create a fuller lip. It can also be used to lift oral commissures and to support the natural structure of the lip. It is still cohesive but you also have high elasticity, which is resistant to deformation, and it gives you a gentle elegant projection. Both products use cutting-edge patented CPM® technology4 which makes Merz lip products unique and, for me, is the future of aesthetics: minimum product, maximum longlasting effect.5

The future I believe facial beauty is about to enter a major renaissance. We saw a sudden increase in demand post-lockdown and I believe that is only going to continue. Zoom is going to be our office space for the foreseeable future and, as such, looking good on camera has never been more important to people, especially as quality improves enabling us to pick up on every fine detail of people’s faces. With the products we now have available and the subtlety of the results we can achieve, I predict lips, along with other aesthetic procedures, will continue to rise in popularity over the next five years. I also believe we are going to see an increase in demand for product longevity as people won’t want to come in for top-ups so often. I predict patients will become increasingly informed and start looking at factors such as these when planning their treatments in future and so the products we use will become even more significant.

Aesthetics | June 2021

This article is sponsored by Merz Aesthetics, UK & Ireland

M-BEL-UKI-0929 Date of Preparation December 2020

REFERENCES 1. Save the Face – Consumer Complaints Audit Report 2017-18. 2. IFU – BELOTERO Lips Contour. 3. IFU – BELOTERO Lips Shape. 4. Fischer,T et al. Hyaluronic Filler Containing Lidocaine on a CPM® Basis for Lip Augmentation Reports from Practical Experience 5. Kerscher M et al, Clin Cosm Inv Dermatol. 2017:10 239-247

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Defining a Medical Procedure Aesthetics looks at the new JCCP definitions of what constitutes a ‘medical’, ‘medically-related’ or ‘cosmetic’ procedure Aesthetic medicine is a specialty led by healthcare professionals, yet is still considered by many to be ‘cosmetic’. This makes it difficult for many within the industry to understand which aesthetic procedures are medical, medically-related, or cosmetic. Indeed, this confusion became even more apparent during the COVID-19 lockdowns, when the UK Government stated that any premises providing beauty services had to close, including ‘cosmetic, aesthetic and wellness treatments’. The Government’s wording left aesthetic doctors, dentists and nurses within the profession wondering whether ‘medical’ aesthetic or cosmetic treatments can be performed at their clinic.1 To help create an understanding throughout the profession, the Joint Council for Cosmetic Practitioners (JCCP), has released new official guidance in order to clarify the difference between the three terms.2 The guidance has been formed with the help of 11 of its clinical advisory board members, and feedback on matters of factual accuracy was also shared with the Medicines & Healthcare products Regulatory Agency (MHRA), the Care Quality Commission (CQC) and the General Medical Council (GMC). Professor David Sines, chair of the JCCP, commented, “It is hoped that these principles can be applied to all instances of aesthetic practice where a medical or cosmetic determination is required, including procedural modalities that are currently outwith the JCCP’s remit, and indeed to be able to be ‘future proofed’ for application to adjunctive or emergent procedures that are not currently recognised officially within the aesthetics sector.”

The difference between ‘medical’, ‘medically-related’ and ‘cosmetic’ The JCCP explains that a treatment that is purely cosmetic in nature is any proposed non-surgical aesthetic procedure that is not linked to a ‘medical’ or ‘medicallyrelated’ diagnosis, as determined by a suitable qualified and registered healthcare professional (HCP), and which does not have a clinically determined therapeutic outcome benefit for the patient. For example, microneedling, laser hair removal and superficial peels for purely cosmetic reasons.

A therapeutic benefit, the JCCP explains, can be determined as a positive outcome that occurs as a result of a method used to treat a disease or disorder. A treatment may be considered to have therapeutic benefit if it improves or enhances a patient’s physical or mental wellbeing. The difference between a medical procedure and a medically-related procedure is that a medical procedure will be linked to an ICD 11 code (the International Classification of Diseases 11th Revision starts on January 1 2022)4 and may (but not necessarily) require CQC registration. This does not apply to medically-related procedures; in such cases the regulated HCP will be required to exercise their clinical judgement and diagnostic skills to determine and evidence a reasonable and genuine therapeutic benefit for the treatment, supported by a written diagnosis and treatment plan.

Can a non-HCP carry out a ‘medical’ procedure? The JCCP emphasises that only a suitably qualified and experienced registered HCP can undertake and determine whether a procedure is ‘medical’ or ‘medically-related.’ However, the JCCP explains that if an HCP makes a fully informed assessment of the patient first and identifies if the procedure is medical or medically-related, a non-HCP may carry out a medical procedure under supervision. Assessments must be made on a case-by-case basis and relate only to a single consultation and treatment and not subsequent treatments provided in the future.

Medical consultations If a procedure identified during a consultation has been determined by a practitioner to have a clinical/therapeutic benefit then it can be considered to be ‘medical’ or ‘medically-related’ in nature, explains the JCCP. They note that the therapeutic basis for any intervention is determined by the HCP and must be justified with an appropriate medical record, assessment treatment plan and an outcomes measurement framework.

The future When is a procedure medical? The JCCP explains that any procedure can be medically determined as long as it can be demonstrated that the procedure has an evidence-based clinical therapeutic benefit. It must also be considered and diagnosed by the registered HCP to be in the patient’s best interests following the completion of an agreed (and recorded) pre-treatment holistic assessment of the patient’s presentation and an exploration of the patient’s expectations with regards to perceived treatment outcome. Must a clinic be CQC registered? The JCCP explains that aesthetic practice for unregulated aesthetic procedures is currently outside the scope of the CQC. However, some procedures fall within the scope of the CQC, for example hair restoration surgery carried out by a healthcare professional. In addition, botulinum toxin treatments may also fall within the CQC scope in some cases where the treatment is related to a disease, disorder or injury. For example, treating spasmatic torticollis, prophylaxis of headaches in chronic migraine. The same can be said of dermal fillers. The CQC has published a specific list of HCPs who are entitled to undertake ‘Regulated Activity of Treatment of Disease, Disorder or Injury’.5

Dr Paul Charlson and nurse prescriber Andrew Rankin, JCCP clinical advisory group co-chairs, commented, “We are delighted to announce the completion of this work which has important implications for the future of cosmetic practice. We welcome this outcome both for its contribution to patient safety and in raising the profile of professional practice.” The JCCP hopes its new guidance will inform future high-level regulatory decisions and calls upon the UK Government to develop and implement primary and secondary legislation, to set standards that determine who can lawfully undertake and perform ‘medical’ or ‘medically-related’ procedures in the UK. To read the full JCCP guidance, go to the Aesthetics website.

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Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

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Consulting male patients

Injecting the Male Periorbital Area Practitioners share their preferred method for treating the aged under-eye area in men using dermal filler “I look tired” is a common concern that aesthetic practitioners will hear at least once a day, with patients continually dissatisfied with their dark and sunken eyes. This is a particular area of insecurity for men, with the Men’s Maximum Difference study in 2015 by Allergan revealing that tear troughs, as well as lateral canthal lines, were the top features identified by male participants as being their problem areas. In addition, 80% of them said that they were most likely to get the eye-area treated before anything else.1 With more men seeking treatments2 and the periorbital area standing out as a key concern, Aesthetics spoke to ophthalmologist Dr Tahera Bhojani-Lynch, consultant ophthalmologist, oculoplastic, aesthetic and reconstructive surgeon Miss Rachna Murthy and aesthetic practitioner Dr Nina Bal, to gain insights about how to successfully treat the male under-eye area and how practitioners should differentiate this approach from female patients.

Eye concerns and the pandemic Miss Murthy has noticed a rise in popularity for male treatments, particularly in the periorbital area, and attributes this to the ongoing pandemic. She comments, “Not only have men had more than a whole year at home staring at their faces on Zoom, but it has also caused an increased strain on the eyes. Similarly, the constant mask wearing has brought a lot more attention to the area as it’s the only part of the face we can see!” Dr Bal agrees, noting that over the past year she’s seen a shift in the reasons that men present to her clinic. “The most common reason I used to see male patients for was forehead lines,” she says, adding, “But thanks to the Zoom Boom this has been replaced by concerns of looking tired and having dark circles, so the under-eye is now my most popular treatment area for men. This is why it’s more important than ever that practitioners know how to correctly address concerns in this area.”

According to Dr Bhojani-Lynch men tend to express similar concerns to women, but they come in at a later stage in life and are unsure what can actually be done. She comments, “Men experience the same issues women do; they complain about crow’s feet, tired looking eyes and dark circles. However, I find that men always come into the clinic when they’re a bit older. I don’t think this is because men don’t notice these issues at the same time as women, but more that they don’t voice them. Women talk to women about what they don’t like about their faces and bodies, and it’s much more open and normalised for them to get treatments. Men don’t talk to other men in the same way, and if they do it’s often turned into a bit of a joke.” This is what makes the initial consultation so key, she says, explaining that men feel vulnerable talking about the fact they have any insecurity. She adds, “This means my consultation style has to be completely different with men and women. What I’ve found helpful is using different terminology that attracts them to procedures and makes them feel more comfortable. Firstly, I don’t ask ‘what bothers you’, as they don’t often want to admit that anything bothers them! Also, rather than saying that a certain procedure will help them look younger, I’ll talk about how the treatment can make them look more attractive. This is very appealing to men.” In Dr Bal’s experience, men often need reassurance when they come to her clinic. She says, “I find that men are always so worried about being judged for having or considering treatments. So, when I first see them, I let them know straight away that this is a non-judgmental space, and I mention that I have lots of other men present to me with aesthetic concerns.” Dr Bal finds that after this, men feel more comfortable to openly express what’s bothering them without holding back. “It’s also a comfort to let them know that you treat other men for whatever concern they have,” she adds. Although Miss Murthy keeps her consultation approach similar for both men and women, she has found that the addition of 3D imaging has made men more trusting of the process. She states, “We use the Vectra H2 3D imaging system for all consultations, but I think our male patients appreciate it a lot more. They tend to have more analytical brains, so they

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

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want to see what they’re getting and what the outcomes could be. By showing them 3D images and helping them to monitor their treatments and the possible outcomes, they’re reassured they won’t leave the room looking feminised or over-filled.” You can read more tips about consulting male patients on p.57.

Before

Pre-treatment considerations Miss Murthy emphasises the importance of assessing a patient’s eye health prior to any treatment around the periorbital area. She says, “You should never go straight into a periorbital treatment without knowing everything about the patient’s periorbital area – you need to do a full eye examination. For example, you should ask what their vision is like, whether they have dry eyes or any underlying oedema in the morning. If this is the case, non-invasive treatments may not be the right option, and they could be better suited to other interventions like surgery. The most important thing to bear in mind when treating all genders is to ensure the procedure is as safe and beneficial to the patient as possible.” In regards to pricing, Dr Bhojani-Lynch suggests practitioners start by quoting the price based on the area rather than by syringe. She comments, “The main thing I advise all practitioners is to not overfill the under eye! Less is always more, and when you think you’re almost done, trust me you are done. But if a patient is paying by the syringe, they’ll try and get you to use all the product so that they get their money’s worth, even if they don’t need it. So, even if your patient asks you to continue injecting, you need to master the power of saying no – remember you can always add more but you can’t take it away as easily!”

Ageing in the male under-eye area Before constructing a treatment plan, Miss Murthy emphasises the importance of practitioners understanding the underlying ageing processes of the periorbital area, as well as the fundamental differences between men and women. She explains, “It’s the first area to age in both genders because we have thinner skin around the eye, typically less than a millimetre. Underneath the skin, we have lots of different muscles which are working all the time, and because there’s no fat under the skin here, you can see loss of plumpness and lines much more quickly. Men are more prone to deeper wrinkles caused by repeated facial expression. Also, collagen loss happens

"The main thing I advise all practitioners is to not overfill the eye! Less is always more, and when you think you’re almost done, trust me you are done" Dr Tahera Bohjani-Lynch

After

Patient before and three weeks after 2ml of Teosyal Redensity 2. Photos courtesy of Dr Nina Bal

steadily and more quickly in men than women throughout their lives, whereas women lose more after menopause. Because males have bulkier facial muscles and flatter cheekbones, this combined with subcutaneous fat and connective tissue loss in the mid-face with age, men tend to develop sagging lower eyelids and hollows below the eyeballs earlier and more severely than in women, making it a key area of concern.” Miss Murthy adds that the brow and the cheek positions are completely different for men compared to women and age differently. “The glabellar and frontonasal suture are more pronounced in males and the eyebrows are flatter, lying below the orbital rim, whereas for women they tend to be subtler, more curved and sit above the orbital rim,” she says, adding, “Because of this, men tend to have more deep-set eyes.” All three practitioners note that it’s important to avoid any feminisation of the periorbital area (unless of course this is what the patient is requesting) by considering these anatomical differences. Dr BhojaniLynch says, “One reason why many men are scared to come into an aesthetic clinic is because they are worried they’ll come out looking feminine. This can be the case if they are treated by unqualified or inexperienced practitioners, and of course I’ve seen some bad results. But, if the practitioner is aware of the differences between male and female anatomy and structure, and is able to treat accordingly, the patient can end up with very natural and subtle results. This is why anatomy is absolutely key to pay attention to.”

Techniques for the tear-trough Because a loss of support from the cheek area can worsen the appearance of the tear trough, Dr Bhojani-Lynch chooses to address volume in this area first. She notes that a common adverse effect when treating the male mid-face is over-filling, resulting in puffiness. She comments, “If you give a woman a fuller mid-face they look prettier, but if you give a man a fuller mid-face, they look feminised. Therefore, although we still have to start with this area in order to provide the under-eye with some support, we aren’t giving men the same curves we would with women.” Less product should also be used, Dr BhojaniLynch advises. “We need to keep the facial layers flat, and we can’t

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

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Visit ultherapy.co.uk for more information REFERENCE: 1. Fabi SG, Joseph J, Sevi J, Green JB, Peterson JD. Optimizing patient outcomes by customizing treatment with microfocused ultrasound with visualization: gold standard consensus guidelines from an expert panel. J Drugs Dermatol. 2019;18(5):426-432. Individual results may vary. M-ULT-UKI-0866 Date of Preparation January 2021

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Before

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After

Patient before and after mid-face treatment using Juvéderm Volift and Voluma. Photos courtesy of Miss Rachna Murthy

afford to give the area too much anterior projection as this will make it appear less masculine! I use a 30 or 27 gauge needle for this area because I find that it gives me a bit more precision.” After injecting the mid-face, Dr Bhojani-Lynch treats the tear trough directly; she prefers to use a 25 gauge cannula. This is because it can help to keep a straight edge running across the cheekbone and is less likely to cause a vascular occlusion.3 She comments, “I make my entry point from the lateral aspect of the cheek and manoeuvre the cannula straight along the face to the tear trough and into the muscle to try and flatten out the dip that goes into the mid-face.” Dr Bal also uses a 25 gauge cannula for her treatment approach, noting that she finds it a safer method for this particular area in both genders. She comments, “I sometimes use a 22 gauge, but the problem with this is that it’s easier to deposit too much product which is exactly what we want to avoid in this area. I normally go from the lateral side of the zygomatic arch, so the entry point will be on the bone, and I inject underneath the muscle, sliding the cannula across to the inner corner of the eye.” She reminds practitioners not to go too superficial with their injections in this area. “It can feel safer sometimes to inject more superficially, but actually this can cause really persistent swelling,” she says, adding, “To make yourself more confident when injecting deeper, I recommend placing your finger in the ridge of the orbit, firmly below the lower lid, in order to be aware of where your cannula is and where it will end up.” Miss Murthy uses her own adaption of Dr Mauricio de Maio’s MD Codes system in order to help determine her injection sites.4 She explains, “The first thing I do is to support the ligaments that are sagging laterally then replace deficient volume medially in the cheek – I would never treat the tear trough as a stand-alone. This means starting at point CK1 – the outer part of the zygomatic arch – and injecting straight down to the periosteum of the bone. I then move on to treat site CK3 (medial SOOF) using a fanning action. Here I tend to only use 0.5ml of product on each side to prevent overtreating. The final part of the procedure is to treat the tear trough itself.” She starts at injection point TT1-3 (the lower lid–cheek junction) going down to the orbital rim. “Here I inject 0.1-0.5ml worth of product which has to be injected deeply, or it will sit on the muscle and cause late onset oedema,” she says, adding, “I also use a cannula here because in my hands, I find it minimises bruising and there is less risk of being in a vessel and causing a vascular occlusion.” Other complications in this area can include the Tyndall effect, asymmetry, post-inflammatory hyperpigmentation, migraines and nodules, Miss Murthy explains. “These can mostly be avoided by having an indepth knowledge of the anatomy,” she adds.

Product selection All practitioners voice the importance of appropriate dermal filler selection for successful outcomes. Dr Bhojani-Lynch comments, “In my opinion, Teosyal Redensity 2 is perfect for treating the under-eye because the hyaluronic acid is created in a way that does not attract as much water as other products I have used. This means there is less expansion of the product, therefore avoiding puffiness which, as mentioned, you want to avoid in this area for all patients, especially for men as it can cause feminisation. For the mid-face I use Teosyal RHA 4.” Teosyal Redensity 2 is also a product Dr Bal will consider for the tear trough, but she also uses Juvéderm Volbella. She comments, “I find that both of these products provide good velocity and give a nice lift without causing any lumps. When addressing volume loss in the mid-face, I like to use Belotero Volume because I’ve found that it never gives the area too much swelling and won’t leave the face with any lumpiness or crepiness.” Miss Murthy explains that she uses a combination of treatments and products for optimal results in the periorbital area, dealing with each consequence of ageing in the different layers. She comments, “To start, I’ll typically use a skinbooster. This is normally Juvéderm Volite, which I find works better on darker skin types than others I have used, so it depends on the patient. Then, when I go onto injectable treatments, I’ll use Juvéderm Voluma for restoring volume in the cheek because it’s long-lasting and gives a natural finish, and then Volbella or Volift in tiny microaliquots on the bone in the tear trough, building up over two sessions if needed.” As well as injectable treatments, practitioners note that it is a good idea to get male patients on board to use topical skincare to maximise the results. Miss Murthy notes, “I advise them to have a daily skincare routine that can help improve the area, such as vitamin C serums, SPF factor 50 which they should apply all the way up to the lashes, and then a very light retinol at night to improve collagen production.”

Treat conservatively All practitioners emphasise the importance of not over-treating the male under-eye area, recommending a less is more approach. Practitioners should be well-versed in periorbital anatomy and the differences between the female and male facial structures for successful results. While treating the tear trough can help to reduce the appearance of tired and ageing eyes, practitioners can also consider using other treatments in conjunction with dermal fillers to tackle concerns in the whole periorbital area, for example botulinum toxin, skin tightening treatments, topical recommendations and surgery. REFERENCES 1. Allergan, Allergan Presents Men’s Maximum Difference Data at American Society of Dermatologic Surgery Meeting, 2015. <https://www.allergan.com/news/news/thomson-reuters/allergan-presentsmen-s-maximum-difference-data-at.aspx> 2. ASPS, 2018, https://www.plasticsurgery.org/cosmetic-procedures/men-and-plastic-surgery 3. Holly Carver, 2020, <https://aestheticsjournal.com/news/study-indicates-that-vascular-occlusion-lesslikely-with-cannulas?authed> 4. MD Maio, MD Codes, <https://www.mdmaio.com/md-codes/>

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

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Understanding Skin Layers and Injectables Miss Priyanka Chadha, Miss Lara Watson and Dr Catrin Wigley provides an overview of the skin’s function and anatomy and its relevance for successful aesthetic treatments The skin is the body’s largest organ, comprising around 16% of a person’s total body weight.1 Its complex structure and range of functions reflect its embryological origin from both ectoderm and mesoderm germ cell layers.2 Its functions are broad, performing a vital role in thermoregulation and water homeostasis, and providing a barrier from harmful agents such as UV rays, pathogens and mechanical trauma, as well as being a key endocrinological organ in vitamin D production.2 Skin also plays an integral role in our everyday psychosocial wellbeing and how we interact with one another, offering information on heritage, age and general health.2 As the skin provides the canvas for almost all aesthetic medicine, a working knowledge of its function and anatomy is essential for clinicians to provide safe treatments, as well as knowing how to optimise results. This article will therefore cover the functional anatomy of the skin in relation to injectable practice, as well as look at the emerging trends that exploit the properties of the integumentary system.

The epidermis

characteristic facial hyperpigmentation seen in melasma.7 Merkel cells are tactile cells that interact with sensory nerves within the basal cell layer of the epidermis. These cells are found in higher concentrations in skin regions that require more touch feedback, such as in the fingertips.4 Langerhan cells, on the other hand, are involved in a variety of T-cell responses and immunity.4 The interface between the epidermis and dermis contains a porous basement membrane that allows the exchange of nutrients such as peptides between the layers, as well as providing structural adherence.8 With age, the epidermis has been observed to become atrophied and so many mild chemical peeling agents, such as glycolic acid, target the epidermis to accelerate the process of desquamation, improving the skin texture and reducing the appearance of fine lines or uneven pigmentation.9

The dermis The dermis is arguably the most clinically relevant skin layer to aesthetic medicine and is where most treatments target their technologies.10 The dermis is the intermediate layer of skin sitting between the epidermis and subcutaneous layer. The role of the dermis is to sustain and support the epidermis, as well as providing elasticity and tensile strength.8 Being connective tissue, the dermis contains ground substance, fibres and cells such as fibroblasts, mast cells and histiocytes.4 The dermis also accommodates vascular and lymphatic channels, nerves and appendages such as hair follicles, sweat glands and sebaceous glands.4,11

The skin can be broadly classified into three layers: the epidermis, dermis and subcutaneous layer, which is anchored to underlying structures by connective tissue.3 The outermost layer, the epidermis, is largely composed of keratinocyte cells arranged into a stratified squamous epithelium.3 The epidermal keratinocytes function to make keratin, a protein that provides the epidermis with its main properties as a barrier. The different stages of maturation of the keratinocytes are arranged into layers; the basal cell layer, Touch receptor suprabasal cell layer, granular cell layer and, (Meissner’s corpuscle) most superficially, the horny cell layer.4 As Pain receptor keratinocytes migrate through the layers of Capillary network the epidermis, they become less lipophilic Sebaceous gland and denser in keratin.3 The epidermis contains no blood vessels, lymphatics or Erector pili muscle nerves, thus cells in the basal cell layer are Heat receptor (Ruffini endings) supplied by diffusion from the upper portion of the dermis.5 Hair follicle The horny cell layer is shed through a Cold receptor (Krause muscle) process called desquamation, and the entire process from the basal cell layer Motor nerve takes around 28 days.3 Around 95% of Hair bulb the epidermal cells are keratinocytes, Vein and the remaining minority consists of Artery melanocytes, merkel cells and langerhans 6 cells. Melanocytes are responsible for Subcutaneous fat the production of melanin, the pigment Subdermal muscle layer responsible for UV protection and in varying Sweat Deep fascia 6 (eccrine gland) skin complexions. It is the overproduction of melanin by melanocytes that causes the Figure 1: Diagram showing the skin structure and function

Hair

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

Epidermis

Dermis

Subcutaneous layer

Nerve endings Pacinian corpuscle (pressure receptor)

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The dermis can be subdivided histologically into the more superficial papillary dermis and the deeper reticular dermis, the latter forming the majority of the layer.4 The papillary layer consists of loose connective tissue containing small capillaries, elastin and some collagen fibres, whereas the arrangement of the reticular dermis is of dense connective tissue, larger blood vessels and thick bundles of collagen.4 Medium-strength chemical peels such as 50% TCA work by penetrating the papillary dermis, whereas deep chemical peels (not as commonly used in practice) penetrate the full thickness of the dermis.12 Collagen provides the majority of the dry weight of the dermis and gives the layer its pale colour.4 Collagen is produced by fibroblast cells and provides the skin with its stress-resistant properties.1 With age, the production and quality of collagen types I and III reduces, playing an integral part of the intrinsic ageing process of skin.9 Topical retinoids and peptides, for example, are a popular treatment for upregulating the synthesis of collagen within the dermis.9 Non-ablative laser resurfacing technologies also target the dermis to generate thermal injury and encourage collagen production.13 Elastin fibres are not as tough as collagen fibres but provide the skin with elasticity, although they do little in the way of shape deformation.4 The ground substance is an amorphous gelatinous matrix largely made up of sugar and protein rich molecules called glycosaminoglycans.1 Hyaluronic acid is an example of a glycosaminoglycan found in the connective tissue, although it is a minor component of the dermal ground substance. Fractional laser has gained popularity over recent years, offering encouraging results.14-16 These lasers, such as C02 lasers, work by evaporating the epidermis and stimulating matrix remodelling within the ground substance of the dermis.13,17 Although a minor constituent of the dermal ground substance, hyaluronic acid plays an integral role in the skin ageing process as it becomes the most depleted glycosaminoglycan with age.18 As it naturally occurs in the dermis, the hypoallergenic and hydrophilic properties of hyaluronic acid have made it a safe, effective and reversible substance for dermal fillers. It is therefore no surprise that these products have become so commercially appealing.19,20 The dermis hosts a two-tier vascular supply made of two interconnecting plexuses. Most superficially lies the superficial plexus within the papillary dermis, followed by the larger deep plexus that sits within the lower reticular dermis surrounding adnexal structures such as sweat glands and hair follicles.8 The nerves of the skin are found in various forms and also lie within the dermis. Sensory afferent signalling within the skin is very complex and includes touch, pain, vibration and pressure.1 Of most relevance, however, non-myelinated free nerve endings responsible for pain transmission are found in abundance within the papillary dermis.4 The most common commercial preparations of dermal filler contain local anaesthetic, such as 1% lidocaine which act on these free nerve endings to make the procedure more tolerable for patients.21 The application of vibration devices in conjunction to dermal filler and muscle relaxants have recently gained impetus.22 The concept is that the devices can influence simulation-induced analgesia making treatments more tolerable, with provisional results appearing promising.22,23

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Subcutaneous fat The deepest layer of the skin is the subcutaneous fat, which sits between the dermis and fascia of the facial muscles. Its role is to provide a cushion to external force, preserve body heat and retain moisture.4 The subcutaneous layer largely consists of fat cells arranged into lobules. The thickness of the subcuticular fat varies according to anatomical site, body habitus and age.24 For example, with age the density of subcutaneous fat in the cheeks is disproportional to other anatomical sites.25 Over time, distinct ‘pockets’ of fat have been noted to become more discrete than other areas, giving rise to characteristic signs of ageing such as the nasolabial fold and jowls.26 Historically, autologous fat was the first commercial dermal filler and is still widely used for longer term volume correction, however its use is generally restricted to the surgical world as the procedure is more technically challenging.27

Applications to practice A working knowledge of the skin’s histology not only provides a framework for optimising results in a broad range of skin types, but also allows the anticipation of potential procedural complications. Atopic dermatitis is a complex condition that largely describes an immune-mediated impairment of the skin barrier function, specifically affecting its keratinisation.28 Subsequently, water is lost more readily from the skin’s surface and has an increased susceptibility to microbes. Clinicians must therefore assess the suitability of patients for dermal filler by the severity of the dermatitis, its proximity to the proposed treatment area, and the risk of complications such as infection.29 Rosacea also affects many patients seeking aesthetic treatments and is a relatively common condition characterised by flushing, telangiectasia, and erythema. Its pathophysiology is complex and in part due to the dysregulated release of peptides from the epidermis.30 Patients with rosacea are at higher risk of postinjection erythema and should be warned about this prior to treatment.31 Another common skin condition affecting the epidermis is psoriasis, a multifactorial immune-mediated reaction resulting in epidermal thickening and hyperproliferation.32 Dermal fillers can precipitate psoriatic flareups via the Koebner response, and may impact how the product distributes throughout the skin layers.29 Other inflammatory skin reactions such as hypertrophic and keloid scarring, and post-inflammatory hyperpigmentation can be initiated by dermal filler.29,33,34 A detailed patient history and thorough assessment of abnormal scarring, hyperpigmentation, and Fitzpatrick skin types must therefore be conducted in all patients to assess for treatment suitability and advise on potential complications. Another such example is in cases of active infection, such as that of herpes simplex virus (HSV). Any active skin infections should defer treatment and, in the case of HSV, there is some evidence to support prophylactic antiviral therapy in patients seeking treatments with a known history.29,35 On assessment of patients, skin thickness and quality must also be considered in patient selection, and in the selection of the dermal fillers used. An example of this significance is in patients with skin atrophy following long-term steroid use, whereby superficial or medium-depth dermal filler would not be suitable, and places patients at increased risk of complications such as the Tyndall effect.29,36

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

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Consider the skin anatomy In this article we have considered the key constituents of the three layers of the skin and their relation to aesthetic practice. An awareness of how therapies such as dermal fillers target specific properties of the skin remains central to providing safe, up-to-date, and optimised cosmesis for patients.

Aesthetics Clinical Advisory Board Member Miss Elizabeth Hawkes says… A sound understanding of skin anatomy is crucial for all aesthetic practitioners and cosmetic surgeons. Success or failure is often determined by skin remodelling, whether it be following injectable treatments, medical-grade skincare, peels, laser or cosmetic surgery. With a thorough knowledge of skin anatomy and physiology, aesthetic practitioners can offer safe and effective treatments. This CPD article discusses the anatomy of the skin with an in-depth description of its layers and cellular subtypes. It continues by applying the scientific knowledge to clinical practice, with descriptions of common skin diseases. Some of the basic principles of aesthetic medicine and ageing are described in this paper, with further reading suggestions in the references. REFERENCES 1. Venus M, Waterman J, McNab I. Basic physiology of the skin. Surgery. 2011. 2. McGrath JA, Uitto J. Anatomy and Organization of Human Skin. In: Rook’s Textbook of Dermatology: Eighth Edition. 2010. 3. Chu D. Overview of biology, development, and structure of skin. Fitzpatrick’s Dermatology Gen Med. 2012. 4. Shimizu H. Shimizu’s Dermatology. Shimizu’s Dermatology. 2017. 5. Cross SE, Roberts MS. Importance of dermal blood supply and epidermis on the transdermal iontophoretic delivery of monovalent cations. J Pharm Sci. 1995. 6. Haake A, Scot GA, Holbrook KA. Structure and function of the skin: overview of the epidermis and dermis. In: The Biology of the Skin. 2001. 7. Ogbechie-Godec OA, Elbuluk N. Melasma: an Up-to-Date Comprehensive Review. Dermatology and Therapy. 2017. 8. Kolarsick P, Kolarsick M, Goodwin C. Anatomy and Physiology of the Skin. J Dermatol Nurses Assoc. 2011;3(4):203–13. 9. Sadick NS, Karcher C, Palmisano L. Cosmetic dermatology of the aging face. Clin Dermatol. 2009. 10. Micheels P, Besse S, Sarazin D, Vincent AG, Portnova N, Diana MS. Quantifying depth of injection of hyaluronic acid in the dermis: Data from clinical, laboratory, and ultrasound settings. J Drugs Dermatology. 2016. 11. Burns DA, Breathnach SM, Cox NH, Griffiths CEM. Rook’s Textbook of Dermatology: Eighth Edition. Rook’s Textbook of Dermatology: Eighth Edition. 2010. 12. Soleymani T, Lanoue J, Rahman Z. A practical approach to chemical peels: A review of fundamentals and step-by-step algorithmic protocol for treatment. Journal of Clinical and Aesthetic Dermatology. 2018. 13. Atiyeh BS, Dibo SA. Nonsurgical nonablative treatment of aging skin: Radiofrequency technologies between aggressive marketing and evidence-based efficacy. Aesthetic Plastic Surgery. 2009. 14. Rahman Z, MacFalls H, Jiang K, Chan KF, Kelly K, Tournas J, et al. Fractional deep dermal ablation induces tissue Tightening. Lasers Surg Med. 2009. 15. Shin MK, Lee JH, Lee SJ, Kim NI. Platelet-rich plasma combined with fractional laser therapy for skin rejuvenation. Dermatologic Surg. 2012. 16. Rahman Z, Alam M, Dover JS. Fractional Laser treatment for pigmentation and texture improvement. Skin Therapy Lett. 2006. 17. Shin JW, Kwon SH, Choi JY, Na JI, Huh CH, Choi HR, et al. Molecular mechanisms of dermal aging and antiaging approaches. Int J Mol Sci. 2019. 18. GHERSETICH I, LOTTI T, CAMPANILE G, GRAPPONE C, DINI G. HYALURONIC ACID IN CUTANEOUS INTRINSIC AGING. Int J Dermatol. 1994. 19. John HE, Price RD. Perspectives in the selection of hyaluronic acid fillers for facial wrinkles and aging skin. Patient Preference and Adherence. 2009. doi: 10.2147/PPA.S3183 20. Price RD, Berry MG, Navsaria HA. Hyaluronic acid: the scientific and clinical evidence. Journal of Plastic, Reconstructive and Aesthetic Surgery. 2007. 21. Allemann IB, Baumann L. Hyaluronic acid gel (JuvédermTM) preparations in the treatment of facial wrinkles and folds. Clinical Interventions in Aging. 2008. 22. Kuwahara H, Ogawa R. Using a Vibration Device to Ease Pain During Facial Needling and Injection. Eplasty. 2016. 23. Guney K, Sezgin B, Yavuzer R. The Efficacy of Vibration Anesthesia on Reducing Pain Levels during Lip Augmentation: Worth the Buzz? Aesthetic Surg J. 2017. 24. Mueller WH, Wohlleb JC. Anatomical distribution of subcutaneous fat and its description by multivariate methods: How valid are principal components? Am J Phys Anthropol. 1981. 25. Raskin E, LaTrenta GS. Continuing medical education article-facial aesthetic surgery. Why do we age in our cheeks? Aesthetic Surg J. 2007.

26. Rohrich RJ, Pessa JE. The fat compartments of the face: Anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007. 27. Groen JW, Krastev TK, Hommes J, Wilschut JA, Ritt MJPF, Van Der Hulst RRJW. Autologous fat transfer for facial rejuvenation: A systematic review on technique, efficacy, and satisfaction. Plastic and Reconstructive Surgery - Global Open. 2017. 28. Pelc J, Czarnecka-Operacz M, Adamski Z. Structure and function of the epidermal barrier in patients with atopic dermatitis - Treatment options. Part one. Postepy Dermatologii i Alergologii. 2018. 29. De Boulle K, Heydenrych I. Patient factors influencing dermal filler complications: Prevention, assessment, and treatment. Clin Cosmet Investig Dermatol. 2015. 30. Yamasaki K, Gallo RL. The molecular pathology of rosacea. Journal of Dermatological Science. 2009. 31. Funt D, Pavicic T. Dermal fillers in aesthetics: An overview of adverse events and treatment approaches. Clinical, Cosmetic and Investigational Dermatology. 2013. doi: 10.2147/CCID.S50546 32. Roberson EDO, Bowcock AM. Psoriasis genetics: Breaking the barrier. Trends in Genetics. 2010. 33. Heath CR, Taylor SC. Fillers in the skin of color population. J Drugs Dermatology. 2011. 34. Taylor SC, Burgess CM, Callender VD. Safety of nonanimal stabilized hyaluronic acid dermal fillers in patients with skin of color: A randomized, evaluator-blinded comparative trial. Dermatologic Surg. 2009. 35. De Boulle K. Management of complications after implantation of fillers. J Cosmet Dermatol. 2004. 36. Luebberding S, Alexiades-Armenakas M. Critical Appraisal of the Safety of Dermal Fillers: A Primer for Clinicians. Current Dermatology Reports. 2013.

Miss Priyanka Chadha currently works as a plastic surgery registrar in London and is co-director of Acquisition Aesthetics training academy. Her academic CV comprises national and international prizes and presentations, as well as higher degrees in surgical education and training. Miss Chadha is a key opinion leader for Galderma. Qual: MBBS(Lond), BSc(Hons), DPMSA(Lond), MRCS(Eng), MSc(Lond) Miss Lara Watson is dual-qualified in medicine and dentistry and works as a registrar in oral and maxillofacial surgery. She is a faculty member for Galderma and is also a co-founding director of Acquisition Aesthetics with a strong background in anatomy and scientific research. Qual: BM, BMedSci, BSc, MRCS(Eng), BDS(Hons) Dr Catrin Wigley is a plastic surgical trainee in Central London. She was previously an academic trainee in the West Midlands and has held several lecturing roles. Dr Wigley practises aesthetics alongside her training and research interests. Qual: BMedSc, Hons MBChB

Test your knowledge!

Complete the multiple-choice questions below and email editorial@aestheticsjournal.com to receive your CPD certificate! Questions

Possible answers

The epidermis is primarily made of what cell type?

a. b. c. d.

Keratinocytes Fibroblasts Melanocytes Langerhans cells

2. What is the main constituent of the

a. b. c. d.

Sweat glands Elastin Collagen Hair follicles

3. What type of substance is hyaluronic

a. b. c. d.

Glycophosphatidylinositol Glycosaminoglycan Glucosamine Glycocyamine

4. In what layer of the skin do the

a. b. c. d.

Dermis Suprabasal epidermis Subcutaneous fat Granular cell epidermis

5. The reduction of which collagen is

a. b. c. d.

II and III I and IV III and IV I and III

dermis?

acid?

sebaceous glands exist?

most associated with the ageing process?

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

Answers: 1. A, 2. C, 3. B, 4. A, 5. D

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Treating the Male Jawline Dr David Jack provides his top tips for treating the lower face and jawline using dermal fillers The jawline is a particularly prominent and defining feature of the male face, with higher muscle bulk, a wider set mandible with a more prominent angle, as well as a wider chin and bulky ramus, when compared to the female jawline.1,2 Most men seeking treatments in my clinic do so for two reasons: antiageing or masculinisation. The former is generally requested by slightly older men who have noticed volume loss and the appearance of jowls, as well as skin changes. The latter tends to be younger men seeking a more defined jawline and wider chin to give a more masculine appearance. Usually, the approach will involve similar treatments regardless of the reason, with supraperiosteal filler placement around the angle of mandible and chin.

Lower facial aesthetics I’m not an advocate for obsessive adherence to aesthetic ‘ideals’, as the ideal jawline will only be ideal in the context of an individual’s face, and ‘correction’ with filler in an attempt to match particular proportions often will result in excessive filling and, more often than not, an odd and unnatural look. This being said, a 2016 study stated that the ideal male jawline has the following characteristics:3,4 • 130° angle in profile view • Intergonial width that is similar to facial width • Vertical position in frontal view at the oral commissure or at least not below the lower lip • Jawline slope in the facial frontal view nearly parallel to (with a maximum 15° downward deviation from) a line extending from the lateral canthus of the eye to the nasal alae • Ascending ramus slope 65-75° to the Frankfort horizontal line and curvature in the oblique view, visible from earlobe to chin and not pointy

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any slight defect there, should there be any. Again, this is a deep injection. Then, I would place a deep bolus onto the surface of the mental process on each side – 0.1-0.2ml – to square the chin if need be. It is sometimes advantageous to use a little bit of filler slightly more superficially in the subcutaneous plane using a cannula along the area of the body of the mandible; however, the need for this varies from patient to patient. I don’t often do this as, frequently, the deeper and lower-risk supraperiosteal injection over the angle of the mandible is sufficient. Injecting superficially in this area is a high-risk procedure, due to the presence of the marginal mandibular branch of the facial nerve and the facial vessels, so should only be attempted by experienced injectors and where there is definite need.

Top tips When treating the male jawline, my advice is to go slowly, using minimal volumes and spreading treatments over several sessions. In my experience, this really is the only way to achieve natural results. I’d usually only do a maximum of two syringes on any patient per appointment, then see the patient at least two weeks later with a view to add more if need be. You should also consider all of the layers of the skin in this area and combine filler with other procedures such as energybased devices like high-intensity focused ultrasound and fractional radiofrequency if needed. These types of treatment can help lift the tissues further and work very nicely in synchrony with revolumisation. Lastly, remember every patient is different and should be treated as such.

This article was produced and funded by Allergan Aesthetics, an AbbVie Company.

Treatment approach Volume replacement with filler is the key consideration for this area. Any filler injected into the jawline will be subject to substantial deforming forces, particularly if it is injected in the masseteric area. I therefore normally select a filler with a relatively high G-prime (high elasticity and viscosity) and usually choose hyaluronic acid. My technique for the male jawline usually involves deep boluses of filler injected directly onto the periosteum in the region of the angle of the mandible using a needle. The needle would be placed perpendicular to the skin and the product injected only once the needle hits the bone. I always favour a slow approach to injecting, using minimal volumes and building up over time. In terms of product selection, I usually would start with one to two syringes of either Juvéderm Voluma or Volux,5,6 then assess and, if need be, repeat the treatment two weeks to one month later. Voluma would typically be my first choice,5 and I would progress to Volux if it’s not providing enough volumisation after the first sitting.6 Usually, if using two syringes of 1ml, the volume injected would be around 0.30.5ml on each side in two to three points at the angle of the mandible. I generally then use a bolus of around 0.1-0.2ml bilaterally, just anterior to the mandibular retaining ligament, to correct 32

Aesthetics | June 2021

For more information go to: www.juvederm.co.uk UK-JUV-2150228 Date of preparation: May 2021

REFERENCES 1. JA Farhadian, et al., Male Aesthetics A Review of Facial Anatomy and Pertinent Clinical Implications 2015 2. Mommaerts MY The ideal male jaw angle, An Internet survey, J Craniomaxillofac Surg. 2016 Apr;44(4):381-91 3. Dr David Jack, ‘Contouring the Male Jawline, 2017. <https:// aestheticsjournal.com/feature/contouring-the-male-jawline> 4. Juvéderm VOLUMA DFU 5. Juvéderm VOLUX DFU

Adverse events should be reported. Reporting forms and information can be found at https://yellowcard.mhra.gov.uk/ Adverse events should also be reported to Allergan Ltd. UK_ Medinfo@allergan.com or 01628 494026.

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Considering Rosacea as a Systemic Disease Consultant dermatologist Dr Firas Al-Niaimi discusses how rosacea can be linked to organ systems and co-morbidities in patients Rosacea is a common inflammatory skin condition with a high prevalence among the Western population.1 Whilst the signs and symptoms predominantly affect the centrofacial part of the skin, there has been increasing interest and emerging evidence linking it with other organ systems and co-morbidities. The question posed is whether rosacea is a cutaneouslimited disease or one with systemic involvement, or perhaps a manifestation of a wider systemic inflammation.

Causes of rosacea During the present time, the exact pathophysiology of rosacea remains unclear. It involves an aberrant neurovascular signalling and a dysregulation of the immune system, in particular the innate system.2 High levels of cathelicidins – anti-microbial peptides expressed by leukocytes and epithelial cells – have often been found in rosacea patients; in addition to kallikrein-5, matrix metalloproteinases 2 and 9, and increased mast cell infiltration.1,2 It is well established that kallikrein-5 cleaves cathelicidin to its more active form of LL-37 which is pro-inflammatory and angiogenic. High expression of cathelicidin has also been found in colonic mucosa of inflammatory bowel disease patients.3 The gut-brain-skin axis is a term that has been existent in medical literature for some time, linking certain inflammatory skin conditions with stress and gut-related pathology.4 In recent years, a better understanding has shed light on rosacea and its systemic links. Several large case-control observational studies have shown an association between rosacea, several systemic diseases and co-morbidities including gastrointestinal, cardiovascular, respiratory, autoimmune, and neurological disorders.5,6 Furthermore, chronic inflammation is a feature of both rosacea and several systemic co-morbidities, notably cardiometabolic disease.5,6 In addition, a genome-wide association study identified loci for rosacea, which was associated with several autoimmune diseases such as diabetes mellitus, coeliac disease, and rheumatoid arthritis.7

Gut dysbiosis and rosacea Association studies linking rosacea to the gastrointestinal system have shown a connection with inflammatory bowel disease and an overgrowth of gut bacteria. These include both helicobacter pylori (H. pylori) and small intestinal bowel overgrowth.8 The microenvironment in the gut is increasingly linked to skin inflammation with gut dysbiosis – an alteration in the harmonious composition of the gut microbiome – playing an important role. This can either be through the mediation of inflammation or through mucosal barrier compromise.9 Gut dysbiosis is based on the influence of age, food consumption, stress, and antibiotics (in anti-microbial doses). Intestinal inflammation and gut dysbiosis have shown to activate plasma kallikrein-kinin system pathway – an inflammatory cascade triggered by an unhealthy gut – which is pro-inflammatory in rosacea.10 In addition, gut dysbiosis leads to mucosal barrier compromise with pro-inflammatory substances circulating in the bloodstream. Control of the harmonious gut microbial, as well as the inflammation, can have a positive effect on the control of rosacea symptoms and is increasingly being recognised as part of the overall management of rosacea.10,11 This is controlled through dietary modification, consumption of probiotics, as well as control and eradication of potential pathogenic microbes such as H. pylori and small intestinal bowel overgrowth.11 Gastrin-induced flushing has also been linked to the presence of H. pylori.8

The skin microbiome The skin microbiome too has increasingly been recognised as an important key player in several inflammatory cutaneous diseases including rosacea.12 The skin microbiome refers

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to the diverse microbial population unique to every individual, comprising bacteria, viruses, fungi, and mites. Some are skin resident and act as symbiont, while others are invaders and often pathogenic. Advances in genomic sequencing research, as opposed to outdated culture-based techniques, has enabled for a better understanding of the microbiome’s composition.13 The skin microbiome is in a delicate environment affected by several factors such as the skin’s acidity, temperature, lipid composition, humidity, stress, pollution, dehydration, and local skin changes such as dry or moist skin.13 These factors can alter the harmony and composition of the delicate microbiome leading in some cases to a pro-inflammatory state. In rosacea, the presence of the mite Demodex folliculorum and the bacteria Bacillus oleronius elicit a proinflammatory state through the activation of pattern-recognition toll-like receptors 2 (TLR2) – expressed on keratinocytes and dendritic cells – as well as interleukin-8 and TNF-alpha, as consequential downstream activation of inflammatory pathways.14 This link is strengthened by the observation of improvement in rosacea symptoms with antiparasitic drugs (targeting the mites) and tetracycline-based antibiotics (primarily targeting Bacillus oleronius). TLR2 are further activated by stress and ultraviolet radiation; the latter increases the production of the antimicrobial peptide cathelicidin, mostly secondary to UV-induced vitamin D3 production. A possible explanation to the low prevalence of rosacea among higher Fitzpatrick skin type individuals is that they tend to have lower levels of vitamin D3, which as a consequence, means there is possibly less cathelicidin present.15

Chronic inflammation Chronic inflammation in rosacea has also been linked to cardiometabolic risks with case-controlled studies linking rosacea to a high incidence of hypertension, dyslipidaemia, obesity, and an elevated fasting glucose level.16 Both rosacea and dyslipidaemia patients express low levels of a protective highdensity lipoprotein-associated antioxidant called paraoxonase-1 (PON-1), as well as a relatively high inflammatory baseline level of C-reactive protein (CRP), found in most cardiometabolic diseases.17 Interestingly, current smokers have a somewhat protective effect on their rosacea symptoms. This could possibly be due to the vasoconstrictive effects of smoking and the worsening of

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

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rosacea symptoms has been observed in past smokers.18 Currently, it remains unclear if strict control of all cardiometabolic factors and diseases can positively correlate to rosacea severity and symptoms, although this association is being observed and clinicians may want to consider this in patients with severe rosacea or those resistant to treatment. Neuropsychiatric associations with rosacea have found links with depression, anxiety, migraines, and Parkinson’s disease.19,20 As mentioned previously, stress can worsen rosacea through stressmediated inflammation as well as through alteration of the gut microbiome, leading to gut dysbiosis.

Conclusion Increasing evidence is linking rosacea to a wider systemic state of chronic inflammation and its associations with the gastrointestinal and cardiovascular systems. This may warrant some adjustments in the approach and management of rosacea patients, particularly in the presence of systemic symptoms. Clinicians should be aware of the systemic associations and co-morbidities of rosacea when treating patients. Dr Firas Al-Niaimi is an award-winning consultant dermatologist, as well as Mohs and laser surgeon based in London. He has published more than 200 publications, 10 book chapters and his own book on preparation for dermatology specialist examination. Dr Al-Niaimi is also a researcher at Aalborg University, Denmark, and is involved in clinical and translational research in the field of lasers and spectrophotometry. Qual: MD, MSc, MRCP, MRCP (Dermatology), EBDV

REFERENCES 1. van Zuuren EJ,‘Rosacea’, N Engl J Med, 18 (2017), pp. 1754-1764. 2. Schwab VD, Sulk M, Seeliger S, et al., ‘Neurovascular and neuroimmune aspects in the pathophysiology of rosacea’,Journal of Investigative Dermatology Symposium Proceedings, 15 (2011), pp. 53-62. 3. Kusaka S, Nishida A, et al., ‘Expression of human cathelicidin peptide LL-37 in inflammatory bowel disease’, Clinical Experimental Immunology, 191 (2018), pp.96-106. 4. Arck P, Handjiski B, et al., ‘Is there a ‘gut-brain-skin axis?’, Experimental Dermatology, 19 (2010), pp. 401-5. 5. El Gemayel M, ‘Comorbidities in rosacea: a systematic review and update’ Journal of the American Academy of Dermatology, 78 (2018), pp. 786-792. 6. Duman N, Ersoy Evans S, et al, ‘Rosacea and cardiovascular risk factors: a case control study’, Journal of the European Academy of Dermatology and Venereology, 28 (2014), pp. 1165-1169. 7. Egeberg A, Hansen PR, et al., ‘Clustering of autoimmune diseases in patients with rosacea’, Journal of the American Academy of Dermatology, 74 (2016), pp. 667-72. 8. Searle T, Ali FR, et al., ‘Rosacea and the gastrointestinal system’, Australasian Journal of Dermatology, 61 (2020), pp. 307-311. 9. Kim HS, ‘Microbiota in Rosacea’, American Journal of Clinical Dermatology, 21 (2020), pp. 25-35. 10. Dreno B, Araviiskaia E, et al.,‘Microbiome in healthy skin, update for dermatologists’, Journal of the European Academy of Dermatology and Venereology, 30 (2016), pp. 2038-47. 11. De Pessemier B, Grine L, et al., ‘Gut-Skin Axis: Current Knowledge of the Interrelationship between Microbial Dysbiosis and Skin Conditions’, Microorganisms, 9 (2021), p. 353. 12. Holmes AD,‘Potential role of microorganisms in the pathogenesis of rosacea’, Journal of the American Academy of Dermatology, 69 (2013), pp. 1025-32. 13. Byrd AL, Belkaid Y, Segre JA, ‘The human skin microbiome’, Nature Reviews Microbiology, 16 (2018), pp. 143-155. 14. Reilly N, Menezes N, Kavanagh K, ‘Positive correlation between serum immunoreactivity to Demodex-associated Bacillus proteins and erythematotelangiectatic rosacea’, British Journal of Dermatology, 167 (2012), pp. 1032-6. 15. Chung C, Silwal P, Kim I, et al., ‘Vitamin D-Cathelicidin Axis: at the Crossroads between Protective Immunity and Pathological Inflammation during Infection’, Immune Network, 20 (2020) p. 12. 16. Searle T, Al-Niaimi F, Ali FR, ‘Rosacea and the cardiovascular system’, Journal of Cosmetic Dermatology, 19 (2020), pp. 2182-2187. 17. Hua T-C, Chung P-I, Chen Y-J, et al., ‘Cardiovascular comorbidities in patients with rosacea: a nationwide case-control study from Taiwan’, Journal of the American Academy of Dermatology, 73 (2015), pp.249-254. 18. Li S, Cho E, Drucker AM, et al., ‘Cigarette smoking and risk of incident rosacea in women’, American Journal of Epidemiology, 186 (2017), pp.38-45. 19. Woo YR, Han YJ, Kim HS, et al., ‘Updates on the Risk of Neuropsychiatric and Gastrointestinal Comorbidities in Rosacea and Its Possible Relationship with the Gut-Brain-Skin Axis’, International Journal of Molecular Sciences, 21 (2020), p.8427. 20. Vera N, Patel NU, Seminario-Vidal L, ‘Rosacea Comorbidities’, Dermatologic Clinics, 36 (2018), pp.115-122.

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

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THE WINNERS After a tough year, the Aesthetics team were delighted to finally host the Aesthetics Awards on May 28 and celebrate everything the specialty has achieved in the last 12 months. Held as a virtual ceremony, the event was as glamorous as ever, featuring a cocktail masterclass, celebrity hosts Cherry Healey and Jon Briggs, and a best-dressed competition – the winners of which will be featured in next month’s journal! A massive thank you to all our judges, who carefully assessed each entry in their assigned categories, ensuring their scores and feedback were as fair and balanced as possible, as well as to our voters for their fantastic feedback. Special thanks must also go to our sponsors; their support enabled us to deliver such a spectacular event! A huge congratulations to all Winners, as well as those who received Commendations and High Commendations. We had some incredible finalists, and everyone who was up for an Award should be proud of everything they’ve achieved and contributed to the specialty throughout the year.

CO M PA N Y W IN N E R S PRODUCT/PHARMACY DISTRIBUTOR WINNER: CHURCH PHARMACY

28 & 29 MAY 2021 / LONDON

Church Pharmacy received this Award for the second year running. The team had fantastic feedback from voters, one of which commented, “Church Pharmacy are a great team who go above and beyond.” HIGHLY COMMENDED: Wigmore Medical COMMENDED: AestheticSource FINALISTS: • Aspire & Co Ltd • Best Brothers Ltd • HA-Derma Ltd • Med-fx

SALES REPRESENTATIVE WINNER: TERINA DENNY

THE ACE AWARD FOR MANUFACTURER OF THE YEAR

WINNER: AESTHETIC TECHNOLOGY LTD One judge stated, “Aesthetic Technology has proven to be a reliable company who has responded well to the COVID-19 pandemic and should be applauded for this.” HIGHLY COMMENDED: Cynosure UK Ltd COMMENDED: Lynton Lasers FINALISTS: • Establishment Labs • Fotona D.o.o • LIPOELASTIC LTD

Comments from Terina’s customers included, “She works harder than any other rep I know,” and, “The most efficient, enthusiastic and supportive rep ever.”

Aesthetics | June 2021

HIGHLY COMMENDED: Thom Klein COMMENDED: Jordan Sizer

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PRO DUC T W I N N E R S

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TOPICAL SKIN PRODUCT/RANGE OF THE YEAR WINNER: HELIOCARE 360 (AESTHETICARE)

THE SKINCEUTICALS AWARD FOR ENERGY DEVICE OF THE YEAR

One voter said, “It never fails me. Whether it’s for a summer holiday or daily SPF I have full confidence when recommending Heliocare 360 to patients of all skin types.”

WINNER: EMSCULPT Our judges had great things to say about EMSCULPT, praising its efficacy by noting that the entry was, “Very detailed and impressive with lots of evidence supplied.” HIGHLY COMMENDED: ENDYMED 3DEEP Skin Science (AesthetiCare) COMMENDED: Soprano Titanium (ABC Lasers) and truSculpt Flex (Cutera) FINALISTS: • BYONIK® Pulse Triggered Laser (Pure Swiss Aesthetics Ltd) • Dermalux Flex MD (Aesthetic Technology Ltd) • Emerald Laser (Erchonia Lasers Ltd) • Fotona StarWalker (Fotona) • ONDA Coolwaves (DEKA in partnership with Lynton Lasers) • Picosure (Cynosure UK) • Teslaformer (Beautyform Medical) • Thermage FLX (Solta Medical)

HIGHLY COMMENDED: ZO Skin Health (Wigmore Medical) COMMENDED: PCA Skin C&E Advanced (Church Pharmacy) and skinbetter science (AestheticSource) FINALISTS: • Dr.LEVY Switzerland • Medik8 • PROFHILO HAENKENIUM • SkinCeuticals Antioxidants

SURGICAL PRODUCT WINNER: PIEZOTOME (BIOSPECTRUM LTD) There was just one finalist in this category, but the judges highlighted that they were hugely impressed with Piezotome’s success so it was awarded the highest accolade!

T R A IN IN G P ROV IDER S SUPPLIER TRAINING PROVIDER

THE DIGITRX BY CHURCH PHARMACY AWARD FOR PRODUCT INNOVATION WINNER: MORPHEUS8 (INMODE UK) Our judges commented that the Morpheus8 device by InMode is a fantastic new product on the market with incredible proven results! HIGHLY COMMENDED: Emepelle® (AesthetiCare) COMMENDED: Juvéderm Volux (Allergan)

WINNER: TEOXANE UK Judges commented that Teoxane’s training covers all needs for both a beginner and an advanced injector with one saying, “Excellent training with amazing support from all the team.” HIGHLY COMMENDED: Wigmore Medical COMMENDED: HA-Derma Ltd FINALISTS: • AlumierMD • Cynosure UK Ltd • Lynton Lasers Ltd • SkinCeuticals Training Team • VIVACY LABORATOIRES

FINALISTS: • Custom DOSE (SkinCeuticals) • Lasergen (Endor Technologies distributed by Elénzia)

THE CCR AWARD FOR INDEPENDENT TRAINING PROVIDER

INJECTABLE PRODUCT WINNER: TEOSYAL RHA (TEOXANE UK)

WINNER: ACQUISITION AESTHETICS

Voters praised the range’s dynamic properties, commenting that they gave a natural but effective result, with less complications and great patient satisfaction. HIGHLY COMMENDED: Juvéderm VOLUX (Allergan) COMMENDED: Aliaxin (HA-Derma Ltd) FINALISTS: • DESIRIAL® PLUS (VIVACY LABORATOIRES) • Sunekos (Med-fx) • APTOS Threads (Novus Medical)

Voters said the training was exceptional, delivered by a very knowledgeable and professional team, as well as noting the great hands-on experience and fantastic aftercare supplied. HIGHLY COMMENDED: Avanti Aesthetics Academy COMMENDED: RA Academy FINALISTS: • Cosmetic Courses • Harley Academy Post Graduate Aesthetics Courses • Interface Aesthetics • Learna Ltd • SkinDerma Pro

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RE G I O N A L C LIN IC W IN N ER S BEST CLINIC NORTH ENGLAND THE INTRALINE AWARD FOR BEST CLINIC SOUTH ENGLAND

WINNER: SDS REJUVENATE MEDISPA The clinic, located in the Wirral, received fantastic praise from judges, with one saying, it was, “A very professional, transparent and open clinic who believe in doing things properly and to the highest standard.” HIGHLY COMMENDED: Dr Sobia Medispa COMMENDED: Lumiere Clinic FINALISTS: • Burgess Hyder Dental Group • Cliniva Medispa • MySkyn Clinic Ltd • Skyn Doctor • VL Aesthetics

WINNER: PERFECT SKIN SOLUTIONS The Portsmouth-based clinic received positive reviews from our judges, with one commenting, “Perfect Skin Solutions is a well led and organised clinic focused on both patient care, and safety with a proactive business model!” HIGHLY COMMENDED: Vie Aesthetics COMMENDED: S-Thetics and River Aesthetics

THE CYNOSURE AWARD FOR BEST CLINIC MIDLANDS AND WALES

FINALISTS: • Atelier • Cosmex Clinic • Elite Aesthetics • Health & Aesthetics • Illuminate Skin Clinic • Weston Beauty Clinic Ltd

BEST CLINIC IRELAND WINNER: AIR AESTHETICS WINNER: BEYOND SKIN The judges were seriously impressed with this entry. One commented, “Some really fantastic business practice – proactive and clearly very passionate about their business. Impressive!” HIGHLY COMMENDED: Freyja Medical COMMENDED: Hampton Clinic

Winning this category for the second year in a row, judges said they were very impressed with Beyond Skin’s company protocols, praising their detailed entry that answered each question well. HIGHLY COMMENDED: Elite Aesthetics Clinic COMMENDED: The Laser and Skin Clinic

FINALISTS: • Outline Clinic • Pure Perfection Clinic • So Aesthetics

FINALISTS: • Belfast Skin Clinic • The New You Clinic • Younique Aesthetic Clinic

THE AESTHETIC TECHNOLOGY AWARD FOR BEST CLINIC LONDON

BEST CLINIC SCOTLAND WINNER: DERMAL CLINIC

WINNER: ADONIA MEDICAL CLINIC This is the second time the clinic has won Best Clinic London! Judges commented that the clinic provided an impressive entry, with very clear and logical processes. HIGHLY COMMENDED: Cadogan Clinic COMMENDED: London Professional Aesthetics FINALISTS: • 111 Harley St. • BelleCell • Cavendish Clinic • Dermasurge Clinic • LINIA Skin Clinic

Judges noted that the team was committed to safety with a good support framework, demonstrating patient satisfaction and excellent growth. HIGHLY COMMENDED: Aesthetic Spirit Rejuvenation Clinic COMMENDED: Renu Skin Clinic FINALISTS: • Clinica Medica • Dr Nestor’s Medical Cosmetic Centre • Smile with Kev

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O T H E R C LIN IC W IN N E R S THE RELIFE AWARD FOR BEST NEW CLINIC UK AND IRELAND

THE ALUMIERMD AWARD FOR BEST NON-SURGICAL RESULT

WINNER: HUNAR CLINIC WINNER: MISS JONQUILLE CHANTREY Hunar Clinic, located in Denham, was opened in 2019 by Dr Puneet Gupta and Dr Prerna Mittal. One judge commented that it was, “A very strong entry which shows a lot of ambition and competence from the owners.” HIGHLY COMMENDED: PICO Clinic London COMMENDED: Koha Skin Clinic FINALISTS: • Azthetics • Beautox • Finesse Skin Clinic • NassifMD Medical Spa UK • Younique Aesthetics Skin Clinic Ltd. • Vitalize Clinic

Miss Chantrey’s case focused on profile rebalancing with submandibular lift, with a patient who had suffered previous facial trauma. After the course of treatment, the patient said she had undergone an incredible experience that enhanced her confidence. Judges said the entry demonstrated an excellent result and strong use of standardised images in animation! Before

After

THE CROMA AWARD FOR CLINIC RECEPTION TEAM WINNER: FREYJA MEDICAL Our judges said that Freyja Medical’s entry had evidence of excellent documentation of training and processes, making it a stand-out competitor! HIGHLY COMMENDED: Vie Aesthetics COMMENDED: Illuminate Skin Clinic FINALISTS: • Adonia Medical Clinic • Cliniva Medispa • Dr Nestor’s Medical Cosmetic Centre • Dr Sobia Medispa • Hampton Clinic • Health & Aesthetics • Outline Clinic • Perfect Skin Solutions • Younique Aesthetics Clinic

Before

HIGHLY COMMENDED: Dr MJ Rowland-Warmann COMMENDED: Mary White FINALISTS: • Dr Yusra Al-Mukhtar • Dr Cormac Convery • Dr Tom Cryan • Dr Sunny Dhesi • Dr Tara Francis • Dr Anna Hemming • Dr James Olding

• Dr Tanja Phillips • Dr Poonam Ram • Dr Linea Strachan • Dr Vincent Wong

BEST SURGICAL RESULT WINNER: MRS SABRINA SHAH-DESAI

After

Mrs Shah-Desai showed how she treated a patient with severe festoons. One judge commented, “This surgery is technically difficult to perform but has significantly improved the excess skin of the upper eyelid. The lower eyelid result also produced a significant improvement in the facial aesthetics.” HIGHLY COMMENDED: Mr Daniel Ezra COMMENDED: Mr Tunc Tiryaki FINALISTS: • Mr Mo Akhavani • Mr Yannis Alexandrides • Dr Grant Hamlet • Mr Dirk Kremer • Mr Dan Marsh

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C L I N I C, CO M PA N Y OR ORG A N ISAT ION BEST CLINIC SUPPORT PARTNER / PRODUCT

THE BEYOND BEAUTY AWARD FOR PROFESSIONAL INITIATIVE

WINNER: FVCE WINNER: BCAM EDUCATIONAL FRAMEWORK Excellent feedback on this entry. One judge commented, “The entry had well presented evidence and story from a group that is providing real value to clinics and their clinicians!”

One judge commented that the BCAM Educational Framework was a, “Fantastic educational entry and will be a shining light for the future of aesthetics.”

HIGHLY COMMENDED: Aesthetic Nurse Software COMMENDED: Allergan Spark

HIGHLY COMMENDED: Consulting Room Relaunch Centre COMMENDED: AlumierMD Professional Portal

FINALISTS: • Aesthetic Response • Inspire to Outstand Ltd • Julia Kendrick PR • Mantelpiece PR • Sophie Attwood Communications Ltd • The Tweakments Guide • Web Marketing Clinic

FINALISTS: • Academic Aesthetic Mastermind Group • Allergan Aesthetics Beauty Decoded Podcast (Allergan Aesthetics) • Black Aesthetics Advisory Board • #IAmMe (Dr Vincent Wong) • ‘In The Consulting Room’ by Miss Sherina Balaratnam • The National Medical Weight Loss Programme • The Plastic Fantastic Podcast (Cosmetic Courses) • The Safe Aesthetic Practitioner (SafeAP)

I N D I V I D UA L P R AC T IT ION E R W IN N E R S THE SUMMIT BY RAJ ACQUILLA AWARD FOR RISING STAR OF THE YEAR WINNER: DR ALEXANDER PARYS (DR ALEXANDER JAMES AESTHETICS)

THE GET HARLEY AWARD FOR MEDICAL AESTHETIC PRACTITIONER WINNER: DR ULIANA GOUT (LONDON AESTHETIC MEDICINE)

All of the judges were impressed with Dr Parys’s ambition to enhance awareness of aesthetic complications in A&E departments, by creating an educational programme for A&E medics focusing on recognition diagnosis and initial management.

As president of the British College of Aesthetic Medicine, key opinion leader, course director, author and appraiser, judges commented that Dr Gout demonstrated that she is a consummate professional, and is passionate about educating the aesthetic community.

HIGHLY COMMENDED: Dr Manav Bawa (Time Clinic Medical Aesthetics and Wellness) COMMENDED: Alice Henshaw (Harley Street Injectables)

HIGHLY COMMENDED: Dr Sophie Shotter (Illuminate Skin Clinic) COMMENDED: Miss Sherina Balaratnam (S-Thetics Clinic)

FINALISTS: • Dr Marwa Ali (The Wellness Clinic) • Dr Zahra Fazal (Tweak Facial Aesthetics) • Dr Jemma Gewargis (Aesthetics By Dr Jemma) • Dr Ana (Anahita) Mansouri (Kat & Co Aesthetics) • Dr Helen McIver (Professional Facial Aesthetics) • Dr Aileen McPhillips (Aesthetics by Dr Aileen) • Dr James Olding (Max Aesthetics) • Nina Prisk (Update Aesthetics) • Dr Hannah (Hoda) Ranjbar (L1P Aesthetics) • Dr Elle Reid (Paragon Aesthetics) • Dr Emily Swift (Dr Swift Aesthetics) • Rebecca Taylor (Rebecca Taylor Aesthetics)

FINALISTS: • Dr Nestor Demosthenous (Dr Nestor’s Cosmetic Centre) • Dr Ifeoma Ejikeme (Adonia Medical Clinic) • Dr Anna Hemming (River Aesthetics) • Dr Ioannis Liakas (Vie Aesthetics) • Dr Brian W. McCleary (Integro Aesthetics) • Dr Devang Patel (West Country Dental) • Dr Sobia Syed (Dr Sobia Medispa) • Dr Rekha Tailor (Health & Aesthetics) • Dr Vincent Wong (VinDoc Aesthetics)

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THE INMODE AWARD FOR CONSULTANT SURGEON OF THE YEAR

THE SPRINGPHARM AWARD FOR AESTHETIC NURSE PRACTITIONER

WINNER: MRS SABRINA SHAH-DESAI (PERFECT EYES LTD)

WINNER: MARY WHITE (OUTLINE CLINIC)

In her second win of the night, judges said Mrs Shah-Desai submitted a thoroughly answered application with impressive detail. HIGHLY COMMENDED: Mr Ali Ghanem (The Ghanem Clinic & Cranley Clinic) COMMENDED: Mr Adrian Richards (The Private Clinic)

One judge said, “Mary had a great entry and is a clearly dedicated nurse,” while another praised Mary’s extensive range of treatments and CQC results. HIGHLY COMMENDED: Cheryl Marshall Williams (S-Thetics) COMMENDED: Jaqueline Naeini (Cliniva Medispa)

FINALISTS: • Mr Mo Akhavani (The Plastic Surgery Group) • Mr Sotirios Foutsizoglou (SFMedica) • Mr Dalvi Humzah (P&D Surgery) • Mr Gerard Lambe (Reflect Clinic) • Mr Dan Marsh (The Plastic Surgery Group) • Miss Rachna Murthy (Aesthetic Clinical Training Academy)

FINALISTS: • Sara Cheeney (Pure Perfection Clinic) • Emma Coleman (EMMA COLEMAN SKIN) • Jane Laferla (Laferla Medical Cosmetics) • Claudia McGloin (The New You Clinic) • Lisa Niemier (Clinic Visjeune) • Julie Scott (Facial Aesthetics Ltd) • Lisa Waring (Facetherapy NI) • Susan Young (Young Aesthetics)

OUT STA N DIN G AC HIE V EM E N T Selected by Aesthetics from within the industry, this year’s winner of the Outstanding Achievement Award is Amanda Cameron, co-founder of private label cosmeceuticals supplier 5 Squirrels and aesthetic business consultant. Mandy has been working in the industry for 40 years, and even helped to launch what’s now known as Sculptra in the UK. As well as working for many aesthetic companies, Mandy was also the editor of the Aesthetics journal for six years and helped to host the Awards and organise the Aesthetics Conference & Exhibition on many occasions. Ahead of her retirement later this year, we wanted to show Mandy recognition for all of her hard work over the years in helping to shape the industry as we know it! Read more about her career by heading to p.69

S E E YOU N E X T YEA R ! We thoroughly enjoyed celebrating with you all this year, and once again want to say a huge congratulations to our winners and to all finalists! Don’t forget to tag us on Instagram @aestheticsjournaluk in the photos of you and your team, and we’ll share them on our social media and in the next issue of the Aesthetics journal! The Aesthetics Awards 2022 will take place on Saturday March 12, following the second day of the Aesthetics Conference and Exhibition. Stay tuned for details of how to enter in September – next year you could be featured as one of our winners!

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consider what he believed were the ideal proportions of the human body and face. Vitruvius divided the face into horizontal thirds that are equal in size and volume; a concept taken up by Leonardo da Vinci’s Vitruvian Man, a practice which is still commonplace in today’s aesthetics analysis and treatment planning.8 Finally, another commonly used facial proportions concept is the neoclassical canon which divides the face vertically into fifths, with the ocular width, intra-canthal distance, and nasal width all measuring one-fifth.9 The general attractiveness of both sexes is traditionally thought to be linked to conformity to the aforementioned ratios, symmetry, youthfulness, as well as ‘averageness’ – all features which are thought to convey genetic stability and be a superficial sign of health, and therefore Mr Daniel Ezra and Mr Mohammad Dehabadi desirability in a mate.10 This aspect of male explore the attractiveness of men and what to aesthetics is not too dissimilar to female consider when treating a male aesthetic patient aesthetics, and many practitioners will be well versed in the creation of more symmetry Men currently represent a small, but growing proportion of or youthful appearance for their patients. aesthetic patients. Between 1997 and 2014, there was a 273% However, a reductionist approach to male beauty is not universally increase in the number of cosmetic procedures performed on men, acknowledged, and it is argued that beauty cannot be broken with neurotoxin and dermal fillers being the most common.1 In 2016, down into measurements and ratios. Nevertheless, there are some 1.3 million aesthetic procedures were performed on men in the US, features that are different between genders and which are important representing 8% of all aesthetic procedures performed.2 In Mr Ezra’s considerations in male aesthetics. own practice specialising in periocular aesthetics, he sees many male Men and women have the same facial musculature, but men have patients who comprise 30% of his database. larger muscle mass, often leading to more prominent dynamic facial Despite this increasing demand, limited resources are available to lines as they age.11 The typical male upper face has a flat, straight help practitioners better understand male aesthetic ideals, as well as brow lacking the arch seen in the lateral third of the female eyebrow.12 the best ways to deliver results for these patients in practice. Additionally, the male brow is positioned low along the supraorbital ridge, with a mild brow ptosis considered to give an impression of Male attractiveness power and leadership, whereas a more severe brow ptosis is seen In common with many other species, humans demonstrate significant primarily as a sign of anger.13 In the mid-face and cheek region, men sexual dimorphisms, including differences in facial anatomy, and have less superficial fat than women, giving rise to a relatively flat midtherefore aesthetic ideals between the sexes. The standards of face and less anterior cheek projection, and generally deeper wrinkles beauty vary widely according to cultures, as well as over time, making as they age.14 objective definitions of beauty somewhat illusory. Male attractiveness though, additionally depends on displaying strong Despite this, there have always been efforts to define beauty in signs of gender dimorphism. Dimorphic features which define the male a reductionist manner by using measurements and proportions. face include a broad forehead, prominent brow, broad squared chin, This approach was developed in ancient times, as far back as the and a prominent jawline.15 From an evolutionary perspective, a male Ancient Egyptian civilisation where there is evidence of ‘ideal facial with a strong jaw, chin, and brow is at a relative selective advantage – proportions’ being used in the depictions of the human face.3 these facial skeletal features are thought to provide better protection to A limestone bust of Queen Nefertiti from 1350BC was carved using their eyes and neck during hunting or fighting off a foe or beast.16 grids of equal-sized squares for symmetry, whereas Phidias, a fifth As much as trends, fashions, and cultures may vary over time, one century BC Greek sculptor based his creations on ratios demonstrated could argue that the human primitive amygdala may subliminally by his ‘golden rectangles’.4 These so called ‘divine proportions’ have continue to identify these features as inherently attractive.16 been incorporated into aesthetic models which divide the face into It is no accident that actors depicting prototypic masculine roles such distinct facial units, and research has shown that ‘attractive’ male and as James Bond, or superheroes such as Batman or Superman, always female faces appear to have facial proportions closer to these divine score highly on the aforementioned male dimorphic features. There values compared to ‘non-attractive’ faces.5,6,7 are also more objective studies which demonstrate that while we may Vitruvius, the Roman architect from 75BC, was widely known for have evolved beyond our hunter-gatherer lifestyles, such dimorphic promoting a reductionist approach to what he described as ideal male features still confer a selective advantage in the modern world. buildings. Friezes, columns and capitals were all carefully described For example, male cadets at West Point Military Academy in the US as ideal ratios of proportions. Vitruvius extended this approach to were found to achieve higher military rank if they possessed dominant

Defining Male Beauty

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male facial features,17 and more ‘attractive’ male lawyers are more likely to achieve higher salaries.18 However, it is also clear that ideals of male beauty are constantly evolving with a move away from strength-based features to a more polished, groomed look, together with an increased acceptability for men to pursue an improvement in their appearance.19,20

Treating men Male faces require a fundamentally different aesthetic approach. While many aesthetic practitioners are well versed in the pursuit of symmetry and youthfulness in their female patients, great care needs to be taken when treating male patients so as to preserve, or even enhance male dimorphic features. So, with this in mind, what considerations need to be kept in mind when treating the male aesthetic patient? It begins with marketing The marketing strategy needs to also incorporate relevant signalling and information for male patients. There are many ways in which this can be achieved. At the extreme end is the creation of male-only clinics, or waiting rooms, but at the very least specific marketing material and/or patient education programmes, aimed at making men feel comfortable might be necessary steps. Many clinics and practitioners appear out of step with this need, with much of their marketing and web material identifying only female faces. In our experience, men need to be reassured that they will not be treated in the same fashion as female aesthetic patients, and that preserving their masculine features is at the forefront of the practice ethos. Treating male patients The most common male cosmetic treatment is botulinum toxin type A injections.21 The presence of larger facial muscles often requires higher doses of toxin to achieve the same effects observed in women.22 To avoid the higher risk of potential complications associated with injecting higher volumes of toxin, lower dilutions can be considered. In Mr Ezra’s experience, when treating forehead rhytids in men, the medial and lateral frontalis should be equally treated to avoid feminising the brow by creating a lateral arch. However, it must also be emphasised that treatment of the forehead should proceed with caution as male brows are heavier and lower, meaning that any weakness of the frontalis muscle is more likely to cause symptomatic brow descent. Lateral canthal lines, or crow’s feet, in men often have a more inferior position due to a larger zygomaticus and a broader orbicularis muscle, requiring a more inferior and superficial injection site to address the wrinkles, while avoiding inadvertent treatment of the zygomaticus major which would cause upper lip asymmetry.23 When dealing with wrinkles in the male patient, the goal should not be to eliminate them, but to improve or reduce them, unless the patient expresses a wish for total elimination of these lines. Filler can be used to augment male dimorphic features, such as chin or jawline augmentation which is increasingly popular with male patients wanting to achieve a more masculine look. Another common use of facial fillers in men is to soften deep lines in the glabellar and nasolabial fold regions. Great care needs to be taken when addressing any cheek volume loss as over-filling the male cheek can create a feminine rounded cheek projection. On p.44 you can read more about using collagen-stimulating fillers in men, while on p.48 Dr Souphiyeh Samizadeh provides an overview of treating Asian men, specifically, with injectables. It is worth mentioning

that non-surgical treatments discussed here can and are increasingly used in the treatment of transgender patients to aid in their transition.24 You can read more about this on p.51.

Summary Male engagement with aesthetic treatments has slowly been gathering pace. It would seem that across time and cultures, the prototypical masculine features described here remain the aesthetic ‘ideals’ for male beauty. While each patient is always approached as an individual with their unique aesthetic goals, it is of paramount importance to take great care in preserving or enhancing male dimorphic features when treating male patients. Mr Daniel Ezra is a consultant at Moorfields Eye Hospital in central London, where he is also director of oculoplastic surgery. He runs a private practice based at 152 Harley Street and at Moorfields focusing on periocular and facial aesthetics. Mr Ezra has a special interest in revision surgery after blepharoplasty and managing filler complications. Qual: MA MBBS, MMedED, MD FRCS, FRCOphth, FHEA Mr Mohammad Dehabadi is currently an accident and emergency, and adnexal and oculoplastics Fellow at Moorfields Eye Hospital in London. He has a keen interest in both the functional, and aesthetic aspects of oculoplastics and facial rejuvenation. Qual: MA, MSc, FRCOphth REFERENCES 1. Joshua A. et al, ‘Male Aesthetics: A Review of Facial Anatomy and Pertinent Clinical Implications’, Journal of Drugs in Dermatology, 14.9 (2015), 1029–34. 2. Terrence C. Keaney et al., ‘The Male Aesthetic Patient: Facial Anatomy, Concepts of Attractiveness, and Treatment Patterns’, Journal of Drugs in Dermatology, 17.1 (2018), 19–28. 3. Farhad B åNaini and Daljit S Gill, ‘Facial Aesthetics: 1. Concepts and Canons.’, Dental Update, 35.2 (2008), 102–4, 106–7. 4. M Alam and J S Dover, ‘On Beauty: Evolution, Psychosocial Considerations, and Surgical Enhancement.’, Archives of Dermatology, 137.6 (2001), 795–807. 5. Naseem Ahmad Khan et al., ‘Evaluation of Facial Divine Proportion in North Indian Population.’, Contemporary Clinical Dentistry, 7.3, 366–70. 6. Hans Pancherz et al., ‘Divine Proportions in Attractive and Nonattractive Faces.’, World Journal of Orthodontics, 11.1 (2010), 27–36. 7. Arezoo Jahanbin, et al., Evaluation of the Divine Proportion in the Facial Profile of Young Females.’, Indian Journal of Dental Research: Official Publication of Indian Society for Dental Research, 19.4, 292–96. 8. Farhad B Naini, et al., ‘The Enigma of Facial Beauty: Esthetics, Proportions, Deformity, and Controversy.’, American Journal of Orthodontics and Dentofacial Orthopedics : Official Publication of the American Association of Orthodontists, Its Constituent Societies, and the American Board of Orthodontics, 130.3 (2006), 277–82. 9. R S Sim, J D Smith, and A S Chan, ‘Comparison of the Aesthetic Facial Proportions of Southern Chinese and White Women.’, Archives of Facial Plastic Surgery, 2.2, 113–20. 10. Anthony C Little, Benedict C Jones, and Lisa M DeBruine, ‘Facial Attractiveness: Evolutionary Based Research.’, Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences, 366.1571 (2011), 1638–59. 11. Keaney, Terrence C., et al., ‘The Male Aesthetic Patient: Facial Anatomy, Concepts of Attractiveness, and Treatment Patterns’, Journal of Drugs in Dermatology, 17 (2018), 19–28. 12. M de Maio and B Rzany, The Male Patient in Aesthetic Medicine (New York: Springer, 2009). 13. Kiersten R Coleman and Jean Carruthers, ‘Combination Therapy with BOTOX and Fillers: The New Rejuvenation Paradigm.’, Dermatologic Therapy, 19.3, 177–88. 14. Mauricio de Maio, ‘Ethnic and Gender Considerations in the Use of Facial Injectables: Male Patients.’, Plastic and Reconstructive Surgery, 136.5 Suppl (2015), 40S-43S. 15. Little, Anthony C, Benedict C Jones, and Lisa M DeBruine, ‘Facial Attractiveness: Evolutionary Based Research.’, Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences, 366 (2011), 1638–59 16. Steve Dayan, ‘It’s Not Raining Men’, Modern Aesthetics, MARCH/APRI (2018). 17. Allan Manzur, Julie MAnzur, and Caroline Keating, ‘Military Rank Attainment of a West Point Class: Effects of Cadets’ Physical Features’, American Journal of Sociology, 90.1 (1984), 125–50. 18. Jeff E. Biddle and Daniel S. Hamermesh, ‘Beauty, Productivity, and Discrimination: Lawyers’ Looks and Lucre’, Journal of Labor Economics, 16.1 (1998), 172–20. 19. Abu Saleh Mohammad Sowad, ‘Influences of Emerging Beauty Industry for Men on Construction of Masculinities of Male Students of Dhaka City’, Masculinities and Social Change, 6.1 (2017), 1–16. 20. Abu Saleh Mohammad Sowad, Masculinity and Male Beauty: Changing Perception among the Male Students of University of Dhaka, LAP LAMBERT Academic Publishing, 2010. 21. Aesthetic Plastic Surgery National Databank, ‘Statistics 2020’, 2020 <https://www.youtube.com/yt/ press/statistics.html>. 22. Alastair Carruthers and Jean Carruthers, ‘Prospective, Double-Blind, Randomized, Parallel-Group, Dose-Ranging Study of Botulinum Toxin Type A in Men with Glabellar Rhytids.’, Dermatologic Surgery : Official Publication for American Society for Dermatologic Surgery [et Al.], 31.10 (2005), 1297–1303. 23. Farhadian, Joshua A., Bradley S. Bloom, and Jeremy A. Brauera, ‘Male Aesthetics: A Review of Facial Anatomy and Pertinent Clinical Implications’, Journal of Drugs in Dermatology, 14 (2015), 1029–34 24. Mona Ascha et al., ‘Nonsurgical Management of Facial Masculinization and Feminization.’, Aesthetic Surgery Journal, 39.5 (2019), NP123–37.

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about their concerns, so asking more detailed questions after the introduction will allow you to discover the real reasons for attending and will shed some light on their main concerns. After hearing these, I then take a full medical history and examine the face to see what changes we can establish and how can we translate the patient’s concerns into a series of physical changes that we can then try to resolve with various treatments. Once the consultation is done, information leaflets are provided to the patient with a suggested treatment plan. The patient will have a cooling-off period before they book in for any treatments.

Treatment method and rationale

Treating the Male Mid-face Dr Xavier Goodarzian presents two case studies using collagen-stimulating fillers to restore male mid-face volume Over the last decade aesthetic practitioners have seen increasingly more men come into our aesthetic practices, and for successful outcomes it’s important that we assess and treat them differently to women.1 In my opinion, men tend to have overall similar concerns as women do about ageing, with both genders generally requesting treatment for facial volume loss and sun damage. However men, unlike women, rarely come in and ask to have their faces ‘filled out’, as treatments like dermal fillers may have never crossed their minds. Instead, the way most men explain their concerns is by saying, ‘I look tired all the time’ or ‘I look like I have dark circles under my eyes’. So, by explaining the ageing process, facial volume loss and how dermal fillers can help this problem, we can often offer them a great solution. During the treatment it is of course important to respect the male facial anatomy by keeping the chin and jawline strong and reducing mid-face volume loss while keeping the treatment subtle.

Consultation In my experience, the consultation process is key to understanding the male patient’s concerns. I find men can be a bit more reserved or shy when coming into clinic,

as it’s not easy for a man to walk into a traditionally female-dominated space. Often the men who come into my clinic are unaware that other men have treatments too, so it’s always good to reassure them and perhaps show some male before and afters. Men can also be quite vague when talking

When it comes to restoring facial volume, we are confronted with two options. Do we offer hyaluronic acid (HA) fillers, or do we offer a longer lasting collagen stimulator? Personally, I am happy using either type of product, but I have to admit that I tend to prefer collagen stimulators for general facial volume correction. When there is generalised facial volume loss, I find better results can be achieved with collagen stimulators because they build over time and are longer lasting. This is preferable for male patients, as they generally want something that lasts longer and does not require six-month top ups like HA fillers. Although there are several collagen-stimulating fillers on the market such as Sculptra, Radiesse and Lanluma, I choose to use Ellansé. It is made of carboxymethyl cellulose (CMC) and polycaprolactone (PCL)

Case study 1 A 40-year-old male presented to my clinic, complaining of looking tired after a 15kg weight loss. After examination, I found that there was fat loss from the medial aspect of the mid-face and hollowing of the tear trough and nasolabial area. We decided on a treatment of 4mls of Ellansé, split into two sessions (2mls per session), six weeks apart. A combination of subcutaneous linear threading and deep supraperiosteal depot technique were used with both a cannula and a needle. Deep supraperiosteal injections are best done with a needle right down to the bone surface, while subcutaneous linear threading is best done with a cannula as it reduces the risk of bruising and, in my experience, is much Before After safer than a sharp needle. Three months later, the patient showed great improvement in the midface, correcting the volume deficit in the frontal cheek area and the nasolabial folds. He was very pleased with the result, and continues to come in for Patient before and three months after treatment with 4mls of Ellansé other treatments.

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When there is generalised facial volume loss, better results can be achieved with collagen stimulators because they build over time and are longer lasting microspheres, and initially acts as a dermal filler, however, over a period of three to four months, type one collagen is deposited around the microspheres, which provides a long-lasting filling effect while the CMC gel is gradually absorbed.2-8 Both CMC and PCL have been used extensively in medicine and their safety has been proven over several years. The CMC gel acts as an instant filling agent and, at the same time, as a carrier for the PCL microspheres. It has histologically been proven that the collagen is formed around the PCL spheres is a high-quality type one collagen, which is the type of collagen that we need as we get older.2-8 This product can be used supraperiosteally for deep volume correction, as well as subcutaneously for enhancing skin quality and restoring skin thickness. I am often asked by other practitioners if I am ever worried using this product as it is longer lasting and is not reversible with hyaluronidase. My answer is that most problems can be avoided by using a strict aseptic technique, knowing your anatomy, knowing your patient and, most importantly, knowing and respecting the limits of your own abilities. Hyaluronidase, although very useful at times, has given far too many of us a false sense of security in thinking that,

Before

After

‘If I use a hyaluronic acid filler I can always dissolve it if it goes wrong’. Ellansé can be administered in a single session using all the required number of syringes, which varies greatly depending on the level of volume loss. However, as the swelling increases with the amount of filler you inject, if a lot of product is needed, this swelling is often not tolerated by many, especially men. In my experience, more than three syringes of Ellansé causes some noticeable swelling for up to 48 hours, which men in particular tend to dislike because they don’t want their treatment to be obvious to their friends and family. To avoid this, I tend to split the treatment into sessions to prevent over-treatment, especially as I’m injecting at high quantities. After about six or eight weeks we do notice a good level of change so it gives us an idea of how to correct at the next session. We can always add more but we cannot take the product out like we can with HA fillers, which is why I prefer a gradual approach.

Potential complications Although there is limited evidence of complications from treatment with Ellansé, as with any other injectable product there is a risk of excessive swelling, excessive bruising, prolonged tenderness, prolonged

Case study 2

A 28-year-old male presented to my clinic, concerned about looking tired and with a desire to improve his chin area, which he felt was too narrow for his face shape. On examination, I saw there had been fat loss from the mid-face and a relatively underdeveloped mandible. It was decided that the treatment plan would involve injecting Patient before and three and a half 4mls of Ellansé split into two sessions (2mls months after treatment using 4mls of Ellansé per session), eight weeks apart. Again, a combination of subcutaneous linear threading and deep supraperiosteal depot technique was used with both a cannula and a needle.

oedema, infection, abscess formation, allergic reactions, nodules, granuloma and arterial occlusion with pending necrosis.5 It is important that these potential side effects are communicated clearly to the patient during the consultation and on the consent form, as well as the actions that you would need to take to treat these in the rare chance that they occur.

Aftercare After any dermal filler treatment, it is important to advise the patient to keep the area clean and to avoid touching the face for the next four to six hours. Trying to sleep on their back with their head slightly elevated will help to reduce swelling for the first two days after treatment. For men, I advise avoiding shaving for a day or two after the treatment to avoid complications such as infections. I would also advise against rigorous exercise for a few days.

Conclusion Men have similar concerns as women with the ageing process, however I find they can be vague when it comes to explaining their specific issues. Facial volume loss is a common concern amongst both genders but men often prefer subtle and long-lasting results, so I feel collagen-stimulating fillers are a good option for this issue. Side effects may occur with any type of filler or collagen stimulator and it is important to be able to deal with them appropriately when needed. Dr Xavier Goodarzian is the medical director and co-owner of the national award-winning Xavier G. Clinic in Southampton. He is a lecturer and trainer at major conferences throughout the UK and abroad, and the past lead trainer for Innomed Training. Dr Goodarzian is a member of the Royal College of General Practitioners and has postgraduate degrees in clinical dermatology and cosmetic medicine. Qual: MD(Hons), MRCGP, DipClinDerm, PGCertCosMed, MBCAM REFERENCES 1. Terrence Keaney, The Increasing Needs of the Male, The Dermatologist, 2013. 2. Philipp Stein, The biological basis for Sculptra-induced augmentation, 2014. 3. Nicolau P, Marijnissen-Hofste J., Neocollagenesis after injection of polycaprolactone based dermal filler in a rabbit, European Journal of Aesthetic Medicine and Dermatology, 2013. 4. Ellansé whitepaper W113.05, Data on File 5. Christen Mo, Ellansé safety report, 2016, Data on File 6. Moers-Carpi MM, Sherwood S., Polycaprolactone for the correction of nasolabial folds: a 24-month prospective randomised controlled clinical trial, Dermatologic Surgery, 2013. 7. M. Khattar, RADIESSE VS ELLANSE, Facial volumising with Ellansé: 1st Ellansé users meeting, 2012. 8. Gritzalaz K., Preliminary results in using a new dermal filler based on polycaprolactone, European Journal of Aesthetic Medicine and Dermatology, 2011.

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

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References 1 Prager W et al. J Drugs Dermatol. 2017; 16(4): 351-357 2 Micheels P et al. J Clin Aesth Derm. 2015; 8(3): 28-34 3 Kerscher M et al. Clin Cosm Inv Dermatol. 2017;10:239-247

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Understanding Asian Men

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The increased demand for cosmetic procedures among East Asian men has been linked to various factors. These included availability, normalisation and acceptance in society, enhanced self-confidence for both personal and professional life, workplace competitiveness, social and emotional competence, attractiveness, and youthfulness.6-10 Male attitudes towards cosmetic surgery are affected by low body image satisfaction, which is impacted by watching television and the use of social media platforms.11,12 However, it has also been reported that social media and television increase the acceptance of surgical and non-surgical procedures for both men and women of Asian origin to enhance or alter their physical appearance. Furthermore, there is an increasingly popular male beauty culture that includes male beauty products, cosmetic and skincare lines aimed at men, and male modelling agencies, which could also be having an impact.13,14

Attractiveness of East Asian men

The impact of male facial masculinity on the perception of personality and attractiveness Dr Souphiyeh Samizadeh outlines East Asian has been studied extensively in the context of male facial features and presents the current evolutionary biology and reproductive strategy. Masculine facial features include a large jaw, popular treatments for this cohort prominent brow ridges, prominent chin and According to a report conducted in 2018 by the American Society cheekbones, and a longer lower face.15-17 Other attractive features of Plastic Surgeons, men had a total of 1.3 million cosmetic on men included clear skin, tattoos and tidy eyebrows, an obtuse procedures (1.1 million minimally invasive and 215,000 surgical). jawline, a thin face, a round chin, and an elevated nose bridge. Since 2017, 1.2 million Asian Americans have had procedures, Generally speaking, masculine facial features have been positively highlighting a 1% increase. The top three minimally-invasive associated with various attributes, including testosterone levels, procedures included botulinum toxin type A injections, laser hair immunocompetence, health, and partner choices;15-18 however, 1 removal and microdermabrasion. it has also been reported that women usually prefer these facial This article will explore the demand for cosmetic procedures amongst features for short-term relationships and more feminine male faces East Asian men, the aesthetic ideals for this cohort and some practical are preferrable for long-term relationships.18 In addition to perceived tips for treatment using injectables. dominance, hypermasculine faces are often associated with ‘coldness’ or ‘dishonesty’.19 Increasing demand for cosmetic procedures Amongst females, masculine facial features appear to be differentially In China, men account for 15% of its sizeable aesthetic medicine valued depending on such factors as the phase of the menstrual cycle/ industry.2 The number of male patients who request cosmetic hormone levels (the hormonal theory of facial attractiveness) and the procedures, particularly non-surgical procedures, are increasing mating strategy.20,21 A study in 2010 reported that across 30 countries, 3-5 internationally. This necessitates an understanding of their independent of wealth and mating strategies, the preference for motivations, expectations and the psychosocial science when it masculinity increased as the population’s national health decreased.22 comes to male aesthetics. Previous studies published on the ideals of beauty among Chinese individuals and aesthetic practitioners have reported that both men and women preferred an obtuse jawline for both sexes and a round narrow chin.23,24 These features represent a more feminine male face (Figure 1). An unpublished online survey involving 643 Chinese participants showed that the majority of female participants’ preferences for male faces was influenced by current famous media or social media influencers.25 The female participants preferred a less prominent jawline in Chinese men, while Chinese men and women rated more feminine, Chinese and Caucasian male faces as most attractive and hypermasculine faces as the least attractive.

The skeletal structure of the East Asian face results in a wide bizygomatic and bigonial width, which leads to a ‘square’ lower face and a wider, shorter face in comparison to Western skulls

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

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Top tips for success with injectables Treating East Asian faces requires a thorough understanding of the differences in ideals of beauty and beliefs, possible differences in anatomy and of the existing skeletal and soft tissue morphology. For example, different injection techniques may be required for botulinum toxin A and dermal fillers. In my experience, the frown line and forehead pattern are usually different from the most frequently recognised patterns taught and observed in Caucasians, hence require modified injection technique, dosage and pattern. Presentation of ‘bunny lines’ is very common in East Asians due to the nasal anatomy and morphology, and the interaction of the relevant muscles with the glabellar complex muscles. My top tips when treating East Asian men: 1. Ask the patient their beauty ideals and facial shape/features they desire. They may be able to show their expectations using photos. 2. When treating the jawline, consider that East Asian males do not often like a dominant square jaw angle and chin. 3. Consider all facial features for balance and harmony. 4. Ask regarding the patient’s belief in facial physiognomy as this may impact treatment planning. 5. Do not just jump straight into injectables – clear blemishfree skin is highly regarded by these individuals. 6. Reduction of size of masseters using botulinum toxin is common but warn patients regarding changes in facial shape and bite force post injection. 7. Gain extensive expertise before performing non-surgical rhinoplasty (a popular request). This is important for all ethnicities. In this population, the nasal morphology and amount of dermal filler required for modification of the nose require further training and risk assessment. 8. Take note when injecting botulinum neurotoxin and dermal fillers that arched eyebrows are not usually desirable. In addition, over-treatment of the forehead area (which may equate to a normal treatment dosage for a Caucasian man’s forehead), could result in eyebrow ptosis and hence further lowering of the eyelids and vision compromise. 9. Consider that a smooth, mildly convex forehead is usually desirable, so take note when using dermal fillers for the forehead area. Accurate and artistic placement of dermal fillers can help balance and harmony of the face. 10. Do not over-treat and over-fill (especially in the jawline).

Although many participants confirmed that their preference for facial attractiveness was influenced by current famous characters from film and social media, they did not necessarily want to look this way. It has been previously reported that British and Japanese women prefer a more feminised male face.24 On the other hand, other research reported that homosexual men usually prefer masculine male faces and data suggests the attractiveness judgement of same-sex faces by homosexuals was not the same as those of heterosexual individuals of the opposite sex.26 Another study examined preferences for masculine features in faces, bodies, voices, and personality characteristics among homosexual men in China and reported preferences for masculinity among all four domains.23 The preference and quest for clear skin has its roots in Chinese

Figure 1: The left shows an example of an East Asian man with more obtuse jawline, representing a more feminine male face. The right is an example of an East Asian male with a wide bizygomatic and bigonial width, causing a ‘square’ lower face and a wider, shorter face compared to Western Caucasian faces.

culture and tradition. A fair, clear complexion has been associated with wealth and affluence.10,11 This explains the large demand for skincare and laser devices to improve the skin’s appearance. The skeletal structure of the East Asian face results in a wide bizygomatic and bigonial width, which leads to a ‘square’ lower face and a wider, shorter face in comparison to Western skulls27-29 The overly prominent zygomatic arches in the East Asian facial structure, along with the delicate central face topography (a small nose with a retruded forehead and chin), results in an imbalance and makes the face appear ‘overly rough, aggressive, and masculine’.30,31 Therefore, this has led to an increased demand by men for facial contouring surgery.31,32 Furthermore, non-surgical procedures are very popular in Asia. Taking into account the above findings, facial structure and morphology of East Asian men, the focus of injectable treatment is on facial contouring and anterior projection of the face.

Summary This information is significant to aesthetic practitioners, not only in China and East Asia, but internationally as the Chinese market is part of the new increasing middle-class that is slowly becoming wealthier. These individuals either immigrate or travel abroad to seek cosmetic procedures. Aesthetic practitioners can increase their understanding of ideals within facial beauty among different nations, perceptions of attractiveness, psychological factors associated with the perception, and trends/changes over time. As such, the development of tailored communication, psychological skills training and treatment plans are needed to achieve results. Dr Souphiyeh Samizadeh is a visiting associate professor, the founder of the Great British Academy of Aesthetic Medicine, and the clinical director of Revivify London clinic. She is an honorary clinical teacher at King’s College London, visiting clinical fellow at University College London. She practices and teaches in the UK and in China. Dr Samizadeh has multiple published peer-reviewed papers, frequently presents at national and international conferences and trains aesthetic doctors, dermatologists and surgeons worldwide. Qual: BDS, BSc, MJDF, RCS(Eng)PGCert (Clin Edu), MSc(Aesthetic Medicine), FHEA

VIEW THE REFERENCES ONLINE! WWW.AESTHETICSJOURNAL.COM

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

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Both patients were counselled regarding the need for an adequate safety support network of family and friends, to be aware of potential downtime after treatment, and to watch out and report untoward incidents following the procedures. Naturally, it was essential to know their skincare Dr Vincent Wong addresses the aesthetic needs regimen. In female-to-male patients, it is normal to encounter frequent breakouts as a result of of patients who are gender transitioning using a enlarged pores and oily skin.4 Thus, most patients on androgen supplementation may require acnecombination treatment approach specific therapy. There are approximately 650,000 individuals in the UK, roughly To address the possibility of pain during the procedure, the patients 1% of the population, who identify as gender nonconforming were advised that the fillers contained lidocaine, and topical or gender diverse.1 Despite these numbers and the growing anaesthesia was applied where appropriate. The threads were mainstream representation of transgender and nonbinary individuals, inserted under local anaesthesia. Both patients were also advised there is paucity of literature exploring non-surgical aesthetic regarding the safety of the products used and were familiarised techniques2 for facial transformation of transgender patients and, on the breadth of clinical experience of the practitioner. They were more importantly, articles that discuss combination modalities. I informed of the longevity of results (e.g. 18 months for the threads) have sought to evaluate treatment outcomes in two patients, one and the reversibility of the procedures. transitioning from female-to-male and one from male-to-female, with sequential deep-to-superficial aesthetic techniques. Treatment Relatively larger quantities of fillers than usual are necessary to Secondary sexual characteristics explain the differences between achieve reshaping of soft tissue volume in the face to achieve male and female faces. The mature male face tends to have a higher masculinisation/feminisation. Essentially, the goal is to build on hairline, more prominent supraorbital ridges, thinner cheeks and a areas that are lacking in volume or projection (e.g. feminine jawline larger mandible (i.e. characterised as ‘squarer’) than the female face. to masculine jawline or masculine cheeks to feminine cheeks). Other traits, such as the presence of facial hair and the distribution of Lastly, the customary approach to multimodal aesthetic therapies is facial fat, also determine ‘masculinity’ according to socially determined from the deep to superficial layers of facial tissue; hence, fillers first gender ideals. The ideal female face is characterised as oval with a (periosteal), followed by threads (subcutaneous) and then peels smooth forehead, a pinched nose, and small, pointed chin. Laterally, (superficial skin). the female forehead is sloped unlike the male forehead, which exhibits For both cases, I used RELIFE Definisse soft-tissue fillers,6 frontal bossing.3 bioabsorbable suspension threads made from poly(L-lactide-coε-caprolactone), along with resurfacing peels from the Definisse Patient overviews Peel Program.7 The choice of products and the combinations used The first case is a 40-year-old female-to-male patient (Patient A) who are likely to affect clinical outcomes, so it is important to select sought to have a more ‘masculine’ jawline and face shape. He had the appropriate product and product combinations that you have not had any previous aesthetic procedures done and was unaware extensive experience in. of the benefits of non-surgical aesthetics in achieving his treatment goals. The patient has been on masculinising hormone therapy for Patient A eight years with excellent tolerability to the regimen and sought to For Patient A in the first session, I used Definisse Core where a have finalisation of his facial transition. total of 5ml of product was injected into each jawline and 3ml The second patient is a 22-year-old male-to-female patient (Patient was injected into the chin, using a 27 gauge needle to achieve B). She had been on oestrogen for three years and sought help to a squarer frame. In order to allow for the healing of swelling and achieve a more feminine (or ‘heart-shaped’) face. She expressed the Before After desire to have more prominent cheekbones. While Patient B had never had any aesthetic procedures in the past, she was keen to be treated, having seen before and after images of my patients on social media. As she has only been on hormone therapy for three years, I advised her to undergo gradual transformation and softening of her features as her facial structure continues to feminise with oestrogen.

Case Study: Transgender Patients

Consultation During my first session with each patient, I made sure to stress that they should have realistic expectations of the treatment outcomes, and explained the need for treating conservatively, rather than overtreating. It was essential to rule out clinically significant distress or impairment in social, occupational, or other important areas of functioning from body dysmorphic disorder or gender dysphoria. A few publications outline routine clinical questions that can be used to recognise and understand body dysmorphic symptoms.4

Figure 1: Patient A before and after eight weeks of treatment using RELIFE Definisse fillers and threads

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

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bruising from the filler infiltration, a two-week rest period is recommended before the next procedure. After these two weeks, I proceeded with Definisse Threads using the Lateral Reshaping (LR) technique. This technique is used to reshape the facial frame by inserting the threads from the tip of the sideburns to the nasolabial fold by lifting the superficial fat compartments of the cheeks upward and sideward. The second needle repositions the superficial fat compartments along the jawline upward and laterally.8 Skin peeling was then accomplished on the third session, which after two more weeks to allow for the healing of the fibrotic tissue surrounding the threads. Definisse classic peel, comprising salicylic acid, pyruvic acid, and retinoic acid was applied to address the excess sebum formation on the patient’s skin (Figure 1). Patient B For Patient B, I used 1.5ml of Definisse Restore injected on the lateral forehead by fanning with a 23 gauge cannula, and small periosteal boluses in the middle forehead in order to reduce supraorbital bossing and to achieve a more convex forehead. Care should be taken when administering in the mid forehead by infiltrating deep and aspirating before injecting the filler. In the nose, 0.3ml was injected to achieve a more pinched/thinner look, which is considered to be feminine.9 Before

After

Figure 2: Patient B before and after eight weeks of treatment using RELIFE Definisse fillers and threads

Definisse Core filler was used in each cheek (1.5ml injected to each side) and in the chin (2ml used). After two weeks, Definisse Threads were placed using the Malar Reshaping (MR) technique and the Oval Reshaping – Vertical (OR-V) technique in order to achieve a more oval, feminine facial shape.8 The MR technique lifts the superficial fat compartments of the malar area upward and laterally, while the OR-V technique lifts the mid and lower-facial superficial fat compartments upward – together, these techniques achieve a three-dimensional superolateral oval reshaping to feminise the face. The Definisse lightening peel, which is a formulation with N-undecyl-10-enoyl-L-phenylalanine (Sepiwhite) and N-undecylenoyl phenylalanine, an alpha-melanocyte-stimulating hormone (MSH) receptor antagonist to reduce hyperpigmentation after eight weeks,1 was used to even out the skin tone (Figure 2). Both patients expressed satisfaction with the results and were informed of the total improvement expected after a certain amount of time.

Side effects/complications Local site reactions, hypersensitivity, infections and errors in placement are rare and reversible complications of these modalities. Vascular compromise can be presumed if there is sharp pain, blanching over a distal area or if there is necrosis, which are considered to be medical emergencies.10 However, the only side effects documented for both patients were swelling and bruising. These were managed using conservative methods such as application of ice packs, elevation of the head when sleeping on the first night and restricting movement and/or manipulation of the treated parts of the face.

Expanding your treatment offering Practitioners of medical aesthetics should be aware of the intricacies associated with the treatment of gender nonconforming patients. All of us should be equipped with adequate knowledge regarding the benefits and challenges inherent in each of the modalities used individually and in combination to achieve individualised aesthetic goals. Discuss your treatment plan openly and professionally with your transitioning patients to allay any apprehension they may have and to ensure that they have their full faith in you as their treating physician. Dr Vincent Wong is an aesthetic practitioner and founder of VinDoc Aesthetics. He has a Bachelor of Science in Medicine from the University of St Andrews and a Bachelor of Medicine and Surgery from the University of Aberdeen. Dr Wong has won a number of awards, is actively involved in research and has more than 35 scientific publications to his name. Qual: BSc Medical Science (First Class Honours), MBChB REFERENCES 1. Bissett, Donald L, Larry R Robinson, Patricia S Raleigh, Kukizo Miyamoto, Tomohiro Hakozaki, Jim Li, and others, ‘Reduction in the Appearance of Facial Hyperpigmentation by Topical N-Undecyl-10Enoyl-L-Phenylalanine and Its Combination with Niacinamide.’, Journal of Cosmetic Dermatology, 8 (2009), 260–66 <https://doi.org/10.1111/j.1473-2165.2009.00470.x> 2. Gender Identity Research and Education Society, ‘Individual Help’ <https://www.gires.org.uk/whatwe-do/individual-help/> 3. Little, Anthony C, Benedict C Jones and Lisa M DeBruine, ‘Facial Attractiveness: Evolutionary Based Research.’, Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences, 366 (2011), 1638–59 <https://doi.org/10.1098/rstb.2010.0404> 4. Moon, HJ, S Fundaro, CL Goh, KC Hau, P Paz-Lao and G Salti, ‘Expert Consensus on the Combined Use of Botulinum Toxin, Subcutaneous Filler and Suspension Threads for Facial Rejuvenation’, Journal of Cutaneous and Aesthetic Surgery, In press (2021). 5. Motosko, CC, GA Zakhem, MK Pomeranz and A Hazen, ‘Acne: A Side-Effect of Masculinizing Hormonal Therapy in Transgender Patients.’, The British Journal of Dermatology, 180 (2019), 26–30 <https://doi.org/10.1111/bjd.17083> 6. Phillips, Katharine A, ‘Body Dysmorphic Disorder: Recognizing and Treating Imagined Ugliness’, World Psychiatry : Official Journal of the World Psychiatric Association (WPA), 3 (2004), 12–17 <https://pubmed.ncbi.nlm.nih.gov/16633443> 7. Salti, Giovanni and Salvatore Piero Fundarò, ‘Evaluation of the Rheologic and Physicochemical Properties of a Novel Hyaluronic Acid Filler Range with EXcellent Three-Dimensional Reticulation (XTRTM) Technology’, Polymers, 12 (2020), 1644 <https://doi.org/10.3390/polym12081644> 8. Tailor, Rekha, ‘Treating Transgender Patients’, Aesthetics, 6 (2019), 53–55. 9. Telang, Parag Shashank, ‘Facial Feminization Surgery: A Review of 220 Consecutive Patients’, Indian Journal of Plastic Surgery : Official Publication of the Association of Plastic Surgeons of India, 53 (2020), 244–53 <https://doi.org/10.1055/s-0040-1716440> 10. Wong, Vincent, ‘Hanging by a Thread: Choosing the Right Thread for the Right Patient’, Journal of Dermatology & Cosmetology, 1 (2017), 86–88 <https://doi.org/10.15406/jdc.2017.01.00021>

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

Advertorial Thermage FLX

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collagen6 and elastin in the tissues of the body. Collagen is a natural protein in our body’s skin which gives it its firmness, however once we enter our late 20s and early 30s, our collagen production starts to decline every year and this includes the body. That’s why treatments like radiofrequency which promote collagen are becoming incredibly popular – especially in areas such as knees, stomach and arms”, says Dr Alexandrides.

What is Thermage FLX®?

Considering Radiofrequency for Body Contouring Dr Yannis Alexandrides presents his advice for successfully contouring the body with radiofrequency The demand for body contouring is rapidly increasing,1 and interest in non-invasive approaches has also grown.2 Patient demand for non-surgical skin tightening with little downtime and preservation of the epidermis has increased by 600% in the past 15 years.3 “We’re in a digital age now where patients are much more image focused and this, of course, extends to the body too,” says plastic surgeon and founder of 111 Harley St, Dr Yannis Alexandrides. “To ensure a fully holistic approach, it is absolutely vital to ensure effective treatments for the body are available within the clinic.” According to Dr Alexandrides, patients are much more knowledgeable too, “We are also working with a much more

informed population as patients are now able to research potential treatments.”

Radiofrequency as a treatment for body contouring While traditionally ablative and nonablative lasers were the primary devices to improve skin laxity non-surgically, by injuring the epidermis and causing dermal collagen remodelling and second skin tightening, these treatments came with associated risks such as burns and irreversible pigmentation changes.4 “RF is an incredibly effective, non-invasive treatment which uses a fluctuating current of electricity to create heat,5 which gets delivered at specific temperatures to the tissues in the body. This controlled heat helps stimulate new

Thermage FLX® advanced features: 25% faster treatments* compared to the previous Thermage CPT version: the new Total Tip 4.0 provides greater surface area coverage than the Total Tip 3.0. AccuREP™ Technology: automatic calibration allows for optimised energy delivery, to provide consistent output. Patient comfort:10 The system also features a new multi-directional vibrating hand-piece** to help enhance patient comfort for body and face, making the treatment much more comfortable than the previous version. Single handpiece: consistent treatment from head to toe without the need to interchange any handpieces. Touchscreen navigation: updated interface brings a modern look and functionality.

Aesthetics | June 2021

Thermage FLX® is different to anything else available in the marketplace at the moment because it’s the only monopolar RF treatment that requires a single treatment as opposed to a full course. The procedure offers significant clinical improvement7 with few potential side effects and little downtime.8 In addition, Thermage® has demonstrated a good safety profile.9 The treatment can be used on all skin types3 and tones and can be done all year round. Thermage® works across the entire face, including forehead, eyes, nasolabial folds, jaw line, jowls and the area under the chin, as well as on the arms, buttocks, tummy and thighs. REFERENCES * www.111harleystreet.com ** R&D Report *** The vibrating function is not available when using the Eye Tip 0.25 cm2 . 1. Medical Insight report Energy - Based-Body Shaping & Skin Tightening – August 2020 2. International Survey on Aesthetic/Cosmetic - 2019 ISAPS. 3. Dayan E, Burns AJ, Rohrich RJ, Theodorou S. The Use of Radiofrequency in Aesthetic Surgery. Plast Reconstr Surg Glob Open. 2020 Aug 17;8(8):e2861. 4. Atiyeh BS, Dibo SA. Nonsurgical nonablative treatment of aging skin: radiofrequency technologies between aggressive marketing and evidence-based efficacy. Aesthetic Plast Surg. 2009;33:283–294. 5. Elsaie ML. Cutaneous remodeling and photorejuvenation using radiofrequency devices. Indian J Dermatol. 2009;54:201. 6. B. D Zelickson, et al. Histological and ultrastructural evaluation of the effects of a radiofrequency-based non-ablative dermal remodelling device: a pilot study. Arch Dermatol. 2004 Feb;140(2):204-9. 7. R. Fitzpatrick et al. Multicenter study of non-invasive radiofrequency for periorbital tissue tightening. Lasers Surg Med. 2003;33(4):232-42. 8. E. Finzi, A. Spangler. Multipass vector (mpave) technique with non ablative radio frequency to treat facial and neck laxity. Dermatol Surg. 2005 Aug;31(8Pt1):916-22. 9. M. Fritz and al. Radiofrequency treatment for middle and lower face. Arch Facial Plast Surg. Nov-Dec 2004;6(6):370-3. 10. Solta Medical, 2009. Report on Gazelle Clinical Study 09-100-GA-T‘Validation of the Thermage 3.0cm2 STC and DC Frame Tips, Comfort Software and Vibration Hand piece on the Face and Thighs’ (#09-019ER). Bothell.,

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A summary of the latest clinical studies Title: Reduction of Telogen Rate and Increase of Hair Density in Androgenetic Alopecia: Results of a Study in Men Authors: Welzel J, et al. Published: Journal of Cosmetic Dermatology, May 2021 Keywords: Androgenetic Alopecia, Hair Treatment, Telogen Rate Abstract: Considerable parts of the global population are affected by androgenetic alopecia (AGA). The efficacy of a foam containing nicotinic acid hexyl ester, polyphenols, zinc, glycine, and caffeine in comparison with a vehicle control foam was assessed in a double-blind vehicle-controlled study in men with AGA over six months. 62 men with AGA were assigned either to the active ingredients (verum) or the vehicle group. They applied the products twice daily on affected scalp areas over six months. Automated phototrichograms were obtained at baseline, after three and six months. A clinical rating by a dermatologist and by subjects themselves was documented using standardized questionnaires. The reduction of the telogen rate from T0 to T6 was stronger in the verum group compared to the vehicle group. The reduction was significant from T0 to T3 and T6 in the verum group, but in the vehicle group only from T0 to T3, not to T6. Increased hair density was noticed in both groups at all time points, but the change from T0 to T6 did not differ significantly between the groups. Cosmetic acceptance of the foam and its application was good in both groups. Slight reddening and burning after application of verum in six cases was due to the presence of hexyl nicotinate. The study demonstrated a reduction of the telogen rate by a cosmetic foam in men affected by AGA, indicating a benefit for cosmetic intervention against male pattern hair loss. Title: Home-Based Devices in Dermatology: A Systematic Review of Safety and Efficacy Authors: Cohen M, et al. Published: Archives of Dermatological Research, May 2021 Keywords: Alopecia, Hair removal, Home Devices, Psoriasis Abstract: There is increasing demand for home-based devices for the treatment of dermatologic conditions and cosmesis. Commercially available devices include intense pulsed light, laser diodes, radiofrequency, light-emitting diodes, and ultraviolet B phototherapy. The objective of this report is to evaluate the current evidence regarding the efficacy and safety of home-based devices for the treatment of skin conditions. Original research articles that investigated the efficacy and safety of home-based devices for dermatologic use were included. Clinical recommendations were made based on the quality of the existing literature. After review, 37 clinical trials were included – 19 were randomized controlled trials, 16 were case series, and two were non-randomized controlled trials. From our analysis, we recommend the home-based use of intense pulsed light for hair removal, laser diodes for androgenic alopecia, low power radiofrequency for rhytides and wrinkles, and light-emitting diodes for acne vulgaris. Trials investigating ultraviolet B phototherapy for psoriasis revealed mixed evidence for home treatments compared to clinic treatments. All devices had favourable safety profiles with few significant adverse events.

Title: New Classification of Late and Delayed Complications after Dermal Filler: Localized or Generalized? Authors: Ryu HJ, et al. Published: Journal of Cosmetic and Laser Therapy, May 2021 Keywords: Delayed Complications, Fillers, Injectables Abstract: As filler injections have become very common procedures worldwide, the number of complications has increased. However, there is a lack of systematised studies and precise classification of late and delayed complications. This study aimed to suggest new and reliable classifications and to characterise the clinical manifestations of late and delayed complications after filler injections. This study analysed patients and suggested a new classification of delayed adverse effects related to filler injection. Patients were classified into two types according to their clinical presentation: Type I (localized) or Type II (generalized). 25 patients were evaluated during a clinically active adverse event suspected to be related to fillers. The most common injected filler substance was hyaluronic acid (68.8%). 76% of the patients were classified with localized complications. In the generalized group, systemic symptoms were common, the treatment response was poor, and fewer patients showed complete remission than in the localized group. We propose a simple new classification method for late and delayed complications after dermal filler: localized and generalized. We expect that this new classification could help provide appropriate treatment and predict patient prognosis. Title: Vitamin C Mesotherapy Versus Topical Application for Gingival Hyperpigmentation Authors: El-Mofty M, et al. Published: Clinical Oral Investigations, May 2021 Keywords: Ascorbic Acid, Depigmentation, Intramucosal Abstract: Vitamin C/Ascorbic acid inhibits tyrosinase enzyme causing melanin biosynthesis suppression. This study aimed to compare the efficacy of intra-mucosal injection (mesotherapy) with topical gel as non-surgical methods for managing gingival hyperpigmentation. 20 healthy non-smokers with mild to severe hyperpigmented gingiva were randomly assigned mesotherapy (G1); intra-mucosal injection of ascorbic acid (one week/three weeks); or gel (G2), topical ascorbic acid gel (one/day/three months). Pigmentation index (DOPI), patient satisfaction, as well as histological analysis were performed at baseline and after six months. Comparison between groups and changes by time were analysed using Mann-Whitney and Friedman’s tests. The median DOPI decreased after one month in G1 compared with non-significant change in G2. No pain experienced during or after treatment in both groups. G1 patients showed significantly higher satisfaction with treatment than G2. Mean area fraction of melanin forming cells was significantly reduced in both groups after six months, but the effect size was higher in G1 than in G2. Vitamin C mesotherapy showed better and early effect than topical gel, and both techniques were not painful and aesthetically satisfying in managing gingival hyperpigmentation.

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

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have had a treatment done, as they believe it can make them look vain. This can make it difficult for men to book in a consultation to discuss their concerns with a practitioner. The COVID-19 pandemic has resulted in video consultations becoming the norm to keep aesthetic businesses going and, interestingly, we have found that video consultations have actually made men more comfortable in having a consultation in the first place. As the world reopens, we will be continuing video consultations for those who are uncomfortable coming in initially, and we recommend that other practitioners ensure that this option is clearly stated on their website, social media and booking page.

Talking to male patients

Consulting Male Patients Dr Teuta Berisha and Mr Benji Dhillon outline how to ensure male patients are comfortable when seeking aesthetic treatments Men are beginning to find it easier to approach practitioners about their facial concerns and in turn, receive treatments which will help them look and feel more confident. Whilst more men are seeking treatments such as dermal fillers, botulinum toxin, hair restoration and body contouring procedures, the majority of procedures continue to be performed on women. A 2019 report carried out by the British Association of Aesthetic Plastic Surgeons highlighted that men only make up 8% of the total number of cosmetic procedures performed in the UK.1 The majority of practitioners continue to have a predominately female patient base, meaning many of them will have less experience in male consultations than they do in female. But with an expected continuing increase in men seeking treatments, practitioners must be carrying out tailored and appropriate consultations for these patients. This article will aim to give clinicians some practical tips and things to consider when they are consulting men.

Conflicts men face when discussing treatments If you spoke to a group of women, you will likely find that most of them know of someone who has had an aesthetic intervention. This has led to more conversations amongst women surrounding the treatments they have had and their experiences. However, in our experience, this is the opposite for men. Men are less likely to be open with others about their treatments, and this can result in them being less tolerant of longer periods of downtime. However, many may not be aware that a lot of the non-surgical procedures available are minimally invasive and have a quick recovery time, so more male-focused education is required. Unfortunately, for men especially, there is still a stigma surrounding these treatments and, consequently, discussions on this topic amongst men tend to be limited. Fewer conversations about this means many men continue to be unaware of the vast range of treatment options that are available and the natural results that can be achieved. Many fear looking like they’ve had ‘work done’ which is further propagated by any overfilled and unnatural results that they may see on females and in the mainstream media. This work is easily noticed and if men see examples of these results, they fear being treated similarly. Another conflict for men is the worry of someone seeing them in a clinic or finding out they

There are subtle differences when consulting men versus women. Usually, we find women are keen to know as much about the variety of options available to them. This therefore requires time to explore what their priorities are and map out and explain the varying treatment modalities. Men, on the other hand, usually prefer a succinct appointment and for the practitioner to identify the treatment or plan they should go forward with. They are unlikely to proceed with multiple sessions of any treatment and prefer to have the minimum number of visits possible. Of course, this has to balance with ensuring they understand what is available to them and managing expectations, which is usually to do with expecting ‘quick’ results. In our experience, men, tend to respond to direct and often honest explanations of what is and what isn’t achievable. Practitioners must also be prepared for the majority of men to not follow aftercare results, as we have found this to be a particular challenge. A good consultation must be conducted before a patient has any medical aesthetic treatment. Specifically, for men, the consultation should be utilised as an opportunity to showcase examples of male patients you have treated. Using these visual aids will help to make it clear to the patient that the treatment you provide is bespoke to the individual and they are not going to be treated in the same way as female patients. Men may worry about others knowing that they have had a treatment done, therefore, these before and after photos will aid in showing the impressive and subtle naturallooking results you can achieve. When showing examples of your work, patients viewing them can worry that you will similarly

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

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Top tips on giving male patients the best experience 1. Show male patients that you will treat them differently to females and will masculinise rather than feminise male faces (if this is indeed their requests). Do this by spending time during the consultation to educate them on the differences between male and female ideals and also on the ageing process. 2. Carefully consider the marketing in your practice and ensure it isn’t tailored towards women only. Aim to include male marketing images in the clinic and have a gender-neutral clinic and website colour scheme. This will help make men feel less out of place in your practice. 3. Offer a range of treatments that are popular amongst men, such as platelet-rich plasma for hair restoration and cryolipolysis for body contouring, to attract more male patients to your clinic. This can also lead to more crossreferrals within the clinic.

IS HERE Get your hands on the new aesthetics magazine for your patients

use their photos in the future. It is worth explaining that you place the utmost importance on confidentiality and will only ever share their photos if you have their consent as per the General Data Protection Regulations.2 Patients need to know and feel that you understand the goal of their treatment and education is very important. By educating patients on the ageing process and the different aesthetic ideals in men versus women, they will be able to trust that you understand their goals and have confidence that you will treat them appropriately.

Purchase for £2 per copy from us and retail for £5.99 from your clinic MALE FOCUS

Summary

MALE FOCUS

REFERENCES 1. BAAPS Annual Audit Results, 2020. <https://baaps.org.uk/baaps_annual_audit_results_.aspx> 2. Official Journal of the European Union, REGULATION (EU) 2016/679 OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL of 27 April 2016, <http://eur-lex.europa.eu/legalcontent/EN/ TXT/PDF/?uri=CELEX:32016R0679&from=EN>

serum concentration antioxidant VITAMIN C: a high n skin’s natural regeneratio for the daytime to aid process and as necessary SPF: apply in the morning sun damage, to protect skin from throughout the day n, lines and wrinkles which can lead to pigmentatio

appearance.” don’t with men is that they He says that the thing will want. While women usually know what they chatted to their friends have done their research, ing of the options and have a good understand “I just to come in simply saying, available, men tend ” want to look a bit better. they will also often say that Men (and some women) after ‘don’t have time’ to look want a ‘quick fix’ and of his Dhillon whips out one their skin. For this, Dr best analogies! wanting to anyone to say He explains, “I’ll always teeth go to the dentist for dodge skincare – you’ll don’t you if but know that whitening or veneers, the best home you’ll never get brush your teeth at looking teeth is the same as results. Brushing your – no matter what aesthetic after your skin at home be as the end result will never treatment you have, is lacking!” good if your skin quality

used in that cleanser can be worth emphasising Dr Dhillon says, “It’s than a minute to slap products will take less the shower and other evening routines too a man’s morning and risk of on, so it’s not disrupting year can prevent the SPF throughout the helps much. Of course, using realise how much it but many men don’t developing skin cancer, benefits of using it can talking about the health so too, ageing with really help.” advises selecting one C product, Dr Dhillon other When choosing a vitamin For women, on the on for maximum effect. with 20% concentrati 10-15%. d recommen hand, he would usually Dr Dhillon says his next

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of to reduce the chance MOISTUR ISERS: dryness or oiliness throughout developing extreme acne to conditions such as the day, which can lead

MALE SKIN IS DIFFERENT TO FEMALE SKIN

collagen at night to increase RETINOID S: used , keeping the skin to ‘turn over’ production and to help close to the surface younger, healthier cells dry skin out and as shaving can really “Most men want a moisturiser Dr Dhillon, adding, “What men don’t explains one make it feel quite tight,” their skin shine, so borrowing makes that are plenty want is a moisturiser undesired effect! There male and can have anINSIGHT differences between from a woman or friend EXCLUSIVE ation is the Obagi There are three key one available – my recommend to Dr Dhillon. Number of matte moisturisers Alto Defense Serum, female skin, according or the skinbetter science thicker dermis, meaning Hydrate Moisturiser moisturiser! is that men have a much needed up as a vitamin C and as of products will be which is great as it doubles a bit of an effort, as well higher concentrations retinoid can seem like he explains. advises, night-time a skin, Dhillon the Dr Adding from. to penetrate so many types to choose treat men tend to have stronger being confusing with The second is that ingredient proven to are the only skincare can result in lines and long term.” however, “Retinoids facial muscles, which face. to better skin in the founder of them will lead than in a woman’s think about wrinkles and using lot deeperrecommend all derived Alice Hart-Davis is the to those just starting to wrinkles being aWhat – anaonline Guidefor number of ingredients, would you term The Tweakments hairier! Dr Dhillon notes treatment – and doRetinoid your is the umbrella everything concentration. tweakments? from And finally, it’s usually resource dedicated to sharing you want thing, is that what itis between them is their a good hard aboutthis in the UK that it is difference to know about aesthetics. Think long ageing, toand you need aesthetic medicine are: from vitamin A. The they little regulation around that when it comes Organisations Reputable applications research. There is so particularly the Beyond Beauty the skin, safe (read to strongest topical any to you to keep yourself You can’t presume thatFrom weakest website).to as facial hair canupstabilise on mytend safe’ section men or the ‘staying the practitioner on p.69 meaning it’s available, nor that area, retinyl acetate) is safe just because around the mouth particular treatment likea white coat. they’re wearing palmitate, retinyl propionate, the mouth competent because it isaround lines • Retinol esters (retinyl not get barcodeoffering men face is treatments? many people should start having • Retinol there a particular age women do. TheIschallenge up to you as the individual. looking completely treatment theiris skin keep tohaving you start signs of ageing – • Retinyl Retinoate Whenbest procedures when the what products are obvious. Most people start considering – start becoming more volume or age spots because wrinkles, loss of facial refreshed and healthy! 20s to try treatments,

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Alice’s Exclusive Advice

the skin, and injectable ultrasound for tightening radiofrequency or skin quality. treatments that boost the signs of ageing were all about erasing Also, back then, tweakments for enhancing cheeks, they are almost as popular on older faces. Now, are for what you could the under-35s as they jawlines and lips among Think of all the Hollywood ’ in the 40-plus group. call ‘age-management as they did in their 30s. as good in their 50s actresses who look

the secret you ready to unlock skin? to beautiful glowing to the next level Take your skincare designed for you! with a facial that is the original 6-stage, The WOW facial is facial which uses onalised interested in or hyper-pers chatting to lots of people of From your experience improve how many don’t tell could you estimate active ingredient s to having aesthetic treatment, various to myissues. their friends/family? Even people who skin ofcome of people. the majoritya multitude

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else you’re thinking start with skincare, whatever like It’s vital! You’ve got to with active ingredients Using effective skincare it glowing of doing to your face. of your skin and get will improve the quality vitamin C and retinol this (called Start with Skincare a whole book about with health. I’ve written about skincare, and there’s masses of information having believe it or not), and There’s little point in work, on my website. looks how specific ingredients the fabric of your face, procedures if your skin, every day non-surgical aesthetic to wearing sunscreen ® also vital to commit light. dull and lifeless. It’s your skin from ultraviolet of winter) to protect (yes, even in the depths

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regenerative aesthetic by the whole area of Yes! I am fascinated our own blood to regenerate plasma taken from body, such medicine. For example, from one part of the or using fat extracted stem the skin or the hair, in the face, or taking thighs, to rebuild volume It sounds as the tummy or the results of fat transfer. that fat to improve the cells extracted from future. sure it’s the way of the a bit out there, but I’m .com

MORNING Nu-Derm my face with Obagi ♦ I start by cleansing oil, is great for eliminating Gentle Cleanser – this on the skin dirt and other debris

WOMEN CAN HELP TOO! on board with skincare? So how do men get recommend that Dr Dhillon says, “I would about male skin starts talking more W E L L N E S S everyone P S Y C H O L O G Y not feminine to take care health and how it’s helps everyone look of skin. Skincare simply more confident – little and and feel healthier skin quality can make wins through enhancing game and give them men feel on top of their succeed in both their the boost needed to life.” professional and personal ds women encourage He also recommen of their own skincare men to trial a little bit in easy it is to use once so they can see how Dhillon advises women a routine! Then, Dr their life to their next to invite the men in , aesthetic practitioner appointment with their practitioner will be noting, “I’m sure your help options and it may happy to talk through life to hear all the facts for the man in your professional.” and figures from a convincing? “Tell them And if they still need as such celebrities male about other men or B Beckham and Michael Ryan Reynolds, David of their skin – they don’t Jordan who take care Dr Dhillon says, just look great by accident!” his own skincare routine explaining that sharing them the best way he gets with male patients is his top tips for us here! on board. He details

Obagi-C would follow this with ♦ After summer, I as I'll usually have a Rx Clarifying Serum – this product contains 'pigmentation hangover' darks is proven to reduce hydroquinone which tone for a more even skin spots and melasma with Obagi Hydrate ♦ Next, I moisturise hydration all day Moisturiser which provides the sun protection – at ♦ Finally, I add some Advanced moment I’m using Teoxane which is tinted so will Perfecting Shield SPF30 n until it goes away cover up my pigmentatio

EVENING ♦ I cleanse with Obagi before alternating:

a practitioner?

even a friend, that’s fab, but recommendation from I could kit If you can get a personal of regulation, you or Because of the lack then, do your homework. set up in business injecting fillers and needles and legal ourselves out with dermal terrifying. There is no legally. And yes, that’s who is: people tomorrow, perfectly you want someone to inject others. I’d say register of people qualified Medically qualified aesthetic procedures Well-trained in specific – we all get better with in doing those procedures Has a lot of experience

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The Tweakments Guide: Fresher Face (£14.95) Start The Tweakments Guide: with Skincare (£9.19) Find out more via thetweakmentsguide.com and follow Alice on Instagram IG: @alicehartdavis

website

following treatment?

you experience provide – they should always practitioner immediately is Get in touch with your them pictures of what contact number – send find a you with an out-of-hours can’t or won’t help you, the problem. If they Reputable bothering you and explain it quickly. Again, the who can help, and do can point you in reputable practitioner section on my website or the ‘staying safe’ to find a Organisations on p.69 problem, you may need it turns out to be a serious the right direction. If solicitor. medical negligence

What should you do if

hugely She has published two successful books:

GRONOW INTERVIEW: CHLOÉ

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wrinkles Professional-C ⇒ The next night Obagi Polish + Mask, which Microdermabrasion or the SkinCeuticals helps smooth the skin, which is great for the Hydrating B5 Mask, is the central heating winter months when drying out your skin

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Gentle Cleanser again

Retinol 1.0 which fights ⇒ One-night Obagi such as lines and against signs of ageing

for?

Read up on you about your face. about what is bothering discuss Think long and hard good practitioner and then go and see a really would suggest, the options available, – and ask what they that you want to change go home with them what it is it might make. Then how much of a difference with why, what it costs, and in for anything – in line more before you book should be and think about it some medical practitioners regulatory bodies, all guidance from their standard. ‘cooling-off’ period as offering you a two week

How should you choose

What are your thoughts aesthetic treatments?

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Is there anything new

DR DHILLON'S SKINCARE ROUTINE

anyone in their I’m reluctant to encourage they are without any don’t realise how gorgeous toxins can most people that age that wrinkle-relaxing It has been proven for further enhancement. lines becoming entrenched, faces to prevent frown We be used on younger the idea of having lines. think we should demonise instance, yet I don’t our feelings. use our faces to express need to be able to

cosmetic I’d say it’s still about learning how events, which are all Tweakments Clinic leading aesthetic practitioners, of benefit and meeting kill treatments can be or ‘My daughters would private, secret mission!’ they often say, ‘This is a would change – which wish these attitudes me if they knew!’ I so honest discussion about have a more open and might, if we could only can do. For many people, they are and what they look as they tweakments, what managing how they are a useful way of our teeth, cosmetic procedures our hair, and whiten acceptable to colour age. It has become the whole idea of having judgement around much so still about it. is yet there shy away from talking our faces that people something ‘done’ to

tweakments and stigma around How is the shame – who It really winds me up! of beautiful people when this whole group ever going to go away deny that they do anything than most – totally the celeb have more procedures of interviews where count of the number of the sort? I’ve lost weird, so I never did but it made me look says, ‘I tried Botox once, good looks are because that their suspiciously it again…’ and claims face cream. We know yoga/use some magic they’ve gone vegan/do with their image, from a huge amount of help imagine that these people get artists. Why do we trainers and makeup personal stylists to spoke up about what procedures? If they cosmetic doing about having they’re above has recently done as Gwyneth Paltrow up they do and why – massively help to open with toxin – it would do. her frown lines treated and what they can around tweakments the whole conversation

for You

about retinoids, their We can talk a lot more should be used safely, benefits and how they issue! The important but that’s for a future can for now is that they thing to bear in mind so they’re not usually dry and peel the skin, skin those with sensitive for ded recommen eczema. conditions such as want “I’d say if a man doesn’t Dr Dhillon advises, should start with a light to risk peeling, they night. other to 1% every retinol of between 0.5 like this would be more Note that for women This is generally thinner. 0.1-0.2% as their skin to every night as increased be can eventually it for best results.” the skin learns to tolerate must who uses a retinoid He adds that anyone morning as they also use SPF the following sensitive to light and, can make skin extremely damage. subsequently, sun

GRONOW WORDS: CHLOÉ

Mr Benji Dhillon is the cosmetic director and owner of Define Clinic in Beaconsfield. Dr Dhillon trained in plastic surgery and worked for Allergan on its clinical trials, following which he switched to fulltime aesthetic practice. He is part of the international faculty for Teoxane.

Trinity I like to call The Holy to start off with is what “The basics I tell men Dhillon. This includes: of Skincare,” says Dr wash the morning and night to CLEANSER : used for fresh, hydrated skin face and remove impurities

more been seeing more and “Since lockdown, I’ve their to think further about men who are starting lot of Dhillon, explaining, “A skin health,” says Dr travelling for work are people who were previously on their and have more time now based at home They might help their skin. hands to research what calls video on themselves are also regularly viewing so are they might look tired, and are noticing that overall they can improve their thinking about how

EXCLUSIVE INSIGHT

Dr Teuta Berisha is an aesthetic practitioner and dental surgeon. She trained as a dental surgeon at King’s College London with a special interest in dental and facial aesthetics. Dr Berisha now splits her time between working at Define Clinic in Beaconsfield alongside Dr Benji Dhillon and working at a private dental practice in Kingston. Qual: BDS

Y MAN THE PRODUCTS EVER SHOULD HAVE…

MEN WANT GREAT SKIN TOO

Although fewer men seek treatment, clinicians need to be confident in how to consult these patients. It is imperative that your clinic and consultation will make your male patients feel comfortable and they should leave feeling educated on the aesthetic treatments that are available to them. This will help to dispel misinformation surrounding these treatments and aid in breaking the stigma associated with men seeking aesthetic interventions.

• Retinaldehyde retinoate (HPR) • Hydroxypinacolone known as retin-A or • Retinoic acid (also tretinoin)

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

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

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

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Creating a Positive Culture for Success Business consultant Stuart Rose shares advice on setting goals and establishing purpose to inspire your team Gandhi said of a nation that its culture resided in the hearts and minds of its people. As such, culture is intangible. Yet how is it that this intangible thing is so powerful that it unites groups of people to achieve amazing results, (and makes them feel good along the way)? Success in business is so often discussed in the context of conflict and we only have to look at past wars where apparently insurmountable military might has been defeated. North America in Vietnam and the Russian invasion of Afghanistan were classic examples where vastly superior firepower was not enough. Why? Because the most potent weapon lay deep within the hearts and minds of the defending nations’ people. A profound belief in what they are doing – an unshakeable sense of purpose. Belief in purpose (mission) is arguably the single most powerful thing that a business can forge. Accompany this with a set of values and overlay it with an inspiring vision and the stage is set for a consistent set of behaviours. It is these behaviours that become the observable culture of a business – of the way we do things around here. It’s well-established that a good culture promotes profitable business growth and staff wellbeing. But if it’s that obvious why isn’t everyone doing it? The reality is that, in our busy worlds, people are focused on near-term operational issues, (the day-job), and this can distract us from focusing on the important things, because they happen to not be urgent.

The worth of culture To fully understand how powerful culture is, it is helpful to employ an analogy. Cast your mind back to genetics and the genotype: phenotype relationship. The genotype is the invisible coding for a set of proteins that determine the function and appearance of so many biological systems and manifestations – our phenotype. Just as when our DNA becomes aberrant, either through inherited gene defects or through faulty repair, the physical manifestation can be profound. A healthy genotype gives rise to a successful phenotype.1 Without getting too Darwinian, the concept of culture is the same. The mix of beliefs, values and goals, (genotype), combine to make us behave a certain way, (phenotype). This analogy gives rise to the concept of Foundational Culture – the bedrock of all that becomes manifest in a business. Healthcare professionals know that the best way to manage disease is through addressing the underlying cause rather than treating symptoms. The same is true of culture – investing time in understanding the elements (diagnosing) and then nurturing them (treatment) makes the same sense as practising medicine itself. And to a private medical practitioner who is running a business, the sense becomes more obvious when you consider the impact good culture has on business performance.

Over the last two decades the concept of employee engagement has grown in popularity and credibility. A key publication over 20 years ago into the relationship between fulfilment and productivity noted that employee satisfaction and, more importantly, employee commitment to the company, directly affect sales increase. It was also noted that it affects sales through improved customer loyalty and improved staff attendance.2 Building on this work, a highly validated workplace survey exists which quantifies the impact of what is called ‘sustainable engagement’. The results, drawn from global employee databases of close to 150,000 respondents, are compelling.3 Companies whose cultures are strong have employees who feel emotionally engaged and are willing to go the extra mile, have the right tools for the job and score well on emotional and physical wellbeing. These employees typically deliver three times more operating profit than those with low engagement scores. They also take 6.5 fewer days off a year, (per employee), and are 41% less likely to leave their job.3 Translating this to a small clinic with few staff is sobering – and exciting! An unstable culture with disengaged staff has some obvious symptoms. It is hard to attract the candidates that really excite you and, on the occasions when you can land them, they don’t stay. The net effect is that you, as the clinic owner or business manager have more work on your plate backfilling the vacant role. On average it takes eight months to get a new hire in place and operationally effective, costing you between one and three times the job holders’ basic salary.4 Staff turnover begets more turnover, compounding the problem. And how much time do you personally invest in recruitment? Each time you lose a good staff member that time becomes an opportunity cost, robbing the business of your expertise in the things that only you can do well. The effect on your business becomes diluting and exhausting. The great news is that understanding and implementing a great culture is actually quite simple and, like eating an elephant, best done in parts! Let’s take a look at the foundational building blocks that comprise culture.

On a mission First, mission and purpose are one and the same. Big businesses often have a mission statement, but the use of ‘purpose’ is becoming increasingly mainstream because it is more literal and self-explanatory. In its simplest sense it is the raison d’etre or

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

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values such as safety, compassion and care are all good examples. But do make sure that your values sit well with your mission and vision. If it feels right, it probably is!

Size matters – doesn’t it?

Figure 1: Illustration of the invisible elements of Foundational Culture, (akin to genotype), which form the basis of an organisation’s visible culture and behaviours, (akin to phenotype)

‘reason for being’ for any business. The purpose of a business is strongly aligned to beliefs. As we grow, we form beliefs based on a blend of facts and opinions. Beliefs are strongly held and so where a mission aligns to an individual’s beliefs there is a natural sense of belonging. A study into what attracted people to a job showed that a decade ago the key attractant was salary and benefits, (culture didn’t even feature back then). Now mission and culture combined are most influential.5 Having a sense of purpose in our work and lives also boosts our mental health, which is an important consideration as clinics emerge from the pandemic shutdown.6 A systematic analysis shows that having meaning (purpose) in our daily work is significantly beneficial in terms of work engagement, commitment, job satisfaction, life satisfaction, life meaning and general health.7 The great news is that defining your purpose isn’t difficult. Investing just half a day of work with all of your staff is enough. The golden rules with a Mission Statement are to keep it succinct (one to three sentences and less than 100 words), and to capture three key elements: • What you do / offer • Who your business serves • Why your company exists Take a look online at some examples to get the hang of it. Many of the big companies have them on their websites. For example Zoom’s is: make video communications frictionless and secure.

20:20 vision Sometimes referred to as a strategic goal, the vision of a business, (specifically from the leader), is where they see the business

in the long-term. This needs to strike the balance between being realistic, (therefore achievable), and aspirational, (so that employees are excited by that destination). Zoom’s vision is: Video communications empowering people to accomplish more. But that’s a big company – what might an aesthetic clinic’s look like? It’s important to remember that it doesn’t need to be rocketscience or overly complicated. Something like: • To be the number one provider of aesthetic services to frontline staff in South West England; or • To be recognised as the go-to destination for aesthetic safety and care What is important is that everyone in the business can understand and believe in the vision so that they can apply their daily work toward supporting it.

Value proposition The final building block of foundational culture is values. These are closely linked to, and influenced by, beliefs and can be seen as a set of standards by which a person evaluates the world. If, for example, a person held the belief that all people are equal, and everyone should be treated fairly, then they may have personal values along the lines of equity, integrity and fairness. Anything that is incongruent to these values, (and therefore to their beliefs), would feel wrong. Zoom’s company values are: Care about: Community, Customers, Company, Teammates & Selves. Typically values for all organisations are things that we all feel some alignment to and, unlike the mission and vision these can be more generic, so don’t worry if your values are similar to some other clinics. In the world of aesthetic medicine

If you think that culture is exclusively the domain of big corporates think again. Culture is always there – its presence is not a choice. Your choice is making it what you want it to be. So, the first thing to be clear on is that your clinic, however small, WILL have a culture. The question is whether it is as good, strong and healthy as it could be. Secondly, scale has nothing to do with culture. Just think about your own family and compare it to others. Small units can still have deep-rooted cultures that are quite different. Paying attention to a culture, nurturing it and the people within makes business sense. Ultimately it will save you time and money. And because your staff are more engaged, they become more effective at their work, they engage your patients and improve their loyalty, thereby improving profitability and the reputation spreads, making your clinic an aspirational place to both work and have treatment. The rub, if there is one? It takes time to invest in culture, but the time invested up front pays huge dividends downstream. If your long-term plan is to exit with a trade sale your chances of doing so are much higher if your business is profitable. It will be much more likely to be profitable if you have stable, engaged and productive employees. Since trade sales are typically based upon factors including a multiple of EBIT (profitability), the time invested up front is worth it. Culture works – can you afford not to be investing in it now? Stuart Rose is an independent consultant with 35 years’ experience in pharmaceuticals, in a variety of commercial and leadership roles. Latterly, he spent 13 years as managing director for Merz in the UK and Ireland, and has created MiViVa Ltd to help private aesthetic practitioners create winning cultures and strategies.

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It’s important to note that franchising is not just for those new to owning a business. The challenges to businesses across the UK have never been more acutely exposed than now, in what might be termed a ‘post pandemic world’. Many business owners will be looking for new opportunities and re-evaluating their own position after the hardship brought about by this protracted period of lockdown. With more support such as that outlined above, locally based aesthetic businesses could benefit from rebranding their own clinic to that of a reputable high-profile brand. In this situation, the business would remain under the same ownership, but with the advantage of the franchisor’s brand profile and access to expanded business opportunities enabling the franchisee to build upon the hard work that has already taken place.

The franchise structure

Joining a Franchise Franchising professional Mark Lemmon explains the benefits becoming part of a franchise can bring your business Individuals planning to start a business often ask me to explain the merits of franchising. My answer is the same every time: as a business model, a franchise providing the backing of a big brand can be a viable option for all aesthetic businesses. Here I will explain the benefits of franchising, and how it can offer huge opportunities for those operating in the industry.

The benefits of joining a franchise So why join a franchise? Well, there are numerous advantages for business owners. The first of which is simply that joining a franchise network doesn’t carry the same risks (or fears) associated with going at it alone. This is because the franchisor has a proven business model in the industry that will help the franchisee to avoid the common pitfalls of running a business, thereby affording it a greater chance of success. I readily accept that franchising is not a suitable route for everyone, but when you consider the high failure rate of all new

business ventures started in good times and bad it is worthy of consideration. Figures show that 50% of new businesses fail within the first five years of trading, while 95% of franchise brands succeed.1 As a general rule, sourcing business finance for a start-up is easier for franchisees because banks, lending institutions and private investors are more disposed to invest in a business with a recognisable and reputable brand, proven track record, successful operating systems and an established customer base.2 Franchisors will also usually offer training schemes, sales and financial management support, access to suppliers and other business contacts and will provide advice and guidance on advertising, marketing and PR, all of which may well be included in the price of the franchise fee (although you should always check this). These factors are also very helpful for medical professionals, who might not be well-versed in the business side of running a business.

I recommend business owners considering the franchising business model seek the following structure from a franchisor having carefully evaluated its reputation, business ethics and core values. This is of paramount importance in the aesthetics specialty. Guidance in site selection Business planning and assessing the financial viability of a location is key when preparing to start a business and is often a big cause of problems once opened. Franchisors have proven experience of building a business viability model that can be applied to any town and location supported by information on the demand for the services that can be offered in that area. Before any new business operation is opened, each area’s risk can be minimised through this use of experience often learnt over many decades. The territory is part of any standard franchise agreement, and the size of that territory will be fairly determined by size, demographics and density of population.3 Given the considerable investment a franchise represents, it should be clear if a protected territory is part of any franchise agreement, which may vary in size due to the density of population. That ‘territory’ will reflect the geographical area that is available to the franchisee and with it the right demographics and population to support the goals of the business. Tailored training plans Training is a key feature of any franchise agreement, but of course some franchisers might offer better training than others, so it’s important to look into this before committing.

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

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Is it the right model for you?

Working with a long-established clinic franchise means that a franchisee can take advantage of the company's long-standing relationships Franchisors often have rigid and detailed expectations of standards to ensure that not only all operational processes and routines become second nature, but that service levels for all patients match their standard. Training can be individually tailored, but the focus is always on the consistent delivery of the brand values and set standards. Training in aesthetics would cover daily operational management, patient management and the specific training of each practitioner involved in providing treatments, to ensure that the same levels of industry knowledge and high standards of treatment delivery are replicated by the franchisees.

support, and social media posts. It is also useful if the franchisee has access to a marketing team that knows the industry and also has a proven track record. My advice is to always look for a company that provides this high level of support.

Business equipment and suppliers Working with a long-established clinic franchise means that a franchisee can take advantage of the company’s long-standing relationships with the leading suppliers in the industry, who deliver the latest equipment, treatments and advances in aesthetics to the franchisee.

How to find the perfect franchise

Management and software Many franchisors will have pre-established relationships with software companies, and others may have brought a team of software and content staff in-house to produce bespoke software that covers their specific needs. As part of the franchise opportunity, the franchisee will also get access to this software, which can be a huge benefit to a new business. This software could handle all the sales leads that come through, bookings, and diary management, patient photos and notes, stock management and elements of HR, all in one simple package. Marketing and PR Brand support with advertising, social media and PR is always a hot topic for any business. It’s useful to check that all franchisees have a dedicated page on the main website, an agreed email marketing campaign, PR

Referral systems You should check to see if your franchiser offers referral systems. Being part of a wider group can be beneficial when having to refer patients, for example if the franchisees are unable to offer more advanced aesthetics treatments or require assistance with complications management.

The search for potential franchise businesses usually starts online. In most situations, the search itself should be undertaken by preferred industry sector and should take into account the kind of business the interested party wants to establish. Making a decision on what type of franchise should depend upon experience of the potential franchisee, and marrying that up with the right franchisor which means taking a close look at the company’s reputation and credentials. Particularly for aesthetics, individuals wishing to administer cosmetic treatments should ensure that the company endorses trained and qualified medical professionals. I advise extensive company searches to establish if the franchising company’s business is in line with your own aspirations and standards. The key factors in making your decision should be professional standards, reputation, innovation and ethical standards – all of these should fit with the potential franchisee’s own criteria. Any potential franchisee can of course add to their own research by looking at Companies House,4 where they can verify the ownership and directors of a company along with their length of trading and trading history.

I have the view that franchising is the most dynamic model for business growth in the world, yet it may not be a good fit for all. Some people prefer the autonomy of running their own business, and with it, the freedom to make every decision and mould the business how they see fit. Franchisees must work to brand guidelines and to a proven recipe for success, so careful thought should be given before opting for this business model. However, joining a franchise comes with many benefits and allows the business owner to operate under the banner of an already established, recognisable and trusted business with a proven track record. In fact, many new business owners are not experienced in launching a brand and would be challenged by the task of working through the labyrinth of choices and decision making, whereas an established brand with a structure and individuals who are familiar with each step can ease the way while offering a guiding hand to avoid the pitfalls that await the unaware. It is vital to spend time researching whether this is the right path for you, and looking into what brand you want to be a part of, carefully assessing whether it aligns with your own values. Disclosure: Mark Lemmon is currently working with Harley Street Skin as part of its national franchise rollout. Mark Lemmon has worked in franchising for more than 25 years as CEO of a well-known financial services business and managing director of a fitness/ gym brand. During this time, he has overseen the opening of more than 250 franchised units. Lemmon has since worked with and advised a wide spectrum of brands across numerous industry sectors. He is currently responsible for the launch of Harley Street Skin’s national expansion via a franchise rollout. REFERENCES 1. Durham City Incubator, 2019, Top Six Reasons Businesses Fail, <https://dcincubator.co.uk/blog/60-of-new-businesses-fail-in-thefirst-3-years-heres-why/.> 2. British Business Bank, How to Fund Your Franchice, <https:// www.startuploans.co.uk/business-advice/how-to-fund-yourfranchise/> 3. Prokil, 2019, Franchise Territory Defined, < https://www. pointfranchise.co.uk/articles/franchise-territory-defined-1291/> 4. GOV.UK, Companies House, <https://www.gov.uk/ government/organisations/companies-house>

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

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“The challenge for me was to be at the forefront of a new and exciting specialty” Mandy Cameron details how she went from NHS nurse to winner of the Outstanding Achievement Award in Medical Aesthetics Born in Bristol, Mandy Cameron was a keen sports and tennis player until the age of 16, when a family tragedy changed her intended career path. She says, “My father passing away definitely steered me into the world of medicine, and after I finished school, I went into nursing. I moved to London to train at St Thomas’ Hospital, and although it was a very hard decision to leave my mother I don’t regret it because I had three amazing years and met some lifelong friends.” After completing her training, Cameron recalls that she had intended to travel and work in the US, but you needed a midwifery qualification to do so. She adds, “This resulted in me heading back to Bristol to qualify as a midwife. I enjoyed it so much that I never got to the US and 10 years later I was still there delivering babies!” In 1986 Cameron made the decision to leave nursing and join the pharmaceutical industry, working as a sales representative and manager for Glaxo. “Not only was it great training for me, but it’s also where I met my husband!” she says, adding, “A few years later in 1989 I entered into the aesthetics industry, which was just in its infancy. I wanted a new sales challenge, and I’d seen a job advert for a nurse with sales experience – I just thought, that’s me!” Two weeks later, Cameron was on a jumbo jet heading for San Francisco to be trained in the first dermal fillers – collagen by Collagen Corporation. Prior to this she had heard little about the world of aesthetic medicine, but was enthusiastic about the opportunity. She notes, “The challenge for me was to be at the forefront of a new and exciting specialty. There was no botulinum toxin in those days and collagen was the only injectable available, so it was a very, very different world! I spent 10 years with the same company and loved every minute of it, watching the

evolution and growth of a new entity.” After her time with Collagen Corporation, Cameron helped to launch what is now known as Sculptra to the UK market. She recalls, “I was always looking for innovation and new opportunities, so my next venture was to be employed by pharmaceutical company Aventis (later Sanofi-Aventis) to develop and launch Sculptra. It was a very exciting time, not only to bring new technology to the market but to also have the opportunity to introduce UK pharma to the world of medical aesthetics – that was quite a journey and I met so many incredible people along the way.” After working for several more US companies, and working with hundreds of practitioners in the industry, Cameron met Chris Edmonds who had just acquired Cosmetic News – now known as the Aesthetics journal! She recalls, “Edmonds asked me to help with the editing of the journal and the education of his team. I jumped at the opportunity! For six years I was very privileged to hold the role of Editor, and I absolutely loved it! Working for the journal enabled me to learn about new technology, keep in touch with all my colleagues, provide a platform for education, work on the ACE conference agenda and present at the Aesthetics Awards – it was a very rewarding time.” Cameron left the journal in 2019 and has since focused on skincare company 5 Squirrels, which she has co-run with Gary Conroy since 2014. Although she notes that being a partner in a skincare company was not something she had ever envisaged for herself, Cameron is thankful she was able to have the opportunity. She recollects, “To have worked with Gary creating 5 Squirrels and enabling clinics to launch their own brands has been truly revolutionary. We have learnt a great deal together over the last few years and I look forward to

watching it continue to grow after I take a step back and retire later this year.” Last month, Aesthetics presented Cameron with this year’s esteemed Aesthetics Award for Outstanding Achievement in Medical Aesthetics. On her win, she commented, “I was stunned and shocked! There are so many amazing people in this industry who are all so deserving, but I’m immensely proud. It feels as though it isn’t just for me, but for everyone that has played a part in my aesthetics journey!” On what advice she would give to anyone starting out in the specialty, she comments, “I would say keep learning and never become complacent. It has become such a competitive industry that it really is becoming more difficult to shine, so just keep working as hard as you can to constantly improve. Grab every opportunity with both hands and embrace it even if you think it’s going to be a challenge!”

What aspects of the industry do you enjoy the most? The fact that you’re always meeting new people, and then being able to watch them grow and be successful! What treatment has impressed you? There have been so many, but it has to be fillers! They are so versatile and, in the correct hands, transformative. What has been a memorable day in your career? In 1995 we launched a breast implant that the MHRA decided to withdraw from the market, and my managers decided I was the person to front the crisis management team – leaving me to tackle all the news channels! Dealing with this was actually a great experience.

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

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The Last Word Mr James Olding argues why NHS trainees should not be deterred from entering aesthetics and how it’s possible to combine it with their specialist training Working as an NHS doctor, dentist or nurse brings its unique rewards and challenges. A career in facial aesthetics may take any number of paths, but the rewards and challenges can be just as great. So why do so many NHS health professionals view our specialty as a zero-sum game, feeling like if they were to delve in, they must sacrifice success in one area to achieve it in another? I am here to debunk the myth that successful progression through NHS specialist training, be that as a doctor, dentist or nurse, is dependent on downplaying your aesthetics achievements. In the NHS, I am a specialist registrar in oral and maxillofacial surgery, this year becoming dual qualified in both medicine and dentistry. In the aesthetics industry, I am the founder and director of the OFQUAL-regulated and accredited, Aesthetics Awards finalist training academy Interface Aesthetics, as well as being a cosmetic injector with a large patient base. Across my roles in clinical practice and training, I hear the concerns that practitioners of all backgrounds have about work in aesthetics and how this could affect appraisals, revalidation and NHS recruitment processes.

at appraisals and national recruitment interviews. More concerningly, I knew of outright bans on trainees of certain specialties in certain deaneries on practising nonsurgical aesthetics. Despite this backdrop, I decided to proceed with caution, and to my delight discovered a passion for nonsurgical aesthetics that has enriched both my personal and professional life. Negative views of aesthetics arise from many different places. From a senior or supervisory perspective there are valid points concerning time commitments and spreading oneself too thinly; something which I believe can be factored into a professional development plan with appropriate support and mentorship. More pernicious is the idea that aesthetics is somehow less of a specialty, regarded as the ‘easy’ option. This idea is based on valid concerns surrounding regulation (or lack thereof), training and differing expectations around the use of platforms including social media. Nonetheless, misconceptions about the specialty and motivations for entering it abound, and as an NHS doctor working aesthetics, it is important to promote the positives while acknowledging the areas of valid concern.

Why the bad reputation?

NHS can coincide with aesthetics

Motivations for forging a new role in non-surgical aesthetics are legion, with the potential for professional fulfilment, remuneration, and greater autonomy among those commonly cited. So why do some individuals perceive there to be a conflict between aesthetics and NHS practice that could lead to negative consequences? As previously one of those individuals, I can talk frankly about my journey from talking down my aesthetics career some years ago, to now championing my non-surgical credentials and experience in every aspect of my NHS career and training. As a trainee surgeon, I feared being penalised for starting my own aesthetics practice when the time came to apply for jobs. Friends and colleagues in careers as diverse as plastic surgery, general practice and orthopaedics all shared stories and concerns about negative reactions of seniors

Since starting out in the industry, numerous well-meaning NHS colleagues from various specialties had advised me to downplay my facial aesthetics practice in my surgical portfolio and CV, and to steer interviewers away from the topic during the national recruitment process for my specialist training post as a facial surgeon. I was lucky enough to have a highly supportive consultant mentor within my specialty of oral and maxillofacial surgery; undoubtedly, she helped to create an environment in which both major aspects of my career were able to flourish. As a result, I felt confident in proudly placing my aesthetics practice, teaching and research front and centre; but of course not everyone has had this positive mentorship. From the perspective of the individual, the potential rewards of entering into the aesthetics field are clear, as are some of the challenges. But I believe that we should

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be asking ourselves an additional question: namely, what we as individuals can do to contribute positively to this exciting and innovative field? The woeful lack of regulation in non-surgical aesthetics puts patients and professionals at risk daily. This sobering truth requires a collaborative approach across professional backgrounds, private and public sectors, and all levels of training. Advocating for legislation and regulation, participating in training via regulated post-graduate courses, promoting patient awareness through responsible platform use, and contributing to research are just some ways in which an NHS nurse, doctor or dentist is able to take this approach. I appreciate that effectively having two jobs presents obvious challenges; navigating training alongside growing and running a business has been one the greatest challenges I have faced. This has required excellent time-management, the ability to prioritise, and an unbending commitment to do good for patients; skills and behaviours that we develop and exercise in the NHS on a daily basis. Most of all, having a supportive and understanding mentor within the NHS is fundamental, and I would urge colleagues to seek out this support both as a means of ensuring all aspects of your career link up, while keeping your ideas in step with the differing expectations that we must meet as NHS trainees. To those colleagues who have reservations, let me be clear; non-surgical aesthetics can and should work synergistically with your NHS training, strengthening your CV and portfolio and providing clear leadership, teaching and research opportunities. In addition to benefiting your NHS career, it could help to bring about the much-needed change required to make the industry safer and better for patients and practitioners alike. Your background and skills make you a leader of the future in this unique area of clinical practice. Do not miss out on joining our growing ranks in this movement; a movement that is literally reshaping our concepts of healthcare, wellbeing and even society itself. Mr James Olding is an oral and maxillofacial surgery specialist registrar in London. He will become dual qualified in medicine and dentistry this year, and is a member of the royal college of surgeons. Mr Olding is the founder and director of OFQUAL-regulated training academy Interface Aesthetics, which provides the Level 7 Diploma in Injectables. Qual: MBChB (Hons), BSc (Hons), MRCS (England)

Reproduced from Aesthetics | Volume 8/Issue 7 - June 2021

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