DECEMBER 2024: Regenerative Innovations

INNOVATIONS IN REGENERATIVE MEDICINE DECEMBER 2024 | VOLUME 12 - ISSUE 1

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CPD: Understanding Pain Relief Options Three practitioners review pain relief options for patients undergoing aesthetic procedures

1. Wu Y et al. J Cosmet Dermatol 2020;19(7):1627–1635.

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Imagery is of actual Restylane® patient. For healthcare professionals only.

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Special Feature: Regenerating Thin and Damaged Hair with Exosomes Combining Injectable Treatments for Facial Rejuvenation

ALSO IN THIS ISSUE

Dr Nicole Chiang demonstrates treating female pattern hair loss with PRP Dr Natalie Haworth looks at increasing your profile through personal branding

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The Allergan Aesthetics Portfolio 1–10

A valuable partner Help address some of your patients’ skin quality concerns with a multimodal treatment approach.1,10-14*†

Produced and funded by Allergan Aesthetics, an AbbVie company.

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References: * Such treatment decisions must be assessed and discussed as part of the healthcare professional–patient consultation prior to any treatment being administered. † Multimodal aesthetics treatment describes the use of more than one type of treatment modality that are administered as part of a patient’s treatment plan.

By scanning the QR code, you are being directed to a third party website on which Allergan Aesthetics, an Abbvie company are only responsible for the references for this article.

Dr Edward Robinson explores the literature around polynucleotide use for hair loss

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Adverse events should be reported.

UK reporting forms and information can be found at https://yellowcard.mhra.gov.uk or via the MHRA Yellow Card app, available at Google Play or Apple App stores. Adverse events should also be reported to AbbVie on ProductSurveillance_EAME@allergan.com.

Irish HCPs are asked to report any suspected adverse reactions via HPRA Pharmacovigilance; website: www.hpra.ie.

CPD: Polynucleotides for Hair Loss

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Models have been treated with Allergan Aesthetics product. Individual results may vary.

The safety and efficacy of HArmonyCa™ has not been evaluated in patients treated with other filling implants.10 There is no data available regarding the safety of injecting a greater amount than 20mL of ALLERGAN dermal fillers per 60kg body mass per year.4 HArmonyCa™ Lidocaine is referred to as HArmonyCa™.

Special Feature: Examining Treatment Approaches to Manage Scars Treating Melasma: Discussing Various Treatment Modalities for Melasma

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Dr Nicole Chiang provides an overview of common facial dermatoses CCR 2024 marks its return with the latest advancements in medical aesthetics

14 & 15 March 2025 Business Design Centre, London

Discover, network & celebrate medical aesthetics (disclaimer: *AbbVie has part sponsored this event, this includes provision of a stand and/or a speaker program/medical symposium. AbbVie has had no influence over the content/topics covered in other parts of the agenda.)

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Contents • December 2024 08 News The latest product and specialty news

18 The Future of Hyaluronic Acid Teoxane discusses the benefits of HA to meet patient demands

19 News Special: Navigating the Impact of the Autumn Budget Aesthetics looks at what the Autumn Budget means for clinic owners

CLINICAL PRACTICE 20 Special Feature: Regenerating Hair with Exosomes Practitioners detail their approaches to enhancing thin and damaged hair

News Special: Navigating the Impact of the Autumn Budget Page 19

24 ACE Marks its Return for 2025 Join your community for clinical and business excellence

27 CPD: Recognising Pain Relief Options Practitioners review pain relief options in aesthetic procedures

30 Understanding Post-Hyaluronidase Syndrome Miss Caroline Wilde and Mr Daniel Ezra explore what can be done about undesirable outcomes post-hyaluronidase

34 Combining HA and Hybrid Injectables Dr Manav Bawa combines HArmonyCa and Juvéderm to address skin laxity

36 Case Study: Polynucleotides for the Intimate Area Dr Sarah Jenkins shares a case study on polynucleotides for GSM

39 Exploring Antioxidant L-Glutathione Dr Ethan Hausman-Marquis examines various applications of L-Glutathione

42 Meet the Trainer: Understanding the Power of HA Filler Four Teoxane UK trainers share their advice on utilising hyaluronic acid fillers

45 Case Study: Combining Injectable Treatments Dr Sonia Soopen explores combination treatments using injectables

48 Managing Female Pattern Hair Loss Dr Nicole Chiang presents a case treating female pattern hair loss with PRP

50 Revolutionising Skin Rejuvenation Introducing the new SkinPen Protocol with BIOJUVE for skin remodelling

51 Abstracts A round-up and summary of useful clinical papers with Professor Sebastian Cotofana

IN PRACTICE 52 Utilising Professional Development Reviews Carla Mills outlines how business owners can use reviews to boost success

56 Standing Out as a Personal Brand Dr Natalie Haworth shares her insights on building a personal brand

58 Exploring Coaching as a Management Style Marcus Haycock explores the effectiveness of coaching as a manager

61 In The Life Of: Dr Shino Bay Dr Shino Bay shares a typical day balancing leadership and innovation in aesthetics

62 The Last Word Dr Greg Williams and Kimberley Cairns discuss BBD patients’ entitlement to hair loss treatment

NEXT MONTH: DEVICES • Treating the Neck with Devices • Physiology of Ageing • Reducing Stomach Fat with Radiofrequency

Special Feature: Regenerating Hair with Exosomes Page 20

Clinical Contributors Mr Richard Scawn is a consultant ophthalmologist and oculoplastic surgeon based at The Clinic at Holland Park, Harley Street and Chelsea & Westminster NHS Trust. He specialises in blepharoplasty, ptosis, eyelid reconstructions for cancer, burns and trauma.

Miss Jennifer Doyle is a consultant oculoplastic surgeon and founder of The Clinic at Holland Park. She also works within the NHS as Oculoplastics Consultant at Milton Keynes University Hospital NHS Trust. She has several years of experience integrating aesthetic and non-surgical treatments into her practice.

Dr Aaminah Haq is an ophthalmology registrar and aesthetic doctor at The Clinic Holland Park, where she provides aesthetic injectables, laser and ultrasound treatments. She uses a variety of pain relief techniques for her patients, both in eye surgery and aesthetic treatments.

Miss Caroline Wilde is a consultant ophthalmologist and oculoplastic surgeon specialising in blepharoplasty. She practises in the NHS and privately, whilst also a senior consultant at The Ezra Clinic on Harley Street. Managing periocular complications related to dermal fillers constitutes a significant portion of her practice.

Mr Daniel Ezra is a consultant at Moorfields Eye Hospital in central London, and is the lead clinician at The Ezra Clinic, a specialist oculoplastic private practice based at 152 Harley Street focusing on periocular and facial aesthetics.

Dr Sarah Jenkins graduated from Cardiff University and has worked in many surgical specialties during RCS surgical training programme, as well as four years as a GP associate in training (AiT) where she found her passion for women’s health. Dr Jenkins now practises as an aesthetic physician at TheDoorW4 in Chiswick.

Dr Ethan Hausman-Marquis is a consultant paediatric oncological surgeon, with a clinic specialising in aesthetic and regenerative medicine in London. He holds a PhD in Cell Biology.

He is also a member of the American Society of Regenerative Medicine and The American Academy of Anti-Aging Medicine.

Dr Sonia Soopen is a general and cosmetic dentist and facial aesthetic physician in Surrey. Dr Soopen adopts a holistic approach and provides dental treatments and bespoke tailored rejuvenation and enhancements.

Dr Nicole Chiang is a consultant dermatologist who subspecialises in hair disorders. She is experienced in treating non-scarring and scarring alopecia with medical and aesthetic treatments. She is an international speaker in the field of dermatology and alopecia.

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Introducing the 2024 Aesthetics Reviewing Panel Aesthetics celebrates the support of our peer-reviewing panel Launched in 2022, the Aesthetics Reviewing Panel (ARP) comprises a prestigious group of experts recognised for their outstanding contributions to the field of medical aesthetics. Each member of this esteemed panel brings a wealth of experience and a commitment to advancing the scientific rigour of our publication. Their dedication ensures that every clinical and CPD article is meticulously reviewed for accuracy, quality and scientific merit, allowing us to provide our readers with trusted, evidence-based content.

As we reflect on the achievements of 2024, we extend our thank you to the panellists for their unwavering support, time and

expertise. Their collective insights and contributions have elevated the educational value of our journal, solidifying it as an authoritative resource within the aesthetics community. We look forward to continuing this journey in 2025, welcoming new innovations and partnerships that will help shape the future of the specialty.

Meet the 2024 panel members Below is the full list of our 2024 Aesthetics Reviewing Panel members. This team includes leaders from various specialties within medical aesthetics, all united by their dedication to advancing knowledge and best practices in the field.

Dr Yusra Al-Mukhtar

Mr Naveen Cavale

Miss Elizabeth Hawkes

Dr Anjali Mahto

Dr Derrick Phillips

Mr Adrian Richards

Dr Mayoni Gooneratne

Anna Baker

Dr Nichola Conlon

Dr Martyn King

Mr Richard Scawn

Jackie Partridge

Dr Stefanie Williams

Melanie Recchia

Sharon Bennett

Dr Raul Cetto

Dr Shirin Lakhani

Dr Souphi Samizadeh

Dr Tapan Patel

Dr Greg Williams

Mr James Olding

Dr Kim Booysen

Miss Jennifer Doyle

Dr Kam Lally

Julie Scott

Dr Dev Patel

Dr Lee Walker

Dr Charlotte Woodward

Kimberley Cairns

Dr Ahmed El-Houssieny

Dr Vix Manning

Dr Sophie Shotter

Khatra Paterson

Looking forward to 2025 As we look to the future, we remain committed to providing cutting-edge, peer-reviewed content that empowers our readers to advance their skills and knowledge. Together, we aim to drive the specialty forward and continue setting benchmarks in medical aesthetics. If you are interested in joining our reviewing panel or if you are keen to see your name in print and write for the journal in 2025, please get in touch at editorial@aestheticsjournal.com.

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Aesthetics | December 2024

Rachel Goddard

Each member’s expertise is invaluable to our mission of upholding high standards in aesthetics education and clinical excellence.

See you next year!

Editor’s letter As we approach the end of another incredible year in aesthetics, the December issue of the Aesthetics Journal celebrates the latest advancements in innovations and regenerative medicine. This month’s articles offer a glimpse into the future, exploring groundbreaking Shannon Kilgariff treatments and techniques that are reshaping Editor & Event patient care and outcomes. One of our Manager highlights is a Special Feature on the use of @shannonkilgariff exosomes for hair loss – a treatment gaining momentum for its regenerative potential (p.20). In addition, our lineup of clinical contributors dive into the complexities of post-hyaluronidase syndrome, understanding pain relief options (p.27) and PRP for hair loss (p.48). December also marks the official launch of registration for ACE 2025! In our event preview (p.24), we highlight what’s new and exciting for next year’s event, which promises to be bigger and better than ever. I’m personally thrilled that Allergan Aesthetics will be delivering two days of unmissable clinical education and insights as our newly announced Headline Sponsor! Don’t miss out on securing

your place early to stay ahead of the curve and register on p.24. This month, we’ve been out and about covering events across Europe. Our On The Scene pieces bring you the highlights from Prague Lab, Croma and Galderma, which all hosted inspiring gatherings to showcase their latest developments. As we wrap up 2024, we’re already looking forward to what 2025 has in store. From innovations in treatments to groundbreaking events in our field, we can’t wait to see you next year for what promises to be an even more exciting chapter in aesthetics.

Plus, stay tuned for our January issue, where we’ll be revealing the highly anticipated Finalists for The Aesthetics Awards! We had a huge number of entries this year, so the Aesthetics Journal team has a lot to get through. It’s always amazing reviewing these entries, and reading the inspiring stories, case studies, developments and achievements from everyone in our specialty this year. A HUGE good luck to all entrants! I’d also like to wish you all a wonderful festive season and a happy New Year from myself and the Aesthetics team. As always, share your thoughts on this issue using #AestheticsJournal and tag us on Instagram @AestheticsJournalUK. Don’t hesitate to get in touch at editorial@aestheticsjournal.com – we’d love to hear from you!

Clinical Advisory Board

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

Sharon Bennett is chair of the British Association of Cosmetic Nurses (BACN), previous UK lead of the BSI committee for aesthetic non-surgical standards, and member of the Clinical Advisory Group for the JCCP. She is a trainer and registered university mentor in cosmetic medical practice, and is finishing her MSc at Northumbria University. Bennett has won the Aesthetics Award for Nurse Practitioner of the Year and the Award for Outstanding Achievement.

Dr Sophie Shotter is the founder & medical director of Illuminate Skin Clinic in Kent and Harley Street, London. Her passion is for natural treatments delivered with utmost attention to safety. She works closely with Allergan as part of their UK and International Faculty.

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

Dr Mayoni Gooneratne (MBBS, BSc, MRCS, MBCAM, AFMCP) was an NHS surgeon before establishing The Clinic by Dr Mayoni and founding Human Health – an initiative combining lifestyle with traditional and functional medicine to provide a ‘cell-up’ regenerative approach to aesthetics. She is also the co-founder of The British College of Functional Medicine.

Dr Anjali Mahto is one of the UK’s leading consultant dermatologists. She is a Fellow of the Royal College of Physicians, member of the Royal Society of Medicine and a spokesperson for The British Skin Foundation. In 2023 Dr Mahto opened Self London, a dermatology and lifestyle clinic aimed at managing skin conditions holistically.

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

Jackie Partridge is an independent nurse prescriber. She is the clinical director and owner of Dermal Clinic in Edinburgh and a KOL for Galderma. She holds an MSc in Non-surgical Aesthetic Practice and a BSc in Dermatology.

Partridge is a stakeholder group member with Scottish Government/HIS, Honorary BACN member and JCCP Fitness to Practice Nurse.

Dr Tapan Patel is the founder and medical director of PHI Clinic, and has more than 20 years’ experience performing aesthetic treatments. He is a KOL for Allergan Aesthetics and Cutera, and is passionate about high standards in aesthetic medicine. In 2023, Dr Patel received The Aesthetics Award for Outstanding Achievement in Medical Aesthetics

Mr Adrian Richards is a plastic and cosmetic surgeon with over 30 years’ experience.

He is the clinical director of the aesthetic training provider Cosmetic Courses and surgeon at The Private Clinic. He is also a member of the British Association of Plastic and Reconstructive and Aesthetic Surgeons and the British Association of Aesthetic Plastic Surgeons.

Dr Souphi Samizadeh is a dental surgeon with a Master’s degree in Aesthetic Medicine and a PGCert in Clinical Education.

She is the founder of the Great British Academy of Medicine and Revivify London Clinic. Dr Samizadeh is a Visiting Teaching Fellow at University College London and King’s College London.

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

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© Copyright 2024 Aesthetics. All rights reserved. Aesthetics is published by Aesthetics Media Ltd, which is registered as a limited company in England; No 9887184

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

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Medical Tourism

Turkey hair transplant death raises concerns

Talk #Aesthetics Follow us on Instagram @aestheticsjournaluk

The procedure’s aim was to remove 4,000 hair grafts from the back of his head to his face, but after experiencing unnatural hair growth and severe pain and discomfort following the procedure, Latour searched for a second opinion. Dr Jean Devroye, a hair transplant specialist based in Belgium, examined Latour and found that 1,000 out of the 4,000 hair grafts would not grow back, resulting in permanent scarring. Latour took his own life only three months after the procedure was conducted.

#Education Dr David Eccleston @drdavideccleston Teaching at The Fresh Life conference at the Crystalbrook Byron Bay with my Aussie buddy Emma.

#Conference Alexandra Mills @am.aesthetics Witnessing the level of care and dedication at the Croma facility has given me a new appreciation for the science and precision behind injectables!

The Aesthetics Journal sought insight from hair transplant surgeon Mr Greg Williams on the risks of medical tourism. He commented, “The main issue is that, at cheap clinics abroad and in the UK, the surgical steps of a hair transplant are often delegated to non-doctor, layperson technicians. This allows the doctor to ‘oversee’ several patients having surgery. There are clinics in Turkey where 50-70 patients were being operated on in one day. These technicians do not have the knowledge or expertise to deliver consistently good outcomes.”

Mental Health

New research uncovers links between BDD and shame #RSM RSM Aesthetics Congress @rsmaestheticscongress Our inaugural RSM Aesthetics Congress was a major success with many of the leading experts in the field present!

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Michael Saul, partner at Cosmetic Surgery Solicitors, said, “Reduced satisfaction rates often force patients to spend more to correct surgical mistakes. Claims against foreign surgeons are difficult, leaving many without recourse to fix errors. This lack of options can worsen mental health, with potentially serious consequences.”

The Aesthetics Journal reached out to the Republic of Türkiye Minister of Health for a comment but received no response.

#Examinations Dr Catherine Fairris @drfairris_skinwessex I am proud to have been able to present the well-deserved MBCAM Certificates at the BCAM Annual Conference!

#Regulations Khatra Paterson @kp_aesthetics_clinic Keeping standards high with CQC regulations and audit workshop.

The experience was informative!

24-year-old French student Mathieu Latour has taken his own life after complications from a hair transplant performed by an alleged layperson in Turkey.

New research conducted by a team at University College London (UCL) has found that symptoms of body dysmorphic disorder (BDD) are strongly associated with feelings of shame.

In the study, 342 adults aged 18-30, some with BDD symptoms, were surveyed on BDD-related symptoms like shame, anxiety, low mood and adverse childhood experiences such as abuse, neglect and bullying.

Following analysis, it was found that the relationship between BDD symptoms and shame was evident even when other negative emotions (such as anxiety and low mood) were considered.

Symptoms of BDD were also found to be linked to the adverse childhood experiences, which are often tied up in shame.

The researchers suggest that in some circumstances, shame from childhood experiences could potentially lead to future BDD symptoms.

Dr Georgina Krebs, associate professor of young people’s mental health, commented, “We have known for a long time that people with BDD often experience high levels of shame, but this emotion is often overlooked and is rarely a focus in psychological therapy for BDD. This new study shows a robust link between BDD symptoms and shame and suggests that it may be one of the routes by which adverse childhood experiences feed into BDD.”

Aesthetics | December 2024

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Awards

Last chance to buy Early Bird Aesthetics Awards tickets Early Bird tickets for the glamorous Aesthetics Awards 2025 ceremony will be available until December 31.

On March 15, 2025, practitioners, clinic teams and aesthetic companies will unite at the UK’s most luxurious awards venue for the highlight of the specialty’s calendar.

Vital Statistics Out of 500 UK adults, 76% believe that aesthetic treatments are more accepted today than they were five years ago (Allergan Medical Institute, 2024)

Statistics show that the BBL is the UK’s most-searched cosmetic procedure, with 708,000 searches from September 2023 to August 2024

Alongside 26 Winners receiving their awards, the night will include a drinks reception, delicious three-course meal, entertainment, celebrity host, photo opportunities and an after party with dancing until the early hours.

Accolades awarded on the night will include The Allergan Aesthetics, an AbbVie Company, Award for Clinic Team Member of the Year, The Crown Aesthetics Award for Best Non-Surgical Result and The Lumenis Award for Best Clinic London.

Shannon Kilgariff, editor and event manager at Aesthetics, commented, “Anyone who has attended The Aesthetics Awards before will know they cannot be topped! It is such a buzz to see so many familiar faces all together dressed to the nines, celebrating the highlights of the past year.

It’s the perfect opportunity to connect with the community, and celebrate true excellence. I truly cannot wait to see you there!”

(Harley Street Skin Clinic, 2024)

Among 1,500 beauty professionals in the UK, 97% think it’s important to be involved in waste reduction efforts (Professional Beauty Group, 2024)

A UK study revealed that out of 200 menopausal women, 52.7% found intercourse was too painful to bear

The Aesthetics Awards 2025 will be taking place at Grosvenor House, London on March 15, 2025, after Day 2 of ACE 2025.

Guidelines

NICE advocates HRT for menopause treatment New National Institute for Health and Care Excellence (NICE) guidelines urge GPs to make hormone replacement therapy (HRT) the go-to treatment for menopause symptoms.

These guidelines, revised in November 2024, focus on diagnosing and managing menopause, including cases of premature ovarian insufficiency.

The new recommendations also provide GPs with an updated discussion aid to help communicate effectively with patients about HRT options.

HRT functions by supplementing the hormones oestrogen and/or progesterone, which decline naturally as women transition out of their reproductive years, usually between 45 and 55. It is available in several forms, including gels, creams, pessaries, tablets, patches and sprays.

(Menopause Research and Education Fund, 2024)

New data from St John Ambulance revealed that out of 1,000 members of the public, a quarter said they never had first aid training (Censuswide, 2024)

The Aesthetics Journal contacted NICE for further insights into any initiatives supporting equitable HRT access for women from ethnic minority backgrounds and lower-income communities. Philip Ranson, media relations manager at NICE, pointed to the Department of Health and Social Care’s Women’s Health Strategy. This strategy includes establishing women’s health hubs, aiming to reduce diagnostic delays and improve access to essential support.

Aesthetics | December 2024

Based on 1,010 British females aged 18-55, 42% didn’t know that the stages of menopause can affect their skin (Hada Labo Tokyo, 2024)

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Events diary 14th-15th March 2025 ACE 2025

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Cosmetic Courses and Sinclair open aesthetic showrooms Aesthetic training provider Cosmetic Courses and manufacturer Sinclair have opened showrooms for aesthetic practitioners at training centres in London and Buckinghamshire.

25th-26th September 2025 CCR 2025

The showrooms feature a selection of Sinclair’s most popular devices, including the Sculpt&Shape, Primelase and Elysion Pro, with additional equipment such as Cooltech Define, Pristine and Infusion expected to be showcased soon. The spaces have been designed with the aim to offer an immersive environment, allowing practitioners to observe live demonstrations and engage with experts.

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

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Aesthetics

Training

15th March 2025 The Aesthetics Awards 2025

ITVX documentary exposes Britain’s backstreet cosmetic surgeries ITVX has released Britain’s Backstreet Surgery Scandal, a documentary unveiling the dangers around backstreet cosmetic surgeries and reigniting concerns surrounding the lack of regulation.

The ITV footage highlights alarming practices, such as individuals receiving injectable training in just a single day under the guidance of unprincipled training providers, and offering treatments in unsafe, non-sterile environments. Professor Ian Whitaker, a consultant plastic surgeon, commented, “I’ve been a doctor for over 22 years, and I never thought in my lifetime I’d see something like that.” The urgent need for stricter regulations is demonstrated through an ITV journalist directly appealing to the Health Secretary. Tristan Mehta, CEO of Harley Academy, commented, “The UK urgently needs tighter regulatory frameworks to ensure only medically qualified practitioners can administer treatments.”

Approved weight loss drug surge linked to nurse’s death The death of a nurse has brought attention to the weight loss drug Mounjaro, as its active ingredient, Tirzepatide, was listed as a contributing factor. Susan McGowan took two low-dose injections of Tirzepatide over the course of two weeks before her death on September 4. This is thought to be the first death officially linked to the drug in the UK. The drug was approved in 2023 by the Medicines and Healthcare products Regulatory Agency (MHRA), including use on the NHS, although the drug is only prescribed for a small number of patients due to factors like cost and availability. Mounjaro manufacturer Eli Lilly and Company commented, “We are committed to continually monitoring, evaluating, and reporting safety information for all Lilly medicines.”

Aesthetics

Consultant plastic surgeon and medical director of Cosmetic Courses, Mr Adrian Richards, commented, “At Cosmetic Courses, we’re committed to leading the way in aesthetic education, and our partnership with Sinclair exemplifies this dedication. This showroom gives our clients a unique opportunity to gain hands-on knowledge with transformative technology, ensuring they remain at the forefront of aesthetic innovation and patient care.”

Research

BAAPS study reveals regret among patients seeking surgery overseas A new study presented to the British Association of Aesthetic Plastic Surgeons (BAAPS) reveals that more than 50% of patients who travelled abroad for cosmetic surgery later regretted their choice.

Awarded the BAAPS Hackett Memorial Prize 2024, the study reviewed ten years of patient outcomes at a UK tertiary plastic surgery unit, focusing on complications from overseas procedures. The research involved 103 patients referred for post-surgical complications between 2012 and 2022. A telephone survey indicated that 83% of respondents cited cost as the main reason for going abroad, with 66% expressing regret over their decision.

BAAPS president Ms Nora Nugent stressed the need for public awareness on cosmetic tourism risks, stating, “This research offers crucial insights that must inform future public health campaigns. Potential patients need to understand the risks involved with travelling abroad for cosmetic surgery, beyond just the financial savings.”

Recruitment

Seriderm UK welcomes new Lutronic business director Seriderm UK has appointed Kevin Williams as the new UK business director for aesthetic device company Lutronic.

Seriderm has expressed William’s expertise within the aesthetics specialty, and explains that he is well-positioned to lead the local team and expand the range of advanced aesthetic devices available.

Previously, Williams was the chief technical officer at Wynyard Aesthetics Academy. He has worked in the laser industry for over 30 years and is one of the original inventors of laser hair removal.

Williams commented, “I am delighted to step into this position. I believe now is the perfect time to fully focus my efforts on advancing the growth of the brand in the UK. I am committed to expanding our presence in this competitive marketplace by continuing to innovate, educate and provide transformative devices and treatments that enhance patients’ lives.”

Aesthetics | December 2024

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Recruitment

Dr Bibi Ghalaie joins Medik8 global advisory board Dermatological skincare brand Medik8 has added Dr Bibi Ghalaie to its board as the brand’s Global Pro Ambassador.

Founder of the Doctor Bibi clinic on Harley street, Dr Ghalaie’s treatment portfolio ranges from skincare and injectables, to chemical peels and facials. She has been a clinical lecturer and trainer for 15 years, and Medik8 shares its excitement to recruit such a passionate, educational figure within the specialty.

Dr Ghalaie commented, “My love of Medik8 is no secret.

I’ve been using the products myself and advocating them to my patients for a number of years. My relationship with Medik8 is authentic and has grown organically. I’m so proud to be a global ambassador for a brand I truly believe in, a brand that has British heritage and whose products are rooted in science and efficacy.”

Skin Solutions

DIBI Milano introduces Meso System Lab for targeted skin solutions Italian skincare brand DIBI Milano has launched the Meso System Lab to address specific skin concerns.

According to the company, the collection includes four advanced skin boosters that integrate with the APG Tech DERMOREGEN device and are compatible with electroporation equipment using microcurrents, making them ideal for post-microneedling treatments. The four sets on offer are the Anti-Age Kit, the Calming Kit, the Spot Correcting Kit and the Purifying Kit. Each booster is formulated with high molecular weight hyaluronic acid for hydration and plumping, according to DIBI Milano.

Andrea O’Donnell, head of education at DIBI Milano, commented, “Discover DIBI Milano’s four advanced skin boosters designed to rejuvenate, hydrate, purify and transform your skin. Powered by high molecular weight hyaluronic acid and potent actives, these solutions target ageing, sensitivity, hyperpigmentation and imperfections. Perfect with post-microneedling or electroporation, they deliver professional, glowing results for every skin type.”

Aesthetics | December 2024

BAMAN UPDATES A YEAR IN REVIEW WITH BAMAN As the end of 2024 approaches, it is the perfect time to reflect on what has been an exceptional year of transformation for the British Association of Medical Aesthetic Nurses (BAMAN), formerly BACN.

BECOMING BAMAN The change from BACN to BAMAN marked a pivotal moment for our association. This rebranding was a renewal of our commitment to supporting members and enhancing the credibility and scope of aesthetic nursing as a vital medical discipline.

AN AWARD WINNING ASSOCIATION Back in March, we were thrilled to win the DermaFocus Award for Best Initiative/ Strategic Project at The Aesthetics Awards 2024! This award was recognition of BAMAN’s commitment to excellence in medical aesthetics nursing, and our work in responding to the Department of Health and Social Care (DHSC) Consultation on Licensing Aesthetics in England. Our submission focused on raising standards, enhancing safety and advocating for a safer, more regulated future for aesthetics in the UK – a huge win for BAMAN.

PUBLISHING THE COMPETENCY FRAMEWORK We’re thrilled to announce that BAMAN Nurse Career and Competency Framework has now officially been published.

The workpiece, led by aesthetic nurse prescriber Anna Baker, is an update on our 2014 edition and supports career progression and sets clear professional standards, providing members with valuable guidance for their development in aesthetic nursing.

LOOKING AHEAD: BAMAN’S 2025 PLANS As we head into 2025, we are excited to announce the return of our advanced practitioner event, BAMAN Spring Symposium taking place on April 4. Dates have also been confirmed for the annual BAMAN Autumn Conference on September 18 and 19.

Our primary focus in 2025 will be on advancing professional development and broadening support for our members. New initiatives are in the pipeline to increase access to mentorship, education and enhanced online resources.

This column is written and supported by BAMAN

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Treatment Options

Fizerchain introduces new aesthetic technologies

14 & 15 March 2025 Business Design Centre, London

Registration Now Open for ACE 2025!

Don’t miss premier education and networking opportunities

Fizerchain, a company specialising in cosmetic and wellness technologies, has introduced new developments to the aesthetics sector.

The Allavi Niosomal technology is designed to improve skin penetration, while the Microbio Liposomal Microneedle Vitamin range focuses on enhanced gut absorption. Alongside these, the NoAge range addresses skin health and ageing, and Orofill is aimed at supporting fertility and menopause.

Bobby Haried, CEO of Fizerchain, commented, “Fizerchain is pleased to launch the new Allavi Cosmetics Range with Niosomal technology for very high skin penetration, along with the Micobio Liposomal Microneedle Technology Vitamin range with the highest efficiency gut absorption available in the world today. This is coupled with our NoAge antiageing youth, skin and Orofill fertility and menopause product, ready to present to the aesthetics world.”

Following the success of CCR, the Aesthetics Conference and Exhibition (ACE) is your next aesthetics event – and registration is now OPEN! Bringing together top pharmaceutical companies and leading brands, ACE is your key destination for injectables, the latest devices, skincare advancements, and more!

Skin Booster

Hydrafacial launches new hyaluronic acid booster Aesthetic device company Hydrafacial has released a new skincare booster to tackle dull and dehydrated skin.

What can you expect?

Taking place on March 14 and 15 at the Business Design Centre, ACE 2025 will feature five tailored educational agendas. Covering in-depth clinical training, the latest research and techniques, and live demonstrations, attendees will gain the most up-to-date knowledge in medical aesthetics.

Highlights include sessions on advanced injection techniques, emerging technologies, and best practices in patient care.

There will also be a whole agenda dedicated to bettering your business knowledge, ensuring you can set your clinic apart from the competition. At the In Practice Theatre, the best business minds and companies will unite to provide you with crucial advice, covering topics such as psychology, social media, tax, AI, and more.

All educational content at ACE is free to attend, so stay tuned for our detailed agenda updates in the coming months!

ACE 2025 also offers extensive networking opportunities, culminating in the prestigious Aesthetics Awards ceremony on the evening of day two. Tickets are on sale now at our early bird rate, so make sure to get them before the offer ends.

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In a clinical study of 38 participants conducted by Hydrafacial, results found a 455% increase in hydration and a 57% reduction in the appearance of wrinkles immediately following the treatment.

Jon Arnold, president of Hydrafacial EMEA and country manager, commented, “As the first Hydrafacial booster with clinical claims to address dry, dull and dehydrated skin, as well as signs of ageing, it sets a new standard. This booster further expands our portfolio of more than 15 boosters, allowing providers to deliver customised Hydrafacial treatments that cater to a wide range of skin needs.”

Devices

Connect at the Oscar’s of aesthetics

Finalists for all categories will be announced in the January journal – best of luck to everyone who entered!

The company shares that the Hydralock HA booster features a blend of triple hyaluronic acid complex, vitamin B5 and fruit extracts, specifically targeting individuals seeking to achieve hydrated skin while firming and minimising the appearance of wrinkles.

Pure Tone Aesthetics releases Supramax Pelvic Floor Chair Aesthetic device company Pure Tone Aesthetics has launched the electromagnetic Supramax Pelvic Floor Chair.

The company shares that the device is designed for non-invasive pelvic floor therapy, and would be suitable for individuals suffering from weakened pelvic muscles, alongside any other pelvic-related issues. According to the company, each 28-minute session delivers the equivalent of 11,000 kegel exercises.

Steven Ballard, director of Pure Tone Aesthetics, commented, “We’re bringing a groundbreaking solution to pelvic health that makes it easier for people to regain control and improve their quality of life. This technology opens up new possibilities for clinics and wellness centres to offer a safe, effective and non-invasive solution to a common issue.”

Aesthetics | December 2024

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Hyaluronic Acid

My Skin Chemistry launches Skincare company My Skin Chemistry has debuted in the UK with three product lines.

The first line, Beauty Method, is powered by HYLACALM technology which uses hyaluronic acid in cleansers, serums and creams to address various skin concerns.

The second line is RENIUX – combining HYLACALM with sterile actives, it hydrates and rejuvenates, making it suitable post lasers, microneedling or peels. The third line is Bioreg, featuring sterile, ready-to-use vials for professionals.

Laura Morgans, commercial director of My Skin Chemistry, commented, “We’re thrilled to launch My Skin Chemistry in the UK. Our sterile, sonicated hyaluronic acid skincare products deliver breakthrough efficacy. With patented HYLACALM, they reduce inflammation by up to 94% and enhances hyaluronic acid’s benefits with a refined multi-molecular blend.”

Skin Health

iS Clinical releases new skin renewal collection Skincare company iS Clinical has introduced the new Skin Renewal Collection, designed to be used on the go for a rejuvenated complexion.

The Cleaning Complex is labelled as a gentle makeup remover while maintaining natural oils, alongside the Reparative Moisture Emulsion which reportedly hydrates the skin day and night. The Active Peel System consists of a two-step treatment that aims to exfoliate and hydrate, next to the Retinol+ Emulsion, designed to soften the appearance of the skin.

Katie Hughes-Dawkins, head of engagement and relations at Harpar Grace International, the distributor of iS Clinical, commented, “The Skin Renewal Collection by iS Clinical is the ultimate gift set for radiant skin. Exclusively available for clinic partners, the set offers exceptional value, perfect for festive gifting.”

Eyecare

Obagi Medical debuts new rejuvenating eye gel cream Skincare company Obagi Medical has launched its new eye product, Daily Hydro-Drops Rejuvenating Eye Gel Cream.

Insider News

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Virtual Account Manager at Sinclair UK, Sam Leon…

Your role is a new one to Sinclair UK, can you explain what you do?

As the virtual account manager (VAM), I am the initial point of contact for anyone interested in our injectable and energy-based devices (EBDs) portfolio. I assess each business’ needs to determine whether you need to meet with a field account manager, or if I can assist virtually, including granting access to the Sinclair College or Sinclair marketing portal.

Tell us about your background in aesthetics…

I started out as a beauty therapist on cruise ships around 25 years ago. When I returned to the UK, I worked with clinics to streamline their businesses, eventually becoming an international trainer for Elemis. I have also worked for companies such as Euromedical and QMed. That is where I discovered my passion for injectables within aesthetics.

Why have you chosen to work at Sinclair?

I have been privileged to work at some fantastic companies and have always enjoyed sales, but after being in the same field, I wanted a new challenge. As the VAM, I get to work in a national role where I still speak to customers every day, as well as collaborate with the commercial, field and marketing teams.

What are you excited for in 2025?

I am excited to continue developing our EBDs and exploring how they enhance treatment outcomes. Sinclair is unique in that we offer both injectables and EBDs, and combining these two can produce the best results for patients while also being financially viable for clinics. We have even introduced finance options to facilitate EBD purchases.

Obagi Medical shares that the product is designed to brighten and depuff the eye area, providing a brighter and smoother appearance. The gel cream contains ingredients such as tuberose, hibiscus oil, Abyssinian oil and shea butter to lighten and tighten skin around the eyes, according to the company.

This advertorial was written and supplied by Sinclair

Simone Shoffman, head of education at Obagi Medical’s UK distributor Healthxchange, commented, “This cream serves as a key complementary offering to the existing hero Hydro Drops line, providing a targeted and proven treatment to a delicate area. The exceptional formula is made possible by Obagi’s proprietary Isoplentix Technology which elevates the potency of each ingredient and only releases their benefits upon application.”

Book an appointment with Sam via the QR code

Aesthetics | December 2024

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Congress Report

DermaFocus and AesthetiCare hold training day with Dr Lee Walker On November 13, medical aesthetic distributor DermaFocus and skin treatment company AesthetiCare hosted a collaborative training day in Leeds, led by aesthetic practitioner Dr Lee Walker.

DIBI Milano and APG Tech host Congress in Italy

The event focused on enhancing the teaching and presentation skills of faculty members, advancing standards in medical education within regenerative aesthetics.

The programme emphasised engagement, interactivity and empathy, with Dr Walker highlighting storytelling as a tool to connect with trainees. Participants practised techniques with peers, reviewed their presentations on video and refined their delivery by focusing on pitch, pace and pauses. Simplifying complex medical concepts was a key theme, helping delegates ensure their teaching is accessible and impactful, the companies shared.

Milad Bemana, co-founder and director at DermaFocus, highlighted, “Investing in our faculty strengthens medical education in regenerative aesthetics. By advancing their knowledge and fostering a thriving community, we elevate today’s standards and shape future leaders in the field.”

International Meeting

Sinclair provides learning at World Experts Meeting in Barcelona Aesthetic manufacturer Sinclair has hosted an international meeting of healthcare professionals at the Palau de Congresos in Barcelona.

On October 18-19, the World Experts Meeting (WEM) invited an audience of 800 attendees to Spain. The event featured 33 speakers, 22 lectures, nine panel discussions and treatment demonstrations. The meeting consisted of leading surgeons, dermatologists and aesthetic physicians delivering clinical sessions, demonstrating the latest injection techniques, protocols and advice.

The theme for WEM was ‘Catalyst for Regeneration’. Dr Tanya Toni De Melo, the event moderator, stated, “WEM 2024 brought together top speakers to share insights and research into aesthetics, fostering discussions to enhance our practices and treatment delivery, with a strong focus on safety.”

Sinclair shared that delegates had the opportunity to visit the Innovation Lab during the congress, with scientists showcasing multiple Sinclair products. Beyond the scientific agenda, the company offered access to a Digital Lab, where practitioners could explore website audits and social media strategies. Digital experts showcased AI applications to help participants stay ahead of emerging trends and boost digital appearance.

Amber Edwards, CEO of Sinclair, commented, “WEM presents an invaluable opportunity to meet with esteemed experts from across the globe. Every two years, Sinclair brings together aesthetic practitioners to learn from the best. WEM provides a platform for eminent speakers to share their world expertise, helping aesthetic physicians to achieve excellence in their practice.”

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Aesthetics | December 2024

Skincare company DIBI Milano and tech company APG Tech hosted an international conference at The Grand Hotel Da Vinci on Italy’s Adriatic Coast.

Taking place on October 14-15, this year’s congress showcased APG Tech’s latest devices, presentations and insights.

Additionally, DIBI Milano revealed a range of skin-boosting mesotherapy solutions, highlighted through the Meso System Lab which is designed to achieve efficient versatile facial treatments.

Andrea O’Donnell, a member of the UK and Ireland education team, showcased APG Tech’s Dermoregen, Shape Define and Epildream devices, and explained that the advanced technology delivers results in rejuvenation. Additionally, opinion leaders took to the stage to share insights into how they are incorporating these devices into their clinical practices.

Nurse practitioner Nikki Zanna delivered a presentation on how she integrates Golden radiofrequency into her patient journey, aiming to enhance both outcomes and patient experience.

DIBI Milano also shared the surroundings of the international conference, as the company gathered over a curated Italian meal to discuss patient success stories and share best practices.

Thomas Klein, sales director for beauty at DIBI Milano, commented, “Taking our valued clients to Italy was more than just a business trip – it was an immersive experience that beautifully blended innovation with culture. Exploring our cutting-edge technology, while sharing moments of Italian elegance, truly underscored the essence of what DIBI Milano and APG Tech stand for: a perfect fusion of beauty, innovation and meaningful connections.”

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Interactive cadaveric demonstrations, ultrasound-guided live injections and live toxin and biostimulator applications provided attendees with hands-on learning opportunities and practical insights into the latest treatment methodologies.

Conference Report

Aesthetic Dialogue throws of the event was the session on regenerative medicine, international symposium Awithhighlight aesthetic practitioner Dr Tapan Patel and Andrew Hansford The Aesthetics Journal attended the Aesthetic Dialogue event, held at Prague Castle on November 8-9, 2024.

The occasion gathered aesthetic practitioners, clinicians and thought leaders to explore the latest developments in medical aesthetics.

Set in Prague’s national historic castle, the event provided a blend of scientific insight, live demonstrations and expert-led discussions on the future of beauty, anatomy and regenerative medicine.

discussing the potential of biostimulators and exosomes to stimulate collagen production, angiogenesis and cell proliferation.

Additionally, the live demonstrations of advanced injection techniques, including gluteal augmentation and facial contouring, showcased the cutting-edge practices shaping the field.

Networking and knowledge exchange were central to the event, with practitioners from across the globe coming together to discuss challenges, share experiences and collaborate on the future of medical aesthetics. The event concluded with a panel discussion on safety in energy-based treatments, underscoring the importance of anatomical understanding and patient feedback in achieving optimal results.

The two-day conference featured a diverse array of sessions covering topics ranging from the perception of beauty and facial anatomy to the role of biostimulators and advanced injection techniques. Leading experts such as anatomist Professor Sebastian Cotofana and aesthetic practitioner Dr Lee Walker led in-depth discussions, exploring key themes like symmetry, ageing and gender differences in beauty perception.

On The Scene

Croma Pharma hosts exclusive event at Vienna HQ On Thursday October 31, Croma Pharma UK hosted 24 aesthetic practitioners, along with the Aesthetics Journal, at its Vienna global headquarters for the exclusive Visit Croma event.

The event offered an in-depth look at the company’s hyaluronic acid (HA) filler manufacturing process.

The day commenced with a comprehensive tour of the manufacturing facility, led by Alexander Wonisch, global event manager at Croma Pharma. Practitioners were guided through the production areas, beginning with the quality and control laboratory where raw materials and samples undergo rigorous testing to ensure safety and efficacy. The tour continued to the automated manufacturing lines, showcasing advanced technologies that minimise human error, including semi-automated lines with dual magnification, specialised light sources and rotating syringes. The facility employs 100% visual inspections and touchless discarding of defective syringes, which according to the company, underscores Croma Pharma’s commitment to maintaining high standards of sterility and product integrity.

Following the facility tour, the programme included sessions focused on the business aspects of medical aesthetics. Daniel de Boer, executive vice president of business development and strategy at Croma Pharma, presented a global perspective on the aesthetics specialty, highlighting emerging trends and strategic opportunities for practitioners.

After a scenic lunch overlooking Korneuburg Castle in Leobendorf, delegates attended detailed presentations on Croma’s Saypha HA

Dr Mayoni Gooneratne – member of the Aesthetics Clinical Advisory Board – attended this event and reported back on behalf of the Aesthetics Journal.

filler portfolio. David Kuroki-Hasenöhrl, director of development, discussed the unique properties and performance characteristics of various HA fillers, including differences in concentration, degrees of crosslinking and specific indications for use. Alice Krames-Juerss, head of clinical operations, reviewed clinical research related to the effectiveness and safety of Croma’s HA fillers.

Regulatory compliance was addressed by Arkan Zwick, corporate director of regulatory affairs, who explained how Croma Pharma meets global standards under the medical device regulation (MDR). The transition from the medical device directive (MDD) to MDR-certified devices was emphasised, ensuring that products adhere to stringent EU regulations.

Valentin Gruber, head of global business services, told the Aesthetics Journal, “MDR approval for Saypha sets a new standard in aesthetic care, ensuring safety, efficacy and transparency. This certification demonstrates Croma’s commitment to meeting stringent EU regulations, guaranteeing the quality and consistency of our dermal fillers. It also reinforces the importance of using these products with trained, accredited healthcare professionals, providing clear information on performance and precautions for both practitioners and consumers.”

The event also highlighted the benefits for healthcare professionals, including involvement in product development, participation in clinical trials for high-risk devices and access to comprehensive product information and training. Emphasis was placed on the importance of safety, performance and patient satisfaction, supported by enhanced traceability measures such as Unique Device Identification (UDI) and safety summary certificates of performance (SSCP).

The day concluded with an interactive session where delegates had the opportunity to formulate their own HA gel. This hands-on experience provided practitioners with practical insights into the formulation process, fostering a deeper understanding of the products. The day’s comprehensive schedule concluded with a networking dinner at Artner am Franziskanerplatz in the heart of Vienna, offering delegates an opportunity to discuss insights and share reflections from the day’s sessions.

Aesthetics | December 2024

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Conference Report

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Product Launch

RAMCE hosts regenerative medicine conference More than 300 medical professionals gathered in London on November 9 to enhance their knowledge of regenerative aesthetic treatments.

It was the second year for the Regenerative Aesthetic Medicine Conference and Exhibition (RAMCE), which took place in the Pullman Hotel, London.

Chaired by Professor Maurizio Cavallini, Dr David Eccleston and Dr Yusra Al-Mukthar, the sessions taught practitioners how to optimise results with innovative treatments and expert techniques.

Speakers explored the differences between polynucleotides and exosomes, treating the intimate area, chemical peeling’s regenerative action, and shaping regenerative medicine for your patients. There were also engaging panel discussions on the value of platelet-rich plasma (PRP) and platelet-rich fibrin (PRF), using combination approaches and the role of dermal fillers, toxins and threads in the regenerative space.

New products were also launched with aesthetic practitioner Dr Xavier Goodarzian introducing the audience to the Liquid Laser. This incorporates Purasomes with chemical peeling and microneedling.

Dr Goodarzian guided delegates through its application and showcased the results.

To conclude the day, Shannon Kilgariff, editor and event manager at Aesthetics, hosted an evening with Professor Cavallini to share more about how he became a polynucleotides pioneer.

Reflecting on the day, Professor Cavallini said, “RAMCE 2024 was a fantastic day of learning and networking. We have already had excellent feedback from delegates, who valued the in-depth discussions and introduction of innovative new products and techniques. I look forward to working with the team to further advance this event in 2025.”

Aesthetic practitioner and president of the British College of Aesthetic Medicine (BCAM), Dr Catherine Fairris, said, “I’m here today because regenerative medicine is the future of medical aesthetics. We’re seeing a huge shift towards more natural and holistic approaches to treatments.”

The Skin Diary celebrates new night cream at launch The Skin Diary unveiled its Night Repair Therapy cream on November 14 at Claridge’s in London, where the venue’s festive decorations set a lively and elegant tone for the evening.

Consultant dermatologist and founder of The Skin Diary Dr Clare Kiely opened the presentation, before welcoming consultant dermatologist and chief scientist at The Skin Diary Professor Chris Griffiths and consultant dermatologist and head of product innovation at The Skin Diary Dr Tamara Griffiths. The duo introduced the cream, sharing its development journey and the science behind its formulation, before highlighting the benefits it offers for patients’ skin.

During a Q&A session with delegates, the Aesthetics Journal asked about the product’s uniqueness in a saturated market, to which the founders emphasised its rigorous scientific foundation and development by leading dermatologists.

The cream was tested through double-blind, placebo-controlled clinical studies on human skin, conducted by the accomplished skin-ageing research team at the University of Manchester, says the company. Prior to indulging in a three-course meal, delegates were treated to a gift box, featuring the new night cream, a scented candle, a bilberry teabag and a silk eye mask and pillowcase.

Dr Kiely said, “The success of the launch is a testament to our shared vision and the culmination of our collective life’s work in skin ageing. We’re not here to fight ageing but to embrace it, focusing on skin longevity and vitality. This incredible milestone marks the beginning of a journey we’re proud to lead.”

On The Scene

PCA Skin celebrates annual Social Symposium Skincare brand PCA Skin held its annual Social Symposium at the Bulgari Hotel, London.

100 attendees gathered on November 8 for a glamorous evening of networking, learning and celebration. Guests were welcomed with drinks and canapes on arrival, with entertainment including a live orchestra and caricature drawings. This was followed by a welcome from UK & Ireland brand manager Lizzie Shaw, discussing the company’s updates throughout the year, including its win at The Aesthetics Awards 2024 ceremony.

This was followed by educational talks from PCA Skin national advanced educator Karen Olsoy, aesthetic practitioner Dr Hannah Higgins and brand communications consultant Sophie Attwood.

After more food and refreshments, the evening concluded with an awards ceremony to mark the achievements of PCA Skin stockists.

Rachel De Bono, PCA Skin brand support coordinator, said, “Thank you to everyone who joined us at this year’s Social Symposium. PCA Skin is committed to creating and shaping a stronger, more connected community. Through these special educational and networking events we continue to build even greater things together and drive our shared vision forward.”

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Aesthetics | December 2024

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Conference Report

Galderma GAIN Masterclass provides education in London Pharmaceutical company Galderma held its educational GAIN Masterclass at County Hall in London on November 12.

The event welcomed 216 healthcare practitioners to experience a variety of presentations, discussions and live injectable demonstrations from speakers Dr MJ Rowland-Warmann, Dr Alessandra Haddad, Dr Ash Soni and nurse prescriber Michelle McLean.

The speakers highlighted their use of Sculptra, a poly-L-lactic acid-based product designed to stimulate collagen production. Dr Rowland-Warmann and Dr Haddad performed live injections, demonstrating techniques such as the slimming lift, firm and lift Restylane application, and addressing a rapid weight loss case.

Dr Rowland-Warmann reflected, “Sculptra is an injectable that I know and love.

With it coming to market 25 years ago, it really has stood the test of time, and today has been a great opportunity to learn how other practitioners are using it. The masterclass has been thoroughly enjoyable, with the educational and organisational standard being exceptional.”

Dr Ash Soni added, “We’re entering a new era, the undetectable era of natural results, and things like Sculptra are at the forefront of this movement.”

In the same week, Galderma hosted a ‘Beauty Through The Ages’ event at Tate Britian, where Dr Haddad met with 30+ journalists and influencers and showcased the company’s 40-year heritage of leading science-based innovation.

Education

Teoxane holds XPAND 2024 conference Global aesthetic manufacturer Teoxane’s XPAND 2024 event, held in London on October 21, brought together professionals from across the aesthetics specialty to discuss trends, clinical safety and technological advancements.

The event covered a range of topics, including artificial intelligence, patient psychology and digital marketing strategies, with insights from speakers such as aesthetic practitioner Dr Benji Dhillon and AI consultant Katie King.

The afternoon of XPAND comprised clinical content such as cadaver reviews, anatomy, technique and product (ATP) overviews, as well as three live demonstrations showcasing ATP treatment fundamentals in each area. Aesthetic practitioner Dr Lee Walker explored the ageing process with tailored treatment plans, while ophthalmologist Dr Tahera Bhojani Lynch and aesthetic practitioners Dr Raul Cetto and Dr Raj Thethi carried out a review of upper body anatomy with evidence-based treatment tips.

Sandra Fishlock, managing director of Teoxane, commented, “XPAND 2024 represents not just an event, but a community of forward-thinking practitioners and innovators. Our HCP partners’ passion and dedication are what drive the future of aesthetics, and we are honoured to be on this journey with each and every one of the exceptional practitioners that make up our specialty.”

Aesthetics | December 2024

News in Brief BABTAC issues warning on unqualified liposuction training A BBC investigation has uncovered UK training centres offering one-day ‘fat reduction masterclasses’ to aesthetic practitioners, despite it being illegal for non-medics to perform surgical procedures such as liposuction. In response, the British Association of Beauty Therapy & Cosmetology (BABTAC) has issued a stark warning to the aesthetics sector and its patients. Lesley Blair, BABTAC CEO and chair, stressed that liposuction is a complex surgical procedure that should only be carried out by qualified surgeons. “This is not a treatment that can be safely performed by untrained practitioners,” Blair stated.

Medik8 announces partnership with The British Beauty Council Skincare brand Medik8 has become a patron of The British Beauty Council, aiming to drive positive change across the beauty industry. The partnership will focus on future talent, ESG and policy initiatives to support the beauty sector and its workforce.

Laura Watson, chief customer experience officer at Medik8, commented, “We’re passionate about driving positive impact for our community. Partnering with The British Beauty Council was a natural fit, providing us with a real opportunity to play an active role in shaping the future of our sector.”

Mr Tunc Tiryaki receives Parliamentary Medal of Honour Consultant plastic surgeon Mr Tunc Tiryaki has been awarded a Medal of Honour & Outstanding Contribution for Humanitarian Efforts by the UK’s Parliamentary Society.

Mr Tiryaki’s efforts within the International Society of Aesthetic Plastic Surgery (ISAPS) have delivered medical care to those in need. Mr Tiryaki comments, “Through our efforts, we weren’t just healing physical scars; we were restoring dignity and a sense of self-worth.”

AlumierMD introduces EverActive C&E + Peptide as single unit AlumierMD has released EverActive C&E + Peptide as a single unit to increase patient conversion. The product is designed to increase hydration and brightness, and AlumierMD shares its aim to build trust between patients and professionals, along with better in-clinic results.

Dr Rayhaneh Zahedi commented, “As soon as patients see the benefits to their skin after using EverActive C&E + Peptide, they will likely be converted.”

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Hyaluronic Acid in Medical Aesthetics Dr Lee Walker discusses the benefits of HA to meet the needs of healthcare professionals and patients and quickly using hyaluronidase, which adds a layer of control and safety. This natural degradability and flexibility make HA fillers particularly safe and adaptable.

The ‘pillow face’ effect explained

Since the 1990s, hyaluronic acid (HA) has been a foundational component in the field of aesthetics, valued for its ability to treat an array of aesthetics needs, from signs of ageing to skin quality concerns. Scientific advancements have allowed manufacturers to refine HA, creating minimally invasive, reversible, and highly effective formulations that offer natural-looking results and a strong safety profile. However, recent discussions on social media, within patients and the healthcare community have raised concerns about its efficacy and aesthetic outcomes. Terms like ‘pillow face’ and ‘filler fatigue’ have surfaced, linking HA to unnatural results. In response, an international panel of experts reviewed HA’s profile and role in modern aesthetics.

Evolving perceptions of HA fillers Despite strong clinical support for HA fillers’ safety and efficacy, evolving perceptions have brought new scrutiny.

Social media and popular discussions have amplified concerns about HA’s potential for overfilled or unnatural results, leading to terms like ‘pillow face’ and ‘filler fatigue.’

Additionally, awareness of filler dissolving as a conservative option has increased, prompting a reevaluation of HA’s true capabilities and limitations.

HA fillers and natural degradation HA is a natural component of human tissue that promotes skin hydration and elasticity.

HA fillers are biocompatible and gradually degrade over time. A significant advantage of HA is its reversibility – practitioners have the possibility to dissolve HA fillers safely 18

The term ‘pillow face,’ associated with unnatural, overfilled appearances, typically arises from product overuse or inadequate injection techniques rather than the properties of HA itself. This effect was more common with early-generation fillers, which were denser and required precise skill to achieve subtle outcomes. Today’s HA fillers are available in a range of consistencies, allowing for natural, refined enhancements when injected by trained professionals who assess each patient’s facial structure, movement, and goals. Achieving balanced results relies heavily on practitioner expertise and selecting the right product for each treatment area.

Understanding and preventing filler migration Concerns about HA filler migration often stem from misunderstandings of filler behaviour in tissue. Properly administered, HA fillers are designed to remain in the targeted area, but migration can occur under certain conditions, such as excessive application, limited anatomical knowledge, or poor technique. In some cases, fillers with low cohesivity (ability to maintain shape) may be more likely to spread.

By ensuring the correct technique and selecting fillers with suitable properties, practitioners can minimise migration risk and achieve the desired results.

Supporting safe and effective use through education and standards Optimal results with HA fillers depend on proper education, best practices, and accountability across the aesthetics field, through three primary pillars, to uphold standards: 1. Advanced training and workshops Ongoing education equips healthcare professionals with techniques for precise application, product selection, and individualised patient care. Hands-on workshops enable practitioners to achieve natural-looking results while minimising adverse effects.

Aesthetics | December 2024

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2. Consensus papers and clinical guidelines Evidence-based guidelines and consensus papers educate practitioners on proper injection methods, filler migration, and filler dissolving techniques. These resources promote a unified approach and clarify misconceptions about HA fillers.

3. Best practices in patient care and product choice · Patient assessment: Detailed patient assessments, considering anatomy, facial dynamics, and prior treatments, are crucial for individualised care. · Injection technique: Precise injection methods ensure even filler distribution, supporting optimal results and reducing migration or overfilling risks. · Product selection: Choosing high-quality HA fillers with appropriate rheological and hygroscopic properties helps meet specific treatment needs while maintaining safety and effectiveness.

The enduring role of HA Healthcare professionals prioritise certain qualities in dermal fillers, including biocompatibility, ease of use, versatility across procedures, and the ability to achieve natural results with appropriate longevity. Based on these criteria, HA fillers remain the preferred choice in medical aesthetics. Their adaptability, proven safety profile, and ability to meet diverse patient needs continue to position HA fillers as a leading solution for facial enhancement treatments.

The future of HA in aesthetics Due to its versatility, safety, and accessibility, HA continues to be a top choice for meeting the demands of healthcare professionals and patients alike.

With ongoing advancements in technology, HA’s potential to cater to an evolving patient base and market is set to grow, solidifying its role in aesthetic practice for years to come.

Dr Lee Walker is a cosmetic dental surgeon, director and clinical lead at the multi-award winning BCity Clinics, Liverpool, and has more than 20 years’ experience in the field of medical aesthetics.

He is a key opinion leader for Teoxane.

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News Special Autumn Budget

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Navigating the Impact of the Autumn Budget Aesthetics looks at what the Autumn Budget means for clinic owners Last month saw the Labour Government’s first budget in over a decade. While the budget aims to boost the economy through new strategies and invest in public services, many small business owners, including those in the aesthetics specialty, may face mixed impacts.

Key budget measures such as National Insurance adjustments for employers, business rates relief, wage increases and digital tax initiatives may affect clinic operations, staffing and financial planning.1 Aesthetics spoke to business consultants Sue Thomson and Alan Adams to find out how the specialty might be impacted, and what people can do to help navigate these changes.

Impact on profitability The budget outlined National Insurance changes, which will see the increase of employers’ contributions from 13.8% to 15%, as well as the threshold for paying National Insurance being lowered from £9,100 to £5,000. However, to support small businesses with these changes, the government is increasing the Employment Allowance from £5,000 to £10,500 and removing the £100,000 threshold, expanding this to all eligible employers.1

She suggests utilising accounting software, like Xero and QuickBooks, that are compliant with HM Revenue & Custom’s digital tax requirements.2 “Practice management software will also be useful for streamlining financial management – this integration helps capture sales data automatically, aiding in accurate tax reporting,” she says.

Adams believes that outsourcing can also be a good idea for those struggling. He says, “The first thing I always recommend is to outsource admin around accounts. A good bookkeeper and accountant will often do things much more efficiently, better and faster than you. I’ve seen people get these things seriously wrong and end up owing taxes or worse still, not claiming for everything they are entitled to.”

Four key budget measures affecting small businesses:

The minimum wage has also increased from £11.44 to £12.21 for staff aged 21 and over.

This may affect clinics who have junior or entry level staff.1

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Thomson suggests that aesthetic clinic owners can mitigate rising employer National Insurance and wage costs by focusing on three key areas: operational efficiency, revenue optimisation and supplier cost management. “Investing in training can enable staff to perform a wider variety of treatments, increasing their overall value without needing additional hires. This also enhances service quality and patient satisfaction. Utilising part-time roles or freelance practitioners for specific treatments, especially during off-peak hours, can optimise labour costs,” she says.

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Thomson also suggests negotiating with suppliers for preferential rates or discounts, noting, “Even small changes in supply costs can positively impact your bottom line.”

Adams suggests analysing staff roles and their time in clinic, explaining, “Front-of-house staff tend to be at the lower end of the pay scale; however, they’ve also got one of the most important roles as they’re the first and last to be seen by patients. It’s worthwhile understanding if and when there are any quiet times in the clinic and perhaps reducing operating hours to improve efficiency.”

Making pricing adjustments Thomson believes pricing adjustments will be a natural consequence that clinics may have to consider. “Rather than blanket price increases, clinics can adjust prices on high-demand, premium services where patients are less price-sensitive. This allows core services to stay accessible while keeping profitability intact,” she says. She adds that loyalty or membership programmes can create steady revenue by offering patients regular treatments at a discount. “It’s a win-win, building retention while providing consistent cash flow” she says.

Adams emphasises the importance of communicating any price increases to your patients.

He says, “A way to position this could be, for example, ‘overall clinical cost have gone up by 15% in the last 18 months, but the good news is that we are capping these rises to 8% for our patients’. It may be that the 15% figure is higher taking into account energy bill increases. Another way to implement changes could be to offset price rises by offering patients today’s prices for treatments they are going to have in the future. This provides you with a cash injection but also keeps their costs down.”

The shift to digital compliance The Government also highlighted the need to streamline the tax system through digitalisation, which could reduce administrative burdens and help clinic owners streamline compliance tasks.1 Thomson notes that while this may seem like a challenge for smaller clinics with limited resources, it’s easier than people may think.

Aesthetics | December 2024

Increased employer National Insurance contributions – employers’ National Insurance rates rise from 13.8% to 15%, with the threshold for payments lowered from £9,100 to £5,000, increasing payroll costs Reduction in business rates relief – the current 75% discount for small businesses will drop to 40% in 2024, increasing operational costs, particularly for those in high-rent areas

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National living wage increase – the minimum wage for workers aged 21+ will rise to £12.21 per hour, raising staff costs for many businesses Simplified digital tax system – a push towards digitalisation aims to reduce tax filing burdens, but small businesses may need to invest in technology to comply

Seeking help Thomson says that for anyone who is struggling, there are several support options open to aesthetic businesses.

“Regional small business grants or innovation funds, available through UK Government channels or local councils, can help clinics invest in technology or training.

Programmes like Business Gateway and Funding Circle are good places to start for digitalisation or growth support,” she concludes.3,4 VIEW THE REFERENCES AT AESTHETICSJOURNAL.COM 19

Special Feature Exosomes and Hair

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Regenerating Hair with Exosomes Practitioners detail their approaches to enhancing thin and damaged hair with exosomes Hair is often regarded as a crucial aspect of self-identity. It can be altered and styled to each person’s individual preferences fairly quickly and easily, with a full head of hair being perceived as a sign of youthfulness, vigour and status.1 When a person loses hair, it can lead to significant psychological stress. Mild to severe symptoms associated with hair loss include anxiety, anger, depression, embarrassment, decreased confidence, reduction in work, declined interest in intimacy, social withdrawal and suicidal tendencies.1 Being able to offer a hair loss solution to people affected can be hugely rewarding for practitioners. A recently emerging non-surgical option is the use of exosomes.2,3 Here, we talk to three practitioners about understanding hair loss, how exosomes can help, what brands they use and the potential results they can achieve.

Understanding hair loss People can lose their hair for a variety of reasons. One of the most common types is androgenetic alopecia. Often referred to as male or female pattern baldness, this hereditary condition shrinks hair follicles and shortens the hair growth cycle.4 20

“I would emphasise that we shouldn’t just rely on one treatment to get the best results.

Consider combining exosomes with other regenerative approaches such as polynucleotides or PRP” Dr Olha Vorodyukhina

Aesthetics | December 2024

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Before

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Special Feature Exosomes and Hair

Dr Olha Vorodyukhina and Dr Juliah Tbarani, and consultant plastic surgeon Mr Sofiane Rimouche. They note that having this information may lead practitioners to recommending other interventions before or alongside treatment.

After

Dr Vorodyukhina explains, “It’s important to check patients’ lifestyle and diet. Things like stress and poor nutrition can influence hair loss, so making some adjustments to better manage these can help.” As an example, she notes that people who are vegan or vegetarian can sometimes be deficient in iron, which can lead to hair loss, so introducing an iron supplement is worthwhile.5 “Looking at each person holistically is so important,” agrees Dr Tbarani, highlighting that she offers blood investigations to every patient to identify any deficiencies, hormonal imbalances Figure 1: Before and after three sessions of E-50 Hair Exosomes, spaced three weeks apart.

Images courtesy of Mr Sofiane Rimouche. or underlying medical issues, which enables her to create a bespoke plan for each. She adds, “We Alopecia areata is another type of hair loss. Affecting should also be very careful with managing patient expectations approximately one in 500 people in the UK, this is an – hair loss is a sensitive subject, and results will vary between autoimmune condition that causes patchy hair loss when the patients. Ensuring they know how long it will take for results to immune system attacks hair follicles.4 become visible, how long they will last and how significant the Alternatively, some people may suffer from telogen effluvium, difference will be is so important.” a temporary form of hair loss that occurs when many follicles Mr Rimouche emphasises, “Practitioners need to understand enter the resting (telogen) phase, leading to excessive the hair cycle and conditions that can occur in order to diagnose shedding. This can be as a result of stress, illness, major surgery, appropriately, rather than offering treatment randomly. Having cancer treatment, sudden weight loss, hormonal changes and thorough training on this will ensure you act ethically and safely.” imbalances, or nutritional deficiency.4 Identifying what type of hair loss your patient is suffering from is key to tailoring treatment approaches and achieving successful results, agree dentist and aesthetic practitioners Before

The science of exosomes Exosomes are small vesicles that carry important materials such as DNA, RNA, proteins, lipids and growth factors from one After

Figure 2: 65-year-old patient before and five months after receiving four HRLV Exosomes treatments, spaced four weeks apart. Images courtesy of Dr Juliah Tbarani.

Aesthetics | December 2024

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Special Feature Exosomes and Hair cell to another. Research has found that exosomes play an important role in modulating paracrine signalling, whereby cells are able to communicate with one another and induce changes.

This enables exosomes to stimulate repair and regeneration of aged and damaged hair follicles, leading to improvements in hair density and quality. 2

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Before

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There are various types of exosomes available, sourced from humans, plants and animals. As human-derived exosomes are not approved for use in the UK, plant and animal-based products are the mainstay. All are applied topically or via microneedling, as they are not licensed for injection.6

Selecting a brand Dr Vorodyukhina uses EXO-GROW Figure 3: Before and four weeks after two treatments with EX-GROW and Dermapen microneedling. from DermapenWorld. “I’ve used the Dermapen microneedling device and the EXO-SKIN range for years with Dr Tbarani uses HRLV Exosomes, developed by ExoCoBio. excellent results, so it made sense to They utilise ExoSCRT technology, which comprises exosomes try the exosomes brand when it came out,” she says. from rose stem cells. HRLV Exosomes are specialised for The EXO-GROW range uses a patented complex of ingredients hair and scalp rejuvenation, promoting healthy hair growth that includes PDRN polynucleotides, clinically shown to by providing essentials nutrients that address hair loss and stimulate hair follicles, improve blood circulation and thickness scalp inflammation.9 of hair, and alleviate scalp inflammation by up to 47%.7 Sophora japonica stem cells are also included, which have been shown to inhibit the activity of 5 Alpha Reductase, leading to reduced production of the dihydrotestosterone hormone that contributes to hair loss.7

Dr Vorodyukhina adds, “They also have multiple amino acids, which play a vital role in hair growth and scalp regeneration, improving circulation and protecting skin from oxidative stress. Three to four treatments are usually recommended as a minimum, but we can go up to six if a person has significant hair loss. These are generally spaced two weeks apart, and in between sessions and patients are advised to use the at-home shampoo, conditioner and hair mask. I also really like the EXO-GROW Lash & Brow Serum. It contains myristoyl pentapeptide-17, which is clinically proven to increase lashes by more than 61%.7 Some patients see improvement in the quality of hair after the first or second session, but we usually need to allow at least six to eight weeks for optimal results.”

Finally, Dr Vorodyukhina highlights that patients welcome the fact that EXO-GROW is plant-based, particularly those who are vegan or vegetarian and want to avoid using animal-derived products.

E-50 Exosomes are Mr Rimouche’s product of choice. “I used to do a lot of PRP, but I changed to exosomes as it’s a simple treatment that can deliver really effective, reliable results,” he explains.

Using the patented ENTR Technology, E-50 Exosomes are collected from salmon testes cells and then cultivated in embryonic stem cell media. Both the cell host and the cell media which are utilised in the creation of E-50 Exosomes are fully salmon-derived. Mr Rimouche says, “The process ensures they are purified effectively, so have low levels of free radicals and impurities.”8 He explains that five treatments are recommended – the second one two weeks after the first, and then each subsequent session four weeks after the previous.7 22

“I chose this brand as rose stem cells have a strong scientific history of supporting skin health,” says Dr Tbarani. She continues, “The company has also demonstrated that they are sourced ethically and appropriately, and go through a strict manufacturing process within their state-of-the-art GMP facilities to maintain their purity.”9 Dr Tbarani uses a microneedling pen to apply exosomes to the scalp in three to five treatments spaced four weeks apart. She says patients can get back to their daily activities straight away and can wash their hair the next day.9

Treatment risks and side effects The practitioners highlight that one of the main draws of exosome treatment is the minimal side effects. Patients can expect mild redness and irritation immediately following each procedure, and there have been no reported complications with any of the exosome brands mentioned.

Dr Vorodyukhina advises, “There is a minimal risk of allergic reaction, so it’s important you carefully outline ingredients and take a full medical history during your consultations.”

To avoid risk of infection, using an aseptic technique is also important, emphasises Mr Rimouche.

Dr Tbarani adds, “When selecting a product, really investigate exactly what’s included and understand how it is purified. Some companies claim to use ‘the most’ amount of exosomes, but if they aren’t purified correctly, then they are not going to be as safe or effective as a brand that has less. Also, if they’re mixed with lots of different ingredients there could be a higher chance of allergic reaction, and it may be more difficult to identify the source.”

Transformative results and ongoing care Like most aesthetic treatments, exosome results aren’t permanent so maintenance procedures and ongoing care is needed to continue to see a reduction in hair loss and improvement in hair quality.

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A worthy investment

“We should be asking about the purification, storage and transportation process to ensure exosomes’ efficacy”

Adding exosomes to your treatment portfolio is a no-brainer, says Mr Rimouche. “There’s a growing market for regenerative treatments and exosomes are becoming more well-known amongst patients. The treatment can also be performed by a therapist, so there’s more opportunity to offer appointments,” he notes. When choosing a brand to use, each of the practitioners highlight the necessity to do your research into the source of the products, the clinical research supporting their use, and real-life experience from peers. Dr Tbarani emphasises, “Specifically in regards to exosomes we should be asking about the purification, storage and transportation process to ensure their efficacy.”

Mr Rimouche adds that it is hugely valuable to invest in a company that will provide training, ongoing support and fairly priced products. “Ask in advance what they offer to make an informed decision before purchasing,” he concludes.

Checklist for purchasing exosomes

Dr Juliah Tbarani

Each of the practitioners recommend patients use specific hair care between treatments.

These include shampoos, conditioners, scalp masks and serums. Mr Rimouche says that it is essential to continue to stimulate hair growth at home for optimal results.

“So far, we have only had positive results and happy patients with EXO-GROW,” says Dr Vorodyukhina. “We have seen improvement in hair density, with the scalp less visible and a reduction in the receding hair line. Patients are also reporting that they are shedding less hair in the shower and when they brush it,” she notes.

Dr Tbarani highlights treatment with HRLV Exosomes can last 12-18 months.9 “I book patients for review after a year and many are still seeing improvement,” she says, noting, “Most see improvement from nine weeks as their hair shaft thickens and their hair looks healthier. Many will get their natural curl back and added shine!”

Mr Rimouche adds, “We have a very high satisfaction rate with E-50 Exosomes, not only because of the excellent results but the fact that treatment with exosomes is not very painful and does not have any downtime.8 It’s just a matter of maintaining results long term.”

Combining treatments Dr Vorodyukhina says that exosomes have been a game changer in her practice, but is quick to add, “I would emphasise that we shouldn’t just rely on one treatment to get the best results. Consider combining exosomes with other regenerative approaches such as polynucleotides or PRP. We also use exosomes to improve growth following a hair transplant.”

Clinical Advisory Board member and aesthetic practitioner Dr Sophie Shotter provides her advice for using exosomes

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Remember that exosomes are merely a delivery mechanism. We need to understand their origin and what they contain rather than just jumping on the word ‘exosome’.

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Check the origin of the exosomes. In the UK, anything of human origin is not legal. This is clearly defined in UK legislation, as adopted from EU Regulation.

Read the packaging. There are, unfortunately many products on the UK market which may not be as clear cut in terms of origin as one is led to believe. An easy way to differentiate between plant and animal derived products is by reading the packaging and looking for whether the product is a ‘lyophilised powder’. If so, then this tells us it is likely not of plant origin as the freeze drying lyophilisation process is not needed for plant derived products.

 

Look for clinical studies. his is to be done if at all possible, as many products in the exosome space at present lack these.

Have a critical eye. The responsibility here isn’t just on the distributor but also on the person administering the product – if they are administering something which is illegal in nature (even if it’s purely because they haven’t done full due diligence), then they could also face investigations from regulatory bodies.

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Alternatively, Dr Tbarani says she doesn’t tend to combine exosomes with other procedures straight away. “I see excellent results and I like to know exactly what has caused them.

Performing treatments in isolation means I can demonstrate to my patients exactly what exosomes can do on their own,” she explains. Of course, she will offer adjunct treatment to certain patients to maximise their results, particularly in more complex cases, after a course of exosome treatment.

Aesthetics | December 2024

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Event Preview Clinical Practice News2025 ACE

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ACE 2025 Marks its Return Join your community to achieve clinical and business excellence Following the excitement of The Clinical Cosmetic Regenerative (CCR) Congress 2024, which united the medical aesthetics community this past October, you may be asking: what’s next on the aesthetics calendar? Get ready for the Aesthetics Conference & Exhibition (ACE) 2025, returning to the Business Design Centre in London on March 14 and 15!

ACE is your opportunity to take a deep dive into the science of aesthetics, learn from experts, and experience the latest advancements and innovations. Hear from key opinion leaders (KOLs) and witness live demonstrations, educational workshops, networking opportunities and an exhibition full of the latest products in the aesthetics market.

We are delighted to announce that Allergan Aesthetics, an AbbVie Company, is this year’s Headline Sponsor and will be hosting two days of free educational symposiums, reinforcing the company’s dedication and commitment to co-creating the future of medical aesthetics.

With registration now OPEN, be sure to mark your calendars for what promises to be an exclusive educational and developmental experience, uniting medical professionals from around the globe.

Live injectable education and demonstrations

Leading pharmaceutical company Allergan Aesthetics, an AbbVie Company, is set to deliver two days of leading injectable content exclusive to ACE. With them, they bring world-renowned KOLs to the Main Auditorium, making this a must-attend for medical professionals eager to expand their skill sets and empower their patients with confidence.

Enhance your skills and professional development

Our clinical and business agendas feature a faculty of KOLs unique to ACE, giving you access to five free-to-attend CPD-certified conferences. Experience a range of live injectable content, device and skincare demonstrations, as well as crucial business advice.

We’re excited to announce that we have rebranded some of our theatres to better capture the essence of the educational experiences they offer. Here is what you can expect for ACE 2025…

Allergan Aesthetics Main Auditorium Journey through treating the full face with expert speakers, live injectable demonstrations and exclusive brand-new content from Allergan Aesthetics, an AbbVie Company, our Headline Sponsor. A must-attend for medical professionals seeking to expand their skillset and discover the latest research to improve product knowledge, better decision-making and enhance patients results.

The Innovation Forum Get ready for a series of engaging sessions featuring the latest product launches, innovative breakthroughs and advanced techniques. Leading KOLs will take to the stage to unveil their boldest ideas and cutting-edge innovations, offering you an exclusive look into tomorrow’s top trends.

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Aesthetics | December 2024

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Event Preview Clinical Practice News2025 ACE

Your gateway to clinical education Returning for 2025, the Platinum Hall brings together the specialty’s most sought-after companies in one destination. Immerse yourself in innovation and clinical expertise as leading aesthetics brands showcase scientifically backed products and groundbreaking advancements. The Platinum Hall also serves as a direct gateway to the Main Auditorium and Aesthetics Mastery Theatre, where top-tier injectable education takes place. Open to everyone, the Platinum Hall is located above the show floor. Confirmed Platinum Sponsors at ACE include Allergan Aesthetics, AestheticSource, Alma, Crown Aesthetics, DermaFocus, Galderma, Medfx and Neauvia.

Meet leading brands Across the busy show floor, both new and established aesthetic companies will bring you the latest products, devices and solutions in the vibrant exhibition area. This will give you the opportunity to explore new options to better your business as well as gain new contacts. Confirmed companies include BTL Aesthetics, Cutera, Croma, DermapenWorld, Hydrafacial, Merz Aesthetics, SkinCeuticals, Sciton, Vivacy and more.

Connect with your community As well as learning, connecting with your peers, friends, suppliers and other aesthetics practitioners is crucial for that all-important advice and support.

Forge genuine connections with the best in the field, exchange insights, discuss emerging trends and gain perspectives from various corners of the specialty at multiple drinks receptions, networking areas and pre-arranged meetings. Opportunities include:

Aesthetics Mastery Theatre Experience live demonstrations and in-depth discussions led by top experts, revealing the techniques and products that are shaping the specialty. Perfect for those who want to go beyond the surface and explore the precision, skill and expertise behind today’s leading treatments.

In Practice Theatre Delve into the latest insights on all things business, including brand building, opening a clinic, mental health, marketing, finance and more. The In Practice Theatre combines the best business minds and award-winning practitioners for live talks, making it the perfect place for clinic owners and teams to discover essential commercial support. Additionally, don’t miss the chance to visit the In Practice Zone in the ACE gallery, where you can connect with service and solution providers who are ready to help you drive the success of your business.

Association Theatre Whether you’re a seasoned professional or just starting out in the field, the Association Theatre is your go-to destination for invaluable resources to elevate your practice. Engage with leading associations at the forefront of the aesthetics field as they discuss essential topics such as ethics, safety and the latest developments in the specialty.

• DermapenWorld Networking Drinks, open to everyone.

• Alma VIP Lounge, invite only.

• In Practice Zone Networking Drinks, open to everyone.

Plus, more to be announced!

Celebrate the specialty at The Aesthetics Awards On March 15 after the second day of ACE, the community will come together to celebrate the achievements of the aesthetics specialty by attending the prestigious Aesthetics Awards. With over 10 years running, the Awards will return for a third year to the dazzling Grosvenor House Hotel, and will host the field’s top KOLs, rising stars and leading brands. It’s the perfect way to round off two jam-packed days of education, expand your network and have fun with like-minded professionals.

Early Bird tickets are now on sale! Purchase yours before December 31 to enjoy a discounted price and guarantee your spot for an unforgettable evening of glitz and glam.

Entry for the Awards has closed, and all finalists will be revealed in the January issue of the journal – good luck to everyone who entered!

14 & 15 March 2025 Business Design Centre, London

Register for ACE 2025 for free now by scanning the QR Code

Aesthetics | December 2024

*AbbVie has part sponsored this event, this includes provision of a stand and/or a speaker program/ medical symposium. AbbVie has had no influence over the content / topics covered in other parts of the agenda.

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CPD Pain Relief

Understanding Pain Relief Options in Aesthetic Procedures Three practitioners review pain relief options in aesthetic procedures, ranging from simple topicals, to custom agents and nerve blockers Millions of people worldwide seek cosmetic treatments to enhance their appearance and boost their confidence.

Concerns about pain or discomfort may be the deciding factor in a patient opting to go ahead with treatment, and indeed fear of needles, injections and/or pain are a barrier in 65% of more than 14,000 aesthetically conscious individuals surveyed.1 In addition, in many of these treatments, a course or maintenance schedule will achieve the best results. A negative patient experience may sway an individual against further treatments, and therefore limit the effectiveness of treatment plans. Effective pain relief improves patient satisfaction, increases the likelihood of referrals and builds a bank of repeat customers.

As an area of critical importance, there is ongoing innovation in the field of pain relief in aesthetics. Options over the counter include systemic analgaesia, topical anaesthetics, higher strength topical numbing agents that can be compounded, devices using cryotherapy or vibration.2 Novel options include neuro-cosmetic topical agents reducing post-procedure pain, microneedle patches and virtual reality. Nerve blocks can also be used for more invasive procedures.

This article will explore various pain relief options, detailing their practical applications.

Mental distraction techniques The body of available evidence supports distraction techniques for needle-related pain in children.3 In adults, evidence is of lower quality, but shows some benefit to certain distraction techniques. In particular, breathing interventions such as asking the patient to cough or hold their breath can be effective in any treatment.

Additionally, warning or priming the patient to experience pain, for example with the ubiquitous phrase ‘sharp scratch’, is potentially less useful than a simple warning about the impending procedure, such as ‘ready?’.4 Cognitive load from another task can reduce pain perception and concurrent stress can also modulate pain perception, though both factors are highly subjective.5,6 More recently, novel studies looking at virtual reality have also shown it can be

an effective pain relief option for medical procedures.5 This immersive virtual reality is delivered by high resolution head-mounted displays, with built-in sound. This limits treatment areas to those not covered by the display unit and may be more suitable in body treatments in aesthetics.7 Distraction ranging from simple to complex virtual reality set ups have the benefit of being suitable for any patient, in any procedure and can be used as an adjunct to other pain relief options.

By tailoring a combined analgaesic offering to the individual patient’s pain threshold, medical history, skin type and treatment plan, patient comfort and satisfaction can be ensured Devices Devices can be used as the sole method of pain relief, and are generally non-invasive and well-tolerated. The choice of device may depend primarily on logistical factors e.g. the size of device contact area vs. size of treatment area.

Vibration Vibratory stimulation, using a vibration anaesthesia device applied to the treatment site for a few seconds prior to the procedure, has been shown as effective to reduce pain perception at time of injection.

This is particularly true of older men undergoing head and neck procedures, though the reasons for this are not known.8 Aesthetics | December 2024

The mechanism of action is stimulation of vibratory signals along nerve fibres, effectively blocking noxious signals from reaching the brain.9 Using vibration at an injection site could be of use in the aesthetic clinic.

Anecdotally, people use the vibration device close to but removed to the injection site, especially if they have an assistant.

This is then held on during the injection.

Light therapy Low-level laser therapy (LLLT) involves the use of laser energy to reduce pain and inflammation at the treatment site by blocking action potentials at the epidermal neural network, as well as enhancing fibroblast activity. It has been shown to be effective in acute sprains, post-surgical pain and orthodontic procedures, among others.

They can be used 10 to 20 minutes prior to a procedure, achieving an approximately 30% neural blockade.10 Laser or light emitting diode (LED) lights are able to help reduce pain, but any device chosen should be checked to ensure it can provide irradiation within the effective parameters.11 These devices could be used in larger treatment areas and post surgically, as well as around injection sites.

Cryotherapy Cold temperatures can be used to vasoconstrict the treatment area and reduce nerve conduction velocity. This has the immediate benefit of analgaesia, with additional benefits of reducing post-procedure bruising, swelling and redness.12 Cold therapy can range from low tech ice packs or cooling masks, to cold spray, to large cryotherapy devices which blow over a large treatment area, to specific point cryotherapy devices with temperature control such as TargetCool or Artek Spot.

Cryotherapy is effective in reducing the pain of dermal filler injections and laser.13,14 It has even been shown to have a good effect in intraocular anti-VEGF injections to treat retinal conditions.15 There is a risk of frostbite if uncontrolled temperatures are applied to an area for too long. Patients with Raynaud’s disease, cryoglobulinaemia or cryofibrinogenaemia would not be suitable for colder 27

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Novel studies looking at virtual reality have also shown it can be an effective pain relief option for medical procedures cryotherapy treatments. In addition, there is a risk of syncope or headache for any patient where cryotherapy is used around the forehead area.12

recovery area available. Careful patient selection is key in this intervention.18 Topical anaesthesia

However, overall it can be considered a great treatment option as it has specifically been studied in aesthetic applications, is non-invasive and is suitable for most patients.

Topical anaesthetics are applied directly to the skin to numb the area, and are widely used in the aesthetics field. Common agents include lidocaine, tetracaine and prilocaine in a variety of combinations and strengths.

Pharmacological

Topical anaesthesia requires 20-60 minutes of contact time to take effect, which varies by concentration and type of product, as well as location used e.g. lips have thinner skin and therefore have quicker absorption than the forehead.19

It is best practice to have an anaphylaxis emergency kit available if any pharmacological treatments are going to be administered.

Systemic oral analgaesics Simple over-the-counter analgaesia i.e. paracetamol and non-steroidal anti-inflammatories (NSAIDS) are inexpensive, widely available and generally well-tolerated. They can reduce the experience of pain during a procedure, but also manage post-procedure discomfort.

A single dose of paracetamol has an onset under one hour and provides a 50% reduction in pain over four to six hours.16 Ibuprofen has a similar onset with a six-to-eight hour duration.17 Therefore, a patient can be advised to take one or both prior to the procedure as part of your usual pre-treatment information, which can also impart a sense of agency and control. Of course, the usual prescribing cautions remain in cases of gastritis, liver damage and allergy.

Oral sedation A light anxiolysis with diazepam or lorazepam may be appropriate for intensive and painful procedures, such as deep laser resurfacing. They can reduce anxiety and discomfort, allowing laser settings to be pushed to the most effective level for the patient’s desired results. This should not be given lightly as there is a risk of respiratory depression with deeper sedation. Sedation is logistically difficult, requiring a patient to be escorted to the clinic, and accompanied at home for the following 24 hours. We would suggest this is really only done by medical prescribers who are able to monitor the entire treatment and have a 28

In general, they are easy to apply, non-invasive and sufficiently numbing for superficial treatments. At higher concentrations in particular, they can cause skin irritation and allergic reactions. Care must be taken not to exceed the maximum systemic dose when applying over large areas, and they should not be used on broken skin.20 They also should not be used in cases of porphyrias, G6PD deficiency, methemoglobinaemia or allergy.20 Several low-strength anaesthetic creams are available over the counter in the UK, including LMX4, EMLA, Denel and Nulbia.

These are easy to obtain and relatively inexpensive, with the patient able to use it at home prior to an appointment, increasing in clinic throughout. They take about an hour to be effective, reaching 3-5mm depth.

Higher strength prescription formulations are available in some countries. Tetrocaine 7% with lidocaine 7% has been shown be effective in as little as 30 minutes, and showed significantly better pain relief in comparison with lower dose creams.20,21 Compounding pharmacies such as Roseway Labs and Specialist Pharmacy can also be used to obtain bespoke anaesthetic formulations. As percentages increase, care must be taken not to exceed systemic toxic doses, which is more relevant when being used in combination with injected anaesthesia, as the measured absorption of lidocaine, for example, is only a tenth of that which could cause side effects by itself.22 Aesthetics | December 2024

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In addition, local anaesthetic can cause changes to skin colour and vasculature, and transient erythema could affect any laser treatment that targets red pigment.

In our practice, we perform red targeting laser treatments with cryotherapy and then use topical analgaesia for other laser procedures.20 With higher strength creams such as lidocaine 23% tetrocaine 7% there is a risk of irritant contact dermatitis, leading to post-inflammatory hyperpigmentation (PIH).24,25 As a result, in our practice we limit the use of high-strength compounded topical anaesthesia to in-office, under physician supervision. Care should be taken to limit the skin area used and systemic absorption. In Fitzpatrick skin types IV+, we use 30% lidocaine, which anecdotally has a lower risk of PIH. Injected anaesthesia Injected anaesthesia with lidocaine and/ or bupivacaine, combined with or without adrenaline, can be tailored to treatment.

Lidocaine gives a rapid, deep anaesthesia, while bupivacaine gives a more extended anaesthesia but with slower onset.26 A combination, or lidocaine alone, is sufficient for our in-clinic treatments. We choose to add adrenaline based on the bleeding risk of the procedure; for example, we use it in deep resurfacing laser around the eyes.

Anaesthesia delivered in this way is deeper and more targeted than topical treatment, with immediate effect. However, it is more invasive than topical anaesthesia, with a risk of introducing infection, allergy and systemic toxicity. Subcutaneous infiltration in the target area is commonly used, but extending your practice to include nerve blocks can anaesthetise a dermatome with a comparatively smaller dose of anaesthetic than infiltrating the entire area, as has been shown in scalp nerve blocks for craniotomy.27

Vibratory stimulation has been shown as effective to reduce pain perception at time of injection

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Nerve blocks can be used to block a specific group of nerves covering the desired treatment area, with 2ml boluses of 2% lidocaine usually sufficient.28

analgaesic offering to the individual patient’s pain threshold, medical history, skin type and treatment plan, patient comfort and satisfaction can be ensured.

Periocular

Infraorbital block For mid-face, lip and cheek. The infraorbital foramen can be felt at the infraorbital ridge, at around the mid-pupillary line. 2ml will be sufficient to block this nerve.29 Mental block For lower face, lip and cheek. This can be accessed percutaneously or intraorally, with an intraoral approach found to be less painful.30 The mental foramen can be palpated in the mandible, and 2-3ml can be injected around, but not inside, the foramen.

Scalp block For hair rejuvenation treatments. This involves the same nerves as the periocular block, with a different angle of approach. Here, the injection is above the brow and angled medially, with a single entry site used to reach both nerves.30 A finger can be placed over the supraorbital foramen to avoid diffusion of anaesthetic into the orbit.

In addition, the pre-auricular nerve is also targeted; 1cm anterior to the temporal artery at the level where the pinna joins the face, the needle is inserted anterior to the temporal artery, then angled backwards.31 Aspiration is particularly important here given the proximity to an artery, to avoid systemic dosing by injecting into a vessel.

The maximum dose of plain lidocaine varies slightly across sources, but a safe guideline would be 3mg/kg (not exceeding 200mg) and for lidocaine with adrenaline 6mg/kg (not exceeding a total of 500mg).32,33 Ideal body weight can be used in calculations for patients at extremes of weight.

Dental blocks Dental blocks should be avoided in patients with history of facial trauma or extensive dental work (unless done by a dentist/expert facial or head and neck surgeon) as landmarks can be altered.

There is a risk of nerve damage, infection and haematoma.34

Novel analgaesia New targets and modalities for pain relief are still being developed. For example, post-procedure neurocosmetics are being marketed that claim to suppress transient receptor potential vanilloid 1 (TRPV1). TRPV1 has been shown to be a key target in somatosensory response to noxious heat sensation.35 Delivery mechanisms are also undergoing proliferation, including novel dissolvable microneedle patches and films, providing effective pain relief without the need for traditional injections. These have not yet been used in aesthetics so more studies are needed.

Choosing the appropriate option The current market includes numerous options for pain relief, which can be used alone or in combination. Understanding these options gives aesthetic practitioners a large toolbox to select and tailor for their individual patients. The ability to provide a tailored analgaesic approach, in addition to access to advanced techniques such as custom anaesthesia and nerve blocks, is a powerful differentiator for the more highly trained practitioner. By tailoring a combined

Test your knowledge!

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

Questions

Possible answers A: Sharp scratch

1. What is the preferred verbal cue before an injection?

B: Ready?

C: This will hurt D: Don’t move

2. What is the maximum systemic dose of lidocaine with adrenaline for a healthy adult patient?

3. What is the depth of action of over-the-counter strength local anaesthetic creams?

A: 3mg/kg B: 500mg/kg C: 7mg/kg D: 300mg/kg A: 3-5mm B: 9-12mm C: 1-3mm D: 5-9mm A. 4ml

4. What is the safe limit of lidocaine?

B. 8ml C. 9.5ml D 11ml A: Low-level laser therapy

5. What does LLLT stand for?

B: Long-acting light lip treatment C: Lateral laser light treatment D: Large laser lip therapy Answers: B,C,A,B,A

Targeting the supratrochlear and supraorbital nerves for upper lid and forehead. The supraorbital notch can be felt in the upper orbit about 2cm from the midline; the needle is advanced from 0.5cm inferolateral to this, with care taken not to enter the notch.

Around 2ml of 2% lidocaine is infiltrated in a band medial and lateral to the notch. The supratrochlear nerve can be found at the supraorbital margin, 3mm medial to a vertical line drawn from the medial canthus.

Mr Richard Scawn is a consultant ophthalmologist and oculoplastic surgeon based at The Clinic at Holland Park, Harley Street and Chelsea & Westminster NHS Trust. He specialises in blepharoplasty, ptosis, eyelid reconstructions for cancer, burns and trauma. He is the founder and surgical lead for The Clinic Holland Park.

Qual: MBBS, BSc, FRCOphth Miss Jennifer Doyle is a consultant oculoplastic surgeon and founder of The Clinic at Holland Park. She also works within the NHS as Oculoplastics Consultant at Milton Keynes University Hospital NHS Trust. She has several years of experience integrating aesthetic and non-surgical treatments into her practice. She is a key opinion leader for Sciton, Sofwave, Skinstorm and Ameela.

Qual: BMBCh, MA(OXON), L7Cert, FRCOphth Dr Aaminah Haq is an ophthalmology registrar and aesthetic doctor at The Clinic Holland Park, where she provides aesthetic injectables, laser and ultrasound treatments. She uses a variety of pain relief techniques for her patients, both in eye surgery and aesthetic treatments.

She trained in the Oxford Deanery as a microsurgeon and undertook her Level 7 in aesthetics at Harley Academy.

Qual: MBBS, BSc

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29

Case Report Hyaluronidase

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Understanding Post-Hyaluronidase Syndrome Miss Caroline Wilde and Mr Daniel Ezra delve into post-hyaluronidase syndrome and what can be done by practitioners The widespread use of hyaluronic acid dermal fillers in medical aesthetics has led to an increase in filler-related complications.1,2 Common issues include swelling, asymmetry and visible lumps, and patients can present soon after treatment or many years later.3 Emerging evidence suggests that some fillers may persist in tissues for over a decade, leading to a growing number of patients seeking corrective treatments.4-6 More severe complications, such as skin necrosis and visual loss, while critical, fall outside the scope of this discussion.7 Hyaluronidase, an enzyme widely used to dissolve hyaluronic acid fillers, lacks a standardised administration protocol, resulting in inconsistent outcomes. Of particular concern is post-hyaluronidase syndrome, characterised by unfavourable changes such as facial hollowing and wrinkling post dissolution. The fear of such adverse effects often deters both patients and practitioners from pursuing filler dissolving treatments.8 In response to this growing concern, we conducted a study that investigated the occurrence of post-hyaluronidase syndrome, leading to the coining of this term. This article summarises the key findings from our research.8 The study offers valuable insights into patient demographics, treatment indications, hyaluronidase dosing and patient outcomes, with a focus on identifying optimal dosing strategies and predictors of poor outcomes like post-hyaluronidase syndrome.8

Post-hyaluronidase syndrome is characterised by unfavourable changes such as facial hollowing and wrinkling post dissolution

30

Post-hyaluronidase syndrome Post-hyaluronidase syndrome can develop after the use of hyaluronidase, an enzyme commonly used to dissolve hyaluronic acid-based dermal fillers. Hyaluronic acid, the main component of most fillers, is a naturally occurring molecule in the body, found in the skin, synovial fluid of joints and the vitreous humour of the eye. In an average person weighing 70kg, there is approximately 15 grams of hyaluronic acid throughout the body. Concerns arise because hyaluronidase may break down not only the injected filler, but also the body’s natural hyaluronic acid in the skin. Filler dissolving with hyaluronidase can lead to changes in skin texture, volume loss and tissue laxity, resulting in a hollowed or uneven appearance. This study aimed to explore the contributing factors to post-hyaluronidase syndrome to provide insights that could inform safer application of hyaluronidase, and to mitigate unwanted effects in future clinical practice.8

Study report Study overview and methodology Our retrospective study reviewed 157 cases over four years in which hyaluronidase was used to dissolve fillers in the periocular region, reflecting the fact we are a specialised oculoplastic centre.8 A detailed history was taken for each patient regarding past injectables, and pre-treatment photographs were taken. The area of interest was first inspected and then palpated. The primary reasons for dissolving fillers were swelling (52%), lumpiness (20%) and preparation for surgical blepharoplasty (17%).8

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The procedure involved cleaning the skin with chlorhexidine and allowing it to air dry. A 1500-unit vial of hyaluronidase was diluted with 0.9% sodium chloride to achieve the desired concentration.

Most cases utilised two concentrations: 150U/ml or a more diluted 75U/ml. The hyaluronidase was administered using a blunt cannula, targeting the borders of the filler deposit. Post injection, the treated area was massaged to facilitate the dispersion and breakdown of the filler.8 Outcome measures Post-treatment outcomes were categorised as satisfactory in 92 patients (59%), insufficient in 37 (24%) and post-hyaluronidase syndrome in 28 (18%).8 1. Satisfactory result: No remaining filler was detectable, and no adverse effects were observed after the initial hyaluronidase treatment.

2. Insufficient treatment: Additional hyaluronidase treatments were required to further dissolve the initial filler.

3. Post-hyaluronidase syndrome: Patients reported a deterioration in appearance following treatment, characterised by facial hollowing and skin wrinkling. This effect was observed at two weeks after hyaluronidase injection. This often required complex treatment including combinations of surgery, fat transfer and further filler injections.

The study predominantly used a hyaluronidase concentration of 150U/mL (66%), followed by 75U/mL (31%). There was no significant difference in outcomes between these concentrations, indicating that both are effective. Importantly, the total dose of hyaluronidase did not significantly influence the risk of post-hyaluronidase syndrome or a satisfactory outcome, suggesting that lower doses and concentrations may be sufficient.8 Post-hyaluronidase syndrome and its predictors Post-hyaluronidase syndrome occurred in 18% of cases, with no correlation to hyaluronidase concentration or dose. There was also no correlation with patient age, gender or location of filler.8 Instead, the syndrome was linked to the original filler’s characteristics. Two significant predictors were identified: the duration the filler had been in place before dissolution (p=0.00019), and the volume of filler used (p=0.000017). The average duration that the filler had been in situ was five years in patients with the post-hyaluronidase syndrome, in contrast to two years in those who were asymptomatic. The mean filler volume was 4ml in patients who reported post-hyaluronidase syndrome versus 1.5ml in those who had satisfactory outcomes. Patients with long-standing fillers and those who had received larger volumes were more likely to develop post-hyaluronidase syndrome.8 The scientific literature presents a growing body of evidence supporting the long-term persistence of hyaluronic acid fillers.

Numerous studies have documented instances of fillers persisting for many years.9-11 Recently, a study utilising MRI imaging reported that hyaluronic acid fillers remained detectable for as long as 12 years in certain patients, with durability influenced by the injection site and the specific product used.12 Our study also observed complications arising from fillers administered many years ago.

For example, one male patient presented with malar oedema secondary to tear trough and cheek fillers injected 13 years earlier.

These findings highlight the potential for prolonged effects and complications associated with hyaluronic acid fillers.8 In the context of reconstructive surgery, fillers may be used as tissue expanders, effectively creating relaxed skin. Consequently, upon removal of the fillers, the skin may exhibit an appearance of looseness and loss of elasticity.13 A confounding factor is the natural age-related changes which may have occurred while the filler has been in situ, and this study is not designed to control for this.

Case Report Hyaluronidase

There may be effects of hyaluronidase on endogenous hyaluronic acid. Further studies will be required to determine which of these components are clinically significant.

Clinical implications For medical aesthetic practitioners, these findings highlight the importance of thoroughly evaluating a patient’s filler history before proceeding with hyaluronidase treatment. Patients with long-standing or high-volume fillers should be informed about the increased risk of post-hyaluronidase syndrome. The use of imaging techniques like ultrasound or MRI is highly recommended to accurately assess filler volume and location before initiating treatment. All patients having hyaluronidase therapy should be warned that there is an 18% risk of developing post-hyaluronidase syndrome. If they are concerned, it may be better to leave the filler in situ, rather than embarking on the process of filler dissolving.

Limitations and future research While this study offers valuable insights, its retrospective design and the subjective nature of some outcome assessments, particularly for post-hyaluronidase syndrome, are limitations. Future research should focus on prospective studies with standardised imaging and objective volumetric analysis to validate these findings and refine hyaluronidase dosing protocols.

As far as we are aware, the syndrome has not yet been identified in other areas of the face, so more research may be needed here.

Treatment of post-hyaluronidase syndrome Due to the variation between each patient, there currently exists no standardised protocol for treating the syndrome. However, as a general rule it should begin with a comprehensive assessment to understand their specific concerns and expectations. Depending on the manifestations of the post-hyaluronidase syndrome, options may include skin therapies such as radiofrequency microneedling or CO2 laser, as well as volume restoration using either dermal fillers or autologous fat transfer.

Conducting further research Post-hyaluronidase syndrome is a notable risk associated with hyaluronidase treatment, particularly in patients with long-standing or high-volume fillers. The study suggests that this syndrome is more closely related to the original filler’s characteristics than to the hyaluronidase dose or concentration. Practitioners should carefully evaluate patients’ filler history and consider using advanced imaging techniques before initiating filler dissolving procedures.

Further research is essential to develop standardised protocols and reduce the incidence of adverse outcomes.

Miss Caroline Wilde is a consultant ophthalmologist and oculoplastic surgeon specialising in blepharoplasty.

She practices in the NHS and privately, whilst also a consultant at The Ezra Clinic on Harley Street. Managing periocular complications related to dermal fillers constitutes a significant portion of her practice. Her work is at the forefront of research in hyaluronidase treatment and facial aesthetics.

Qual: MB ChB, MRes, FRCOphth Professor Daniel Ezra is a consultant at Moorfields Eye Hospital in central London, and is the lead clinician at The Ezra Clinic, a specialist oculoplastic private practice based at 152 Harley Street focusing on periocular and facial aesthetics. Professor Ezra has a special interest in revision surgery after blepharoplasty and managing filler complications.

Qual: MA MBBS, MMedED, MD FRCS, FRCOphth, FHEA

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31

Clinical Practice News

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33

Advertorial Allergan Aesthetics

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Combining Hyaluronic Acid and Hybrid Injectables Dr Manav Bawa presents a case using a combination of HArmonyCa and Juvéderm® to address skin laxity1-2 and volume loss3-4 TM

This article is produced and funded by Allergan Aesthetics and is intended for aesthetic healthcare professionals.

Juvéderm®, HArmonyCaTM and this content is intended for adult (>18 years) audiences only.

Assessment A 37-year-old man presented to me with concerns of looking tired and sunken. I assessed him by reviewing his medical history, checking there were no red flags psychologically, and examining his face from different angles. I analysed his face when static and while moving, and then took pictures to help illustrate to the patient what I noticed, which was that he had a loss of volume, skin laxity and lack of definition in the mid-face.

Treatment plan and product choice To achieve both skin tightening2 and a lifting effect, 2-4 I developed a treatment plan that combines the benefits of HArmonyCa™ hybrid injectable with the Juvéderm® dermal filler portfolio. I chose HArmonyCATM because it in my experience it helps to address laxity in the skin,1-2 and create definition of the cheekbone.4 In my experience Juvéderm® is beneficial to replace lost volume and create contouring. 3-4 For most of the injections, I opted for a cannula (Table 1) as it allows me to cover a larger area with fewer entry points, minimising trauma by using just a single injection site. I used a needle for the periosteal injections in the temple, zygoma and medial cheek, as I find that I can get greater precision in these areas.

Following HArmonyCa™ treatment, I schedule follow-up appointments at one month, three months, six months, and one year to assess the product’s and determine if any additional treatments are necessary as the results continue to evolve over time.

Dr Manav Bawa, Allergan Faculty Member and consults for the company. He has not been paid for this advertorial.

This article is based on Dr Bawa’s personal experience, and ultimate decisions regarding patient care lies with the treating healthcare professional and the patient.

Individual patient results may vary.

The patient was happy with his results (Figure 1) and felt a lot more confident in his appearance. He noted that his skin was much improved, while still looking natural.

Combining treatments The most important factor for practitioners to consider when planning combination injectable treatments is ensuring that the selected products effectively target the patient’s specific concerns.

“To achieve both skin tightening2 and a lifting effect,2-4 I developed a treatment plan that combines the benefits of HArmonyCa™ hybrid injectable with the Juvéderm® dermal filler portfolio” 34

Aesthetics | December 2024

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Product

Area

Depth

Instrument

Technique

Volume Right

Volume Left

Juvéderm® Voluma

Zygoma

Periosteal

Needle

Bolus

0.1ml x3

0.1ml x3

Juvéderm® Voluma

Medial Cheek

Periosteal (lateral to mid-pupillary line)

Needle

Bolus

0.2ml

0.2ml

HArmonyCaTM

Zygomatic Arch

Subdermal

Cannula

Fanning

0.2+0.25ml

0.2+0.25ml

HArmonyCaTM

Subzygomatic region

Subdermal

Cannula

Fanning

0.2+0.2ml

0.2+0.2ml

HArmonyCaTM

Angle of mandible

Subdermal

Cannula

Fanning

0.2+0.2ml

0.2+0.2ml

Juvéderm® Voluma

Medial Cheek

Deep medial fat

Cannula

Fanning

0.5+0.5ml

0.5+0.5ml

Juvéderm® Volift

Medial Cheek

SOOF

Cannula

Fanning

0.5+0.5ml

0.5+0.5ml

HArmonyCaTM

Cheek - submalar

Submalar

Cannula

Fanning

1.25ml

1.25ml

Juvederm® Voluma

Temple

Periosteal

Needle

Bolus

0.5ml

0.5ml

Table 1: Injection points, technique and product amounts. SOOF stand for suborbicularis oculi fat.

Before

“If there is an issue with the skin, for example laxity, then HArmonyCa™ would be a suitable option2”

Five months after

My advice for combining is to not use both products in the same area at the same time. For instance, when using HArmonyCa™ in the subcutaneous layer, just beneath the skin, I avoid placing filler in the same area. If I intend to add volume within the same layer, I typically wait around two months before proceeding with additional treatment. This is to ensure that if there is a problem, I know what product has caused the side effect and I can treat it accordingly. Secondly, I want to be sure that my patient really needs the additional volume. I like to wait, bring the patient back in, and treat them accordingly. ©AbbVie 2024. All rights reserved. Material produced and funded by Allergan Aesthetics, an AbbVie company. www.allerganaesthetics.co.uk UK-HAR-240159 | DOP October 2024

Figure 1: 37-year-old patient before and five months after treatment using HArmonyCaTM and Juvéderm®. A total of four HarmonyCaTM syringes were used, as well as 4ml of Juvéderm® Voluma and 2ml of Juvéderm® Volift.

References 1. Allergan Aesthetics. HArmonyCaTM Lidocaine IFU. M032 v01. 2021.

2. Urdiales-Galvez F et al. J Cosmet Dermatol. 2023;00:1-12 3. Juvéderm® VOLIFT with lidocaine DFU. 73652JR10.

Revision 2019-09-09.

4. Juvéderm® VOLUMA with lidocaine DFU. 73650JR10. Revision 2019-09-09

Adverse events should be reported.

UK reporting forms and information can be found at https://yellowcard.mhra.gov.uk via the MHRA Yellow Card app, available at Google Play or Apple App stores.

Adverse events should also be reported to AbbVie on ProductSurveillance_ EAME@allergan.com

Aesthetics | December 2024

By scanning the QR code you will be taken to Instagram, with promotional content from Allergan Aesthetics, an Abbvie Company

35

Case Study Polynucleotides

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Exploring intimate polynucleotides PNs are used extensively in general medicine as injectables, with well-documented publications showing an evidence base for improvement in problems such as joint issues and non-healing ulcers.7-9 PNs are highly purified DNA polymers taken from either trout or salmon gametes, providing a boost to patients’ own ribonucleic acid (RNA) pool for cellular turnover.10 They bind to A2A adenosine receptors, providing an anti-inflammatory response, and stimulate fibroblast activity producing collagen synthesis in the extracellular matrix.10 PNs strengthen the microvasculature by stimulating vascular endothelial growth factors and DNA synthesis, resulting in remodelling, hydration and thickening of skin tissue.10

Case Study: Polynucleotides for the Intimate Area Dr Sarah Jenkins shares a case study using polynucleotides to treat the genitourinary syndrome of menopause Perimenopausal, menopausal and post-birth women often present with vulval skin changes causing dryness, itching, lack of natural lubrication, changes to ‘normal discharge’, painful sex and urinary leakage.1,2 When I was working in the NHS, the only approved treatments I could offer were topical oestrogen and physiotherapy, and often these solutions fail or even exacerbate symptoms.3 I found many women would say the oestrogen makes the skin more sensitised and did not reduce symptoms, and even when they could see a menopause specialist via the NHS, I encountered that utrogestan tablets administered intravaginally may exacerbate mild prolapses and vaginal atrophy.4 While working in private practice, I wanted to be able to offer my patients a treatment option which can provide improved symptoms and ameliorated quality of life.

Polynucleotides became the option I opted to explore due to the increasing research around them, as presented in the case study shared in this article.

Changes during the menopause During perimenopause and menopause, there is a cascade of hypo-oestrogenic conditions causing changes to the vaginal epithelium which becomes thinner.5 The vaginal rugae decrease, tissue elasticity decreases and the vaginal canal shortens, along with the urethra and the secretory activity of Bartolini’s glands reduces.5 Vaginal mucosal columnar cells transform into squamous epithelium, and vaginal pH also changes due to glycogen, resulting in dry vaginal and vulval skin.5 In turn, this increases the likelihood of trauma to the tissues, rubbing or chafing of the intimate skin, loss of skin integrity increasing the likelihood of urinary tract infections, candida fungal infections, bleeding associated with atrophic vaginitis and painful intercourse.6 In some cases, women have not been unable to undergo cervical smears due to the speculum causing damage and pain.

36

Aesthetics | December 2024

While they have previously been used for skin disorders and rejuvenation, they are more recently being used for novel applications. Currently, there is one PN formulation approved for treating the intimate area – Newgyn from Mastelli by DermaFocus. The product contains 10mg/ ml PN, combined with non-cross-linked hyaluronic acid (HA) and mannitol.12 The mannitol stabilises the HA, and aids the product’s longevity once injected into the vulva.10 PN combined with HA is specifically good for the female intimate area as the hydrophilic qualities of HA helps rehydrate the vulval tissues, reducing symptoms of ‘vaginal dryness’, while PN provides highly purified long-chain DNA fragments, aiding cellular ‘self-repair’ to collagen production and protecting the skin barrier.10 When PN and HA are combined with mannitol, the temporary function of this injectable lasts longer, providing a longer-term symptomatic relief when compared to PN without mannitol.10 When PN was compared to HA fillers alone using in vitro tissue samples, transmitted light micrographs of scratch testing revealed the dermis and epidermis treated with PN had a denser, more homogenous appearance of fibroblast activity.12 There was almost complete tissue repair achieved, with mature and well-organised collagen fibres resulting in a healthy, uniform extra cellular matrix.

The HA-only group revealed incomplete healing compared to the PN-treated group, and collagen fibres only partially filled the extracellular matrix.12 The study’s 19 subjects reporting 59% improvement in vulval dryness, 59% improvement to dyspareunia and 76% improvement to vulval itching.12

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Case Study Polynucleotides

Case study

The treatment

A 57-year-old woman presented to clinic post-hysterectomy and cancer treatment, with severe vulval atrophy and lichen sclerosis with a non-healing fissure to the perineum. Every day was painful and sore, majorly affecting her quality of life. She had not been able to have sexual intercourse with her husband for more than five years and no previous solution she had been prescribed – such as the steroid cream Dermovate – had worked to relieve her symptoms.

The PN protocol is a course of six PN injections into the labia majora administered two weeks apart. Contraindications would be active infection in the genital area including herpes simplex virus and thrush; conditions such as this should be remedied before any rejuvenating treatments are administered.22 The skin area is prepped like any other area of skin about to be injected for clean technique, rather than aseptic technique. I use a compounded topical anaesthetic 30 minutes prior to injecting.

She felt a lack of support from cancer specialists after her cancer treatment had finished, and as a result of surgery and chemotherapy, experienced constant pain and skin changes due to what I refer to as ‘post cancer treatment menopause exacerbation’.

We have all heard of surgical menopause where hysterectomy and oropharyngectomy bring forward menopause, however many practitioners are unaware of the complications women face to their intimate area post any cancer treatment. This is because cancer treatments such as chemotherapy are non-selective and can stop all new cellular growth, thus drying out the skin.13-15 My patient was willing to try this novel treatment as a potential resolution to her problems, and I felt that it could be potentially effective for her.

The consultation

The treatment protocol remains the same for all patients – one syringe is injected as microdroplets into the dermis of the vulva and perineum. For aftercare, I advise all women not to bath/ swim/engage in sexual intercourse/use a hot tub for 48 hours to lower risk of infections.23 Possible complications like haematoma, itching or sore injection points are minor and self-limiting as it’s a very superficial injection technique.24 Allergy, including allergy to fish, should not be a risk factor with this brand as the DNA has been highly purified in a laboratory and controlled to EU standards.22

Most women believe there is nothing which can be done to treat GSM and associated urinary leakage other than wear a pad.

More than 60% will suffer from these symptoms at some stage of life

The majority of my patients initially come to clinic for facial aesthetics, but during every consultation I take a holistic approach, conducting a comprehensive systems review and specifically asking about urogenital issues in women. This is because most women believe there is nothing which can be done to treat GSM and associated urinary leakage other than wear a pad. However, more than 60% of women will suffer from these symptoms at some stage of life, and when asking a GP for help, often feel dismissed, or have never been asked by a doctor about such symptoms.16-18

To assess and quantify patient symptoms before and after treatment, we use our own questionnaire that gynae-oncologist Dr Vivek Nama and I designed. We inquire about vulval dryness, how many UTIs have been experienced in the past three months, HRT status, sexual dysfunction symptoms, pain during sexual intercourse, urge incontinence and stress incontinence. The patient then completes the same questionnaire post-treatment to measure reported symptoms and how they may have been improved.

During my consultation with this patient, we discussed the other options for treatment. My usual gold standard practice is platelet-rich plasma (PRP) in combination with radiofrequency (RF) microneedling, because it is an autologous approach so its safety profile is high.19-21 However, I did not feel the RF microneedling aspect of this would be appropriate immediately due to the non-healing fissure she was suffering with, and because she was in remission from cancer treatment so would not have had good quality PRP. She was open to the idea of trying this alternative modality as she was a medical professional herself, and was willing to try anything to relieve her symptoms.

The results After two treatments, the fissure in my case study was visibly improved and the patient reported pain improvement. After a course of six treatments, the patient reported that she was no longer constantly aware of pain, discomfort and irritation. I reviewed this patient at three and six months with satisfactory feedback, and administered one maintenance treatment at eight months following the patient’s request for a ‘top up’. The published protocol suggests six-monthly maintenance treatments are typically effective to maintain results.25

If this treatment protocol did not work, a course of PRP injections would have been initiated. Once the skin fissure was improved, it would be appropriate to use RF with or without microneedling for skin contraction to correct the atrophy, and further stimulate collagen and elastin production.

A life altering treatment modality Vulval PNs are showing very promising results for women suffering with perimenopausal and menopausal issues, and is considered safe and low risk.12,19 For my case study, PN provided eight months of symptom relief before she requested another single treatment.

Going forward, I would like to see a large, multicentre longitudinal study to assess PN efficacy compared to PRP and HA fillers in this area.

Dr Sarah Jenkins graduated from Cardiff University and has worked in many surgical specialties during RCS surgical training programme, as well as four years as a GP associate in training (AiT) where she found her passion for women’s health. Dr Jenkins now practises as an aesthetic physician at TheDoorW4 in Chiswick with a special interest in aesthetic gynaecology, as well as being an international trainer and KOL for InMode, Neauvia, RegenLabs and DermaFocus.

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Antioxidants L-Glutathione

Maintaining GSH homeostasis is critical for cellular function, as dysregulation of GSH biosynthesis and its depletion are implicated in various pathological conditions.3

Antioxidant and detoxification functions of L-Glutathione GSH stands as a cornerstone of cellular defence, primarily through its potent antioxidant and detoxification capacities.

These functions are intrinsically tied to its unique tripeptide structure and the reactivity of its cysteine thiol group.4 Direct antioxidant action

Exploring L-Glutathione Dr Ethan Hausman-Marquis examines the various applications of antioxidant L-Glutathione in aesthetic skin treatments and overall health L-Glutathione (GSH), a ubiquitous tripeptide thiol, holds a pivotal role in maintaining cellular redox homeostasis and protecting against oxidative stress. Its potent antioxidant capacity stems from the reactive thiol group of cysteine, enabling GSH to scavenge reactive oxygen species (ROS) and regenerate other antioxidants.

Beyond its antioxidant function, GSH participates in detoxification of xenobiotics, modulation of protein function via S-glutathionylation and regulation of cellular signalling pathways.1 GSH biosynthesis, a two-step ATP-dependent process, is tightly regulated by the rate-limiting enzyme glutamate-cysteine ligase (GCL). Cellular GSH levels are maintained through a dynamic balance between its biosynthesis, utilisation and degradation. This introduction lays the groundwork for exploring the multifaceted roles of GSH in human health and disease, with a focus on its implications in neurodegeneration, cardiovascular diseases, cancer and ageing.1 In this article, I will explore the multifaceted roles of GSH in human health and disease.

Additionally, I will discuss the use of GSH in skin treatment, and explore various methods of administration, considering their advantages and limitations.

Biosynthesis and regulation GSH biosynthesis occurs in two sequential, ATP-dependent steps.2 First, glutamate-cysteine ligase (GCL) catalyses the formation of γ-glutamylcysteine from L-glutamate and L-cysteine. Second, glutathione synthetase (GS) joins glycine to the C-terminal of γ-glutamylcysteine, yielding GSH.3 GCL is the rate-limiting enzyme in GSH biosynthesis, and is composed of a catalytic (GCLC) and a modifier (GCLM) subunit. GCLM increases GCLC’s affinity for glutamate, enhancing its activity. GCL is subject to feedback inhibition by GSH, ensuring tight regulation of its production.2 Several factors influence GSH biosynthesis. Oxidative stress and electrophilic compounds increase GCL expression and activity via the transcription factor Nrf2. Pro-inflammatory cytokines also upregulate GCL. Conversely, GSH depletion can occur through excessive oxidative stress, xenobiotic exposure or impaired biosynthesis.2,3 Aesthetics | December 2024

GSH acts as a direct scavenger of reactive oxygen species (ROS) including superoxide anions, hydroxyl radicals and hydrogen peroxide. This occurs via the oxidation of its thiol group to form glutathione disulfide (GSSG). The enzyme glutathione peroxidase catalyses this reaction, showcasing the integrated nature of GSH’s antioxidant system.5 Indirect antioxidant action Beyond direct scavenging, GSH indirectly bolsters the antioxidant network by regenerating other vital antioxidants such as vitamins C and E. This recycling process ensures a sustained defence against oxidative stress, crucial in maintaining cellular redox balance.6 Detoxification via conjugation GSH’s detoxification role centres on its conjugation with electrophilic xenobiotics and endogenous metabolites. This process, facilitated by glutathione S-transferases (GSTs), renders harmful compounds less reactive and more water-soluble, facilitating their excretion.7

Cellular signalling and regulation GSH is not merely an antioxidant; it’s a dynamic participant in cellular signalling and regulation, impacting various physiological processes.8 Protein S-Glutathionylation One of the most significant ways GSH influences signalling is through protein S-glutathionylation, the reversible addition of GSH to protein cysteine residues.

This post-translational modification can alter protein function, localisation and stability, affecting diverse pathways including metabolism, cell proliferation and apoptosis. Research has shown that S-glutathionylation modulates key proteins like actin, Ras and NF-κB, highlighting its broad regulatory scope.9,10 Transcription factor modulation GSH also interacts with transcription 39

Antioxidants L-Glutathione factors, impacting gene expression.

It activates the antioxidant response element (ARE) through Nrf2, leading to the expression of cytoprotective genes.

Furthermore, GSH influences AP-1 and NF-κB, affecting inflammatory and immune responses.11,12 Redox signalling The GSH/GSSG ratio acts as a (reduction–oxidation) redox sensor, influencing signalling pathways. Changes in this ratio can activate or inhibit various kinases and phosphatases, affecting downstream signalling cascades.13,14

Ageing and L-Glutathione Ageing is associated with a progressive decline in GSH levels and antioxidant capacity, contributing to increased oxidative stress and cellular damage.15 This decline impairs redox homeostasis, detoxification processes and cellular signalling, rendering individuals more susceptible to age-related diseases.16 Restoring GSH levels through supplementation or promoting its endogenous synthesis has emerged as a potential strategy for mitigating age-related physiological decline and promoting healthy ageing.17 Beyond its critical roles in cellular function and disease prevention, GSH also holds promise in aesthetic applications in terms of skin health and radiance, which will be explored further later in the article.18

Implications in human health GSH deficiency is implicated in various pathologies including neurodegenerative diseases, cardiovascular disease, cancer and ageing. In neurodegeneration, GSH depletion exacerbates oxidative stress and mitochondrial dysfunction. In cardiovascular diseases, GSH protects by scavenging ROS and modulating endothelial function. While GSH protects normal cells, it can confer resistance to therapy in cancer cells. GSH decline in ageing contributes to increased oxidative stress and damage.19-21

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L-Glutathione holds a pivotal role in maintaining cellular redox homeostasis and protecting against oxidative stress L-Glutathione and neurodegenerative diseases Neurodegenerative diseases (NDs), including Alzheimer’s and Parkinson’s, are characterised by progressive neuronal loss and dysfunction.22-24 Oxidative stress, mitochondrial dysfunction and protein aggregation are key pathogenic mechanisms in NDs.25 GSH plays a crucial role in maintaining redox balance and protecting neurons from oxidative damage. GSH depletion and impaired GSH metabolism have been observed in various NDs, suggesting a potential therapeutic target. Restoring GSH levels and enhancing its antioxidant capacity may offer neuroprotection and ameliorate disease progression.26,27 Cardiovascular implications Oxidative stress and inflammation play pivotal roles in cardiovascular disease (CVD) pathogenesis. GSH protects against CVD by scavenging reactive oxygen species (ROS), inhibiting lipid peroxidation and modulating endothelial function. GSH deficiency is associated with increased CVD risk, while supplementation may improve cardiovascular outcomes.28-30 This deficiency can have a profound effect on a variety of cardiovascular conditions.

GSH depletion exacerbates endothelial dysfunction, atherosclerosis, hypertension and heart failure, while supplementation of the antioxidant improves endothelial function, reduces blood pressure and attenuates myocardial injury.31-34 Clinical trials suggest potential benefits of GSH in

GSH depletion can occur through excessive oxidative stress, xenobiotic exposure or impaired biosynthesis 40

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managing CVD risk factors and improving quality of life.35 The paradoxical role of L-Glutathione in cancer GSH exhibits a complex relationship with cancer. While its antioxidant properties protect normal cells from oxidative damage and carcinogenesis, elevated GSH levels in cancer cells can confer resistance to chemotherapy and radiation therapy.

GSH contributes to tumour cell survival by scavenging reactive oxygen species (ROS), detoxifying chemotherapeutic agents and modulating redox-sensitive signalling pathways.36,37

Effects on the skin GSH has gained popularity as a skin whitening agent in East Asia (notably Korea, China and Japan) although its mechanism remains controversial. Research has suggested that GSH may inhibit tyrosinase, a key enzyme in melanin synthesis.18 Glutathione has a range of other potential benefits for skin health, thanks to its antioxidant and detoxifying properties.

· Antiageing: Glutathione combats

oxidative stress, a major contributor to skin ageing. By neutralising free radicals, it can help protect against collagen breakdown, reducing the appearance of wrinkles and fine lines.38 · Reduces pigmentation: At higher doses, GSH’s antioxidant properties could reduce oxidative stress, indirectly influencing melanogenesis.39 · Reduces inflammation: Glutathione has anti-inflammatory properties, which can be beneficial for conditions like acne, eczema and psoriasis. It may also help calm redness and irritation.40,41 · Protects against sun damage: While not a replacement for sunscreen, glutathione can help protect the skin from the harmful effects of UV radiation. It can help reduce the damage caused by free radicals generated by sun exposure, which can lead to premature ageing and skin cancer.42

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Antioxidants L-Glutathione Topical application

GSH’s antioxidant properties could reduce oxidative stress, indirectly influencing melanogenesis · Improves skin tone and texture: By promoting cell renewal and reducing

oxidative stress, glutathione can contribute to a brighter, more even skin tone and smoother texture.43

Methods of administration GSH can be administered via various routes. The choice of administration method often depends on the desired therapeutic effect, patient convenience and clinical setting.

Oral administration Oral glutathione supplements are widely available, but their bioavailability is limited due to extensive degradation in the gastrointestinal tract. Studies suggest that oral glutathione may have some benefits for specific conditions, but its overall efficacy for systemic antioxidant support remains controversial.45,46 This method is convenient for daily supplementation, potentially supporting overall skin health and antiageing.18

· Liposomal glutathione: Encapsulation of glutathione within liposomes may improve its

absorption and bioavailability. However, more research is needed to confirm its clinical superiority over conventional oral formulations.47 · Reduced glutathione: This form of glutathione is more stable and may offer slightly better absorption than oxidised glutathione.45 Intravenous (IV) administration IV glutathione delivers a high concentration directly into the bloodstream, bypassing the limitations of oral absorption. This method is often used in clinical settings for conditions requiring rapid and substantial antioxidant support, such as acute liver toxicity or certain neurological disorders. The high bioavailability allows for a rapid increase in glutathione levels, potentially leading to noticeable improvements in skin brightness and texture, and a reduction of hyperpigmentation.48

· High bioavailability: IV glutathione achieves rapid and near-complete bioavailability,

ensuring maximum therapeutic effect.49 · Clinical applications: IV glutathione has been investigated for its potential in managing various conditions, including Parkinson’s disease, chemotherapy-induced toxicity and heavy metal poisoning.50 Intramuscular (IM) and subcutaneous (SC) injections IM and SC injections offer an alternative to IV administration, allowing for sustained release of glutathione over time. These methods are less invasive than IV administration and can be self-administered in some cases. The slower, sustained release of glutathione may provide longer-lasting effects compared to IV, potentially supporting collagen production and reducing fine lines.38

· Slower absorption: Compared to IV, IM and SC injections result in a slower but

prolonged release of glutathione, potentially offering sustained antioxidant benefits.49 · Patient convenience: IM and SC injections may be more convenient for long-term therapy or in outpatient settings.

Topical glutathione formulations, such as creams and lotions, are primarily used for skin conditions like hyperpigmentation, melasma and photoageing. This is because topical application allows for targeted delivery of glutathione directly to the affected areas, maximising its antioxidant and skin-brightening effects.39 Overall, glutathione strengthens the skin’s natural defences, helping it look clearer, brighter and more resilient in the face of ageing.38,40,51 Topical glutathione is often incorporated into professional aesthetic treatments to enhance results. For example, it can be applied after microdermabrasion or chemical peels to promote healing and brighten the skin.

Considerations for safe use Side effects from GSH usage can range from mild injection site reactions to more serious issues like allergic responses, gastrointestinal problems and even potential kidney or liver damage.55 Furthermore, GSH can increase sun sensitivity, making proper sun protection crucial to avoid further hypopigmentation.55

A powerful ingredient When using GSH, factors like dosage and individual responses play a significant role in effectiveness and safety, and the long-term effects remain unclear.52,53 L-glutathione treatments should be part of a holistic skin health strategy that includes a balanced diet, sun protection and proper skincare.54 While further research is needed to elucidate the full spectrum of GSH’s actions and clinical applications, the existing evidence supports its central role in promoting health and combatting disease.

Dr Ethan Hausman-Marquis is a consultant paediatric oncological surgeon, and clinical director at The Catalyst Clinic in London, specialising in aesthetic and regenerative medicine. He has a PhD in Cell Biology from the Karolinska Institute.

Qual: MD, PhD, FACS, FAAP

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Nebulised inhalation Nebulised glutathione delivers the compound directly to the lungs, making it particularly useful for managing respiratory conditions like asthma, chronic obstructive pulmonary disease (COPD) and cystic fibrosis.

· Targeted delivery: Inhalation targets the respiratory system, maximising local antioxidant effects and minimising systemic exposure.49 · Clinical applications: Nebulised glutathione has shown promise in improving lung function and reducing oxidative stress in patients with respiratory diseases.49

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bespoke treatment plan based on their needs.”

Dr Rennie explains that he uses the ATP approach when consulting and treating patients:

· A stands for anatomy, ageing

and assessment · T is for technique choices (based on the anatomy, ageing and assessment) · P relates to product choice, ensuring that the correct product is utilised in the correct area “If these three fundamental pillars are addressed, then results can truly be natural, impactful, individualised, but most importantly safe,” he says.

Combining HA fillers

Meet the Trainer: Understanding the Power of HA Filler Four Teoxane UK trainers share their advice on utilising hyaluronic acid fillers Hyaluronic acid (HA) fillers have revolutionised the field of medical aesthetics. With their unparalleled versatility, HA fillers provide aesthetic practitioners with the tools to deliver bespoke, natural-looking results tailored to individual patient needs. However, over the last year there has been some growing negativity and controversy over their use.

Four of Teoxane UK’s leading trainers uncover how they incorporate HA fillers in their practice, advice for optimal results, and why they will always be a staple part of any practitioner’s toolkit.

The importance of HA fillers According to aesthetic practitioner Dr Bonny Armstrong, HA fillers are the foundation of many aesthetic treatments due to their unique ability to address multiple patient needs. “HA fillers are fundamental in addressing a wide spectrum of patient concerns, from rejuvenation, beautification to structural enhancement. From fine lines and surface hydration to deep structural support, their versatility lies in the variety of formulations tailored to different facial layers and treatment goals,” she says.

“One of the main advantages of HA fillers is their unique hydrophilic ability, which helps to restore volume and provide improvement in the appearance of depleted or flattened regions of the face,” adds Dr Chris Rennie.

For Dr Jeremey Issaac, the safety and efficacy of HA fillers cannot be understated.

“They’re the most universally used method of orientation of the face, so they’ve got a very high safety record and a lot of evidence behind them,” he says, adding that it is a huge beneficial factor, for both practitioner and patient, that HA fillers are dissolvable.

There is really no substitute for HA filler,” he says.

Tailoring treatments to individual needs Personalisation is at the heart of successful HA filler treatments, says Dr Armstrong, noting, “I never treat two patients in the same way, each patient at my clinic has a 42

Aesthetics | December 2024

Aesthetic nurse Rachel Goddard notes that she regularly uses HA fillers alongside other treatments in order to achieve the best results for her patients. “I will carry out treatments to improve skin health and quality first. This could be skincare, laser, radiofrequency, skin peels, skin boosters or polynucleotides. Then we move on to the dermal filler treatments. By doing this, you are optimising the skin quality first which will further enhance the results of the dermal filler treatment,” she says Dr Rennie agrees, noting that incorporating HA fillers as part of a multimodal treatment approach allows for comprehensive facial rejuvenation and enhancement that addresses a range of aesthetic concerns more effectively than any single treatment modality alone.

Tackling current misconceptions Recent research has indicated that HA fillers may have greater longevity than previously thought. Dr Isaac says, “Some controversy and worry has come from an MRI scan showing filler is lasting longer in the face – however, everyone needs to remember that the person who had the scan looks perfectly normal. There is nothing to worry about in this regard – we just need to take it into consideration when we are placing fillers.”

Dr Armstrong emphasises ensuring your patients are aware of the longevity of the treatments, and to monitor results accordingly. “It’s important to recognise that fillers can last longer than 12-18 months, and over time, we can become accustomed to our new appearance. Patients often return requesting more filler, not realising that much of the original result is still there.

This is why I always advocate for baseline photographs before treatment – so we can monitor how well the results last and assess if further treatment is truly necessary.”

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Dr Rennie’s suggested combination plans for HA filler:

1

Combining HA fillers with neuromodulators for dynamic and static wrinkles: Neuromodulators are highly effective for softening dynamic wrinkles caused by muscle movement, while HA fillers work well for treating static wrinkles and volume loss. In combining both, I can target lines formed by expression while also replenishing volume and support in areas affected by ageing. This dual approach creates a smoother, more youthful appearance with improved definition and natural movement.

2

Pairing with skin treatments for improved texture and quality: Skin treatments such as chemical peels, device-based resurfacing, or mechanical micro-needling will potentially enhance skin texture, tone and quality, but they do not address volume loss or contouring. By incorporating HA fillers, I can simultaneously improve the skin’s appearance on the surface and restore volume at a deeper level. This combination is particularly effective for patients with age-related volume loss combined with photo-ageing as the fillers provide support and structure, while the skin treatments address pigmentation, texture, collagen stimulation and elastin quality.

3

Supporting results of facial sculpting procedures: HA fillers are excellent for refining and enhancing results of other facial sculpting procedures. In patients who have had surgical or non-surgical treatments targeting specific areas, HA dermal fillers can add finishing touches to enhance symmetry and balance, creating a cohesive aesthetic.

4

Addressing holistic facial rejuvenation needs: In many cases, patients benefit from a full-face approach to rejuvenation that addresses multiple aspects of facial ageing rather than isolated areas. For example, a comprehensive plan might include HA fillers for mid-face volume restoration, neuromodulators for dynamic wrinkles, and skin treatments for texture and radiance. This integrative approach provides subtle, natural-looking improvements across the entire face rather than a singular focus, resulting in a harmonious and refreshed appearance.

5

Improved longevity and synergistic effects: When combined, treatments like HA dermal fillers and skin-tightening methods often produce longer-lasting and more synergistic results than when used alone.

She adds that maintaining and reviewing dermal filler treatments should be done thoughtfully and in small, refined increments.

The RHA range All four practitioners use the Teoxane RHA range in order to achieve optimal results. “The range offers nine specialised HA products designed to seamlessly mimic natural facial tissue. It gives us the tools to tackle a range of patient needs, whether it’s smoothing fine lines, enhancing contours or restoring volume. From early signs of ageing to more pronounced skin laxity, HA fillers allow us to choose the perfect product that integrates harmoniously with the anatomical layer we are targeting,” says Dr Armstrong.

Goddard explains that the rheology of a product is an important consideration so that she can achieve lift and projection (if appropriate), whilst ensuring the results are natural looking and undetectable. “The wide selection of HA fillers in the Teoxane portfolio means that I can select a product that is suitable specifically for an individual patient’s age and aesthetic concerns. For example, when we need deep volumising and structural support, I personally find the best option is to use an HA filler that will give firm support here. These concerns require a high strength, low stretch HA filler to target deep volume loss, and to provide structural support,” she says.

Tips for success All practitioners agree that a conservative approach to treating with fillers is the best option. “Treatments are like building your dream home – you cannot build it in a day, there’s a strict process to follow, structural support is needed and it is an investment. Once the house is built, it’s a case of maintaining it regularly. If work is neglected, it’s often more costly to fix and that’s exactly the same for aesthetic treatments!” says Goddard. He adds that this not only helps to realign patient expectations of factors such as treatment results and costs, but also help to build trust which is essential for the clinician-patient relationship.

Dr Isaac emphasises that practitioners need to understand less is more.

“The underlying problem of why people are looking bad and overfilled is that practitioners are trying to give them 100% correction on the day, but when the product hydrates and volumises over time they then have a 200% correction after a few weeks. It shouldn’t all be done at once – it needs to be a journey,” he says. He adds that small amounts selectively placed in the right planes and right tissues is going to give you the best outcomes. “Be selective – less is more,” he concludes.

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Case Study Combining Injectables

Case Study: Combining Injectable Treatments Dr Sonia Soopen explores the role of combination treatments using hyaluronic acid fillers, neuromodulators and polynucleotides Botulinum toxin and hyaluronic acid (HA) dermal fillers have become the most popular choices for addressing the visible effects of facial ageing.1-3 Combining these modalities has become a standard of care when it comes to achieving the most harmonious and natural-looking facial rejuvenation results and addressing multiple concerns.3 More recently, polynucleotides have emerged as an injectable regenerative treatment to enhance skin quality.4,5

Combination treatments Combination treatments can provide more desirable results.6,7 Emerging research also hints at the possibility that the synergy between dermal fillers and botulinum toxin may extend the longevity of results. The interplay between these treatments could potentially contribute to sustained effects over an extended period.6,7 The popularity of injectable agents, such as soft tissue fillers and botulinum toxin type A, has experienced a significant surge in recent years.8,9 This is attributed to the growing preference for minimally-invasive procedures.8,9 These treatments often rank as the most frequently undertaken cosmetic treatments performed, with botulinum toxin type A injections leading the way and dermal fillers coming in second.8 Like many other regenerative medicine tools, polynucleotides have a history of being used in general medicine before their introduction to the world of medical aesthetics, but are now increasingly being used in combination with other aesthetic treatments, including toxin, dermal filler and mesotherapy.5,10,11 Whether employed individually or in conjunction, these agents prove highly effective in addressing wrinkles and replenishing lost facial volume when treating the signs of ageing.12,13 Comparative studies have established the safety and enhanced efficacy compared with solo treatment of combination procedures for lower face rejuvenation.3,14,15 Curtis et al. reported that cross-linked HA and onabotulinumtoxinA combination therapy might provide better overall aesthetic results and a longer duration of aesthetic improvement than cross-linked HA monotherapy.14 This was

based on a study of 22 patients who received combination therapy to a melomental fold area while also receiving cross-linked HA and a placebo saline injection to the contralateral side. Blinded physician evaluators and patient self-evaluators clinically and photographically assessed responses during standard intervals over 12 months.14 The study showed that melomental folds treated with combination therapy had significantly greater aesthetic improvement than the monotherapy-treated side at two weeks and one month upon physician photographic review. Furthermore, the median time for return to pre-treatment rhytids was six and a half weeks longer in the combination therapy side. Patient assessment also revealed improvement over baseline for the combination therapy at one month.14 Carruthers et al. also noted that “combination therapy is superior to either modality (onabotulinumtoxinA and HA gel) used alone”.15 This was based on a study of 90 female participants aged 35 to 55 randomised to one of three groups: 24-mg/mL cohesive gel alone (n=30), onabotulinumtoxinA alone (n=30), the combination (n=30). Effectiveness outcomes included perioral, lip fullness and oral commissure assessments, and scores on the Cosmetic Improvement and Global Aesthetic Improvement Scales. Adverse events were monitored throughout.15 For all endpoints and most time points, subjects treated with onabotulinumtoxinA plus the 24-mg/mL cohesive gel had greater improvement from baseline than subjects treated with onabotulinumtoxinA or the 24-mg/mL cohesive gel filler alone.15 A consensus report on the use of polynucleotides in medical aesthetics suggested that polynucleotides can be useful for ‘priming’ before another skin treatment strategy, such as lasers, fillers, peeling, needling Deep bolus (needle) and surgery.4 Interfascial (cannula) Superficial (cannula) Fern technique (needle) Superficial (needle) Line of Ligaments: Temporal adhesion Lateral orbital thickening Main zygomatic ligament Manibular ligament

Case study Consultation A 60-year-old Caucasian female patient presented with concerns about facial ageing, saying she did not recognise herself in the mirror anymore and wanted to feel more refreshed.

Figure 1: Treatment mapping for injection points and techniques

An in-depth consultation involved discussing the patient’s medical history, lifestyle and expectations. As a retired nurse, the patient said she had a very stressful life (which she rated as 9/10).

However, since retiring, she said she spent her time doing exercise classes and felt much calmer (now self-rating as 2/10).

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Case Study Combining Injectables

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She admitted to high sun exposure in her 20s and 30s; however, said she now has very little sun exposure and wears SPF50. Her skincare regime involved cleansing her face with soap morning and night.

Clinical assessment Detailed clinical assessments, including observations at rest and in animation, were performed to facilitate an understanding of the anatomical changes contributing to the patient’s perceived emotions. Depletion of volume in specific facial planes, muscle dynamics and structural support deficiencies were identified.

Photographs were taken at different angles and she was asked what facial areas and emotional expressions concerned her, along with the handheld mirror.

Treatment plan The patient did not want laser or surgery due to downtime and financial reasons, so we agreed upon a combination of dermal filler to replace volume and strategically reposition tissues, and neuromodulators to help reduce muscle activity of the lower face.

Polynucleotides were injected in the perioral area to improve the skin structure, overall elasticity and bioreactivating primers of the skin, as well as medical-grade skincare.

Treatment approach To achieve a natural and harmonious facial rejuvenation, a nuanced combination of techniques was executed (Figure 1).3 Superior To improve the convexity of the forehead and improve the depth of rhytids, the forehead was treated with 0.3ml of Teosyal RHA2 using a 25G cannula and utilising an interfascial, retrograde linear thread technique.

In the temple I wanted to support and lift the brows and open up the periorbital area. I also wanted to improve the volume deficiency, resulting in ‘lifting’ of the lower face due to its parallel arrangement of the fascial layers. For this 0.3ml of Teosyal RHA4 was placed deep using a 27G needle and utilising a bolus and gunshot technique.

Lateral To treat the zygomatic ligament I injected 0.2ml of RHA4 using a deep injection bolus. If injecting too lateral, the deep periosteum is fused with the superficial temporal fascia, and dermal filler can travel upwards, which can worsen the temporal hollowing.

In order to reposition tissues and improve the jawline, the pre-auricular region was injected with 0.2ml of RHA3 using a 25G cannula. I injected subdermally and therefore out of the way of the parotid gland. I made sure I was behind the Line of Ligament theory.17 The line of ligament is 1cm lateral to the lateral canthus, a vertical line cranial to cauda, connecting the major facial ligaments. The line also represents the most lateral aspect where the muscles of the facial expression originate from the bone.

For the posterior jaw I injected 0.2ml of Teosyal Puresense Ultra Deep using a deep injection bolus to provide structural support. I also injected 0.2ml of RHA4 sub-dermally. This was to give structural support to the medial tissues and regain posterior support without widening the width of the jaw.

Medial I injected the MSOOF/LSOOF lateral cheek with 0.2ml of RHA4 to improve the lid-cheek junction. This opens an aperture and gives a myomodulatory effect under the muscle where it expands, so the eye opens and lifts. For this I used a deep injection bolus and a 27G needle.

A total of 0.2ml of RHA3 was used in the maximum projection point using a 25G cannula, subdermally. I used the Dr Arthur Swift ‘double scoop’ technique to create a higher trajectory.18 46

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For the deep medial cheek fat, 0.2ml of Ultradeep was injected per side using a 27G needle and a deep injection bolus. This was to support the ligaments, restoring lost structure and improving tear trough deformity.

As we mature, we lose submalar fat, transitioning from cheek to the lower part of the face. This creates the contrasting contour to the highlight made at the apex. So, for the lower face contour I used 01.ml of RHA4 per side using a 27G needle and a deep injection bolus.

To treat volume loss and help improve the nasolabial fold I the pyriform fossa was injected with 0.2ml of Ultradeep using a 27G needle, a deep supraperiosteal bolus injection.

For the nasolabial folds/rhytids and marionette area 0.2ml of RHA3 was injected per side.

I performed small superficial linear threads perpendicular to the course of the rhytid topographically, known as the fern technique.19 This was to provide structural support and tension under the rhytid, improving the rhytid, but not completely removing it.

To address chin shadows 0.3ml was injected per side of RHA3 superficially using a 25G cannula and a fanning technique. I injected retrograde linear threads in the subcutaneous fat plan.

This was to provide support in the marionette area and oral commissure. This fanning also helped add structural support in an angle crossing the dynamic smile lines, which helps prevent the skin from creasing in both static and dynamic mode. I injected superficially into the depressor anguli oris (DAO) muscle, obstructing the muscle and decreasing the downward pull.

For the lips, 0.2ml of RHA2 was injected at the first session and then 0.3ml at the second session six weeks later.

A superficial injection technique was implemented with a 30G needle. The aim of the first session was to provide definition and to reduce the perioral rhytids. At the second session my aim was to evert the lip and add volume.

For the periorbital area 0.2ml of RHA1 was injected using a superficial fanning technique using a 25G cannula at the first session to add volume and support for the skin, and for subcision of the attachment of the dermis on the muscle.

At the second session, two weeks later, polynucleotides (2ml/ session; 40mg/2ml) were injected intradermally using a 25G cannula and a fanning technique.

This was to generate a synergistic effect with the dermal filler.

Further subcision was performed with cannula to regenerate

Combining HA fillers, neuromodulators and polynucleotides in a strategic and patient-specific manner can address emotional attributes

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of product targeted structural loss, while superficial placement aimed at de-shadowing, collectively improving the visualised ligament anatomy affected by deflation and descent of surrounding tissues.

After

The effect of botulinum toxin A on the DAO and the platysmal bands resulted in less dermal filler being required to achieve the outcome.

The overarching goal was to restore youthful proportions, strategically altering light reflection points while preserving the patient’s inherent natural character.

Aftercare

Figure 2: Patient before and after treatment using 6.5ml of dermal filler, 14 units of botulinum toxin and 6ml of polynucleotides

collagen synthesis, strengthening skin structure and improving elasticity.

For this, PhilArt, an injectable gel consisting of long-chain polynucleotides, was used. Polynucleotides boost the hydration of the skin, scavenge free radicals and promote the production of new collagen and elastic fibres, stimulating the body’s own cell regeneration. This product was beneficial as we did not want to add too much volume in the periorbital area with RHA1 or any other product with a high G prime, as it would look unnatural.

Instead, improvement of the skin quality would help. The patient understood poor skin quality could not be eradicated completely. This was performed over three sessions, two weeks apart.

To elevate the corners of the mouth and reduce the marionette lines and jowling, the DAO was injected superficially using two units of botulinum toxin per side with a 32G needle. In the platysmal bands, four units of botulinum toxin were injected per band. For prominent platysmal bands, this means the upper portion (above the line of convergence) only pulls down, whereas the lower elevates, therefore only treating the negative vector.

Finally I used the modified Nefertiti technique to weaken the downward pull of strong muscle, which can decrease jowling, tighten the jawline and increase mid-face volume. Two units of botulinum toxin were injected per point (six units per side) with a 32G needle.20 The sequence of the injections played a pivotal role in the process. Lateral injection points took precedence, effectively

revitalising the identified areas before addressing medial points. This sequential approach minimised the required product volume due to tissue repositioning in a posterolateral direction, inducing a subtle yet impactful ‘lifting effect’.

The strategic use of suborbicularis oculi fat (SOOF) injections proved highly beneficial, leveraging a remarkable 98-99% surface volume coefficient. This minimal product volume yielded maximum benefits, showcasing the dual potential of volumising medially and lifting laterally.

Adhering to a comprehensive treatment plan, neuromodulators and polynucleotides were administered over three sessions.

A synergy of techniques was employed to achieve optimal results while minimising product volume. Emphasising the importance of lateral injection points, the process involved reinvigorating structural areas before addressing medial aspects.

This facilitated the lifting and stretching of medially and inferiorly located facial soft tissues in a posterolateral direction.

The anatomy of the osseous cutaneous ligament was strategically considered during treatment. Deep medial cheek fat injections supported the ligament, alleviating strain and concealing the herniation of the periorbital fat pad. This led to a reduction in injected soft tissue filler volume, contributing to a visually appealing aesthetic outcome.

The significance of the osteocutaneous ligaments was further exemplified in addressing the nasojugal groove and tear trough deformity. Deep placement Aesthetics | December 2024

Because of the volume of injection, treatment is not carried out in one go; the product is placed as boluses and very small droplets to minimise risks such as occlusion, swelling and bruising. The patient was advised to have pineapple beforehand due to the bromelain effects.

Bromelain is a type of proteolytic enzyme that causes the body to make substances that fight pain and swelling. It also reduces inflammation.21 She was also advised to take arnica tablets post-treatment.22 Results Through a comprehensive evaluation and a shared educational journey, the patient gained insight into the complex origins of her aesthetic concerns, appreciating a holistic approach to treatment. She reclaimed her comfort in self-reflection and rediscovered the joy of smiling freely (without hiding her mouth), and regained her confidence, which impacted her overall quality of life.

Utilising combinations Our face biologically changes as we age, affecting multiple layers and cellular pathways, which all need to be targeted.

Combining HA fillers, neuromodulators and polynucleotides in a strategic and patient-specific manner can address emotional attributes, providing patients with a refreshed and natural appearance.

This article underscores the importance of a comprehensive assessment, anatomical understanding and a tailored treatment plan for successful facial rejuvenation.

Dr Sonia Soopen is a general and cosmetic dentist and facial aesthetic physician in Surrey.

Dr Soopen adopts a holistic approach and provides dental treatments and bespoke tailored rejuvenation and enhancements.

Qual: BDS, MJDF, RCS

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Managing Hair Loss Platelet-Rich Plasma

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Managing Female Pattern Hair Loss with PRP

diagnosis of the scalp disorder, followed by selecting the appropriate patients. Patients with an active infection, haematological disorder, an active malignancy and those who are on anticoagulants are not suitable candidates for this procedure.1

Dr Nicole Chiang presents a case study on the treatment of female pattern hair loss using platelet-rich-plasma

When counselling patients about PRP, it is important to educate them about realistic outcomes. Patients need to be informed that the treatment effects of PRP can be variable.1 This variability will be further explored in the article.

Platelet-rich plasma (PRP) was first described in haematology in the 1970s as a small volume of plasma containing higher concentrations of platelets than the peripheral blood.1 The growth factors and cytokines released by PRP play important roles in wound healing and tissue regeneration (Table 1).2 Several studies have shown that PRP can be effective for hair growth.3 Hair growth is regulated by the β-catenin signalling pathway, which is activated by the Wnt ligands. PRP has been shown to activate the Wnt/β-catenin signalling pathway needed for melanocyte and keratinocyte proliferation and initiation of hair follicle development.3,4 PRP can also exert some anti-apoptotic effects to increase the survival of hair follicle cells and prolong the anagen (growing) phase of the hair cycle.4,5 Systematic reviews have shown that PRP is a safe and effective treatment for female pattern hair loss, increasing hair count and hair density.5,6 It is a treatment with minimal side effects. This includes transient pain during injections, local injection site reactions (mild redness and swelling on treated area) and mild headache.

Factors influencing hair loss Female pattern hair loss is the most common cause of hair loss in adult women.8 It is characterised by progressive follicular miniaturisation with a reduction in the anagen phase of the hair cycle, and gradual hair thinning on the centre of the scalp.8,9 The condition may appear in the early reproductive years and has a second peak incidence at around the time of menopause.

Several factors are thought to be involved, including genetic predisposition

(e.g. polymorphisms in the aromatase gene), hormonal factors (enhanced androgen action in the scalp), chronic low-grade scalp inflammation and possibly environmental factors (e.g. lifestyle, diet, stress).8 Female pattern hair loss is often observed at menopause as oestrogen levels decrease abruptly after menopause, leading to an enhanced androgen action in the scalp that drives follicular miniaturisation.9

Mechanism of PRP in hair growth PRP contains many growth factors that influence the hair growth cycle.

Epidermal growth factor (EGF) activates stem cell renewal in the hair bulge and produces new follicular units. EGF also protects the hair follicle from excessive inflammation. The Chemokine Ligand 2 (CCL2) promotes hair follicle-specific innate immunity and stimulates the recruitment and differentiation of M1 macrophages that promote hair growth. Insulin-like growth factor 1 (IGF-1) and fibroblast growth factor (FGF) prolong the anagen (growing) phase of the hair by upregulating the Wnt/ β-catenin signalling pathway in the hair bulge and dermal papilla. Vascular endothelial growth factor (VEGF) stimulates angiogenesis to ensure adequate nutritional delivery to the hair follicle.10

Practical considerations When performing PRP, there are some practical considerations to be taken: such as correct diagnosis and appropriate counselling with patients.

Patient selection Patient selection for PRP is key. The process involves first establishing the correct

Platelet-released growth factors

Biological activities

Keratinocyte growth factor (KGF)

Growth and new keratinocyte generation

Platelet derived growth factor (PDGF) Cell growth, generation and repair of blood vessels, collagen production Vascular endothelial growth factor (VEGF)

Promotes angiogenesis and wound healing

Epidermal growth factor (EGF)

Promotes epithelial cell growth angiogenesis and wound healing

Fibroblast growth factor (FGF)

Growth factors present in the epithelisation phase of wound healing, keratinocytes cover the wound, forming the epithelium

Insulin-like growth factor (IGF)

Regulates cell growth

Transforming growth factor – Beta (TGF-β)

Promotes wound healing, as well as growth and neogenesis of epithelial cells and vascular endothelial cells

Connective tissue growth factor (CTGF)

Promotes angiogenesis, cartilage regeneration and platelet adhesion

Table 1: Main platelet-released growth factors and their biological activities2

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Procedural preparation and injection technique It is important to choose a safe and closed PRP system to avoid contamination during the procedure. A closed system involves a PRP kit that does not expose the blood to the environment after blood collection. There is currently a wide variety of commercially-available kits in the preparation of PRP. However, the main principle is that whole blood is centrifuged and the PRP is separated from other blood components (e.g. red blood cells and white blood cells). The concentration of growth factors present in PRP is dependent on the PRP kits and the associated method used for preparation of the PRP, as well as the quality of the PRP and platelets of the individuals. Even within the same individual, depending on time and activity, the concentration of growth factors in PRP can also vary. This explains the variable treatment effects of PRP.1 Nappage technique is commonly used. The depth of intradermal injections tends to be 1.5-2.5mm deep, with 1-3cm apart from each injection point. Various gauge needles have been used, commonly between 22-30G. Microneedling and mesotherapy guns have also been used.1

Combination treatments with PRP PRP can be combined with other treatment modalities for female pattern hair loss. A recent systematic review showed superior treatment response with a combination of PRP and topical 5% minoxidil compared to topical 5% minoxidil monotherapy.13 If PRP is combined with topical minoxidil, patients need to be counselled about potential side effects of topical minoxidil, which include irritant and allergic contact dermatitis, pruritus, scalp irritation and facial hypertrichosis.12

Case study Patient background A 64-year-old post-menopausal woman attended the clinic with concerns about hair thinning over the past five years. She did not have any scalp symptoms and had not experienced excessive hair shedding.

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STEM CELL β-CATENIN SIGNALLING

VEGF

VASCULARISATION

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IGF-1

STEM CELL REVIVED

EGF

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FGF DERMAL PAPILLA β-CATENIN SIGNALLING

M1 MACROPHAGES

PROMOTING HAIR GROWTH T-CELL MEDIATED INFLAMMATION

PROMOTION OF INNATE IMMUNITY

CCL2

Figure 1: The key growth factors in PRP and how they work collectively to promote hair growth10

She felt that the thinning was most obvious at the front and top of her scalp. At the time of consultation, she already had all the relevant blood tests performed by her GP which showed that she had no thyroid disease, and there were no nutritional (e.g. iron, vitamin B12, folate and vitamin D) deficiencies. She had a total hysterectomy 15 years ago which led to early menopause.11 She had no other past medical history, no family history of pattern hair loss, and was not on any regular medications. She had no known allergies.

Upon examination, her scalp skin was healthy with no inflammation or significant scaling. There was diffuse thinning of hair with a widening of the midline parting on the frontal and vertex scalp.

Dermoscopic examination showed healthy scalp skin, but significant miniaturisation of hairs on the frontal and vertex scalp, as compared to the posterior scalp (Figure 2). This was in keeping with female pattern hair loss (Sinclair Grade 3 – widening of the central part and loss of volume lateral to the part line).17 Before

After 3 sessions

After 6 sessions

Figure 2-4: 64-year-old post-menopausal woman’s hair density at baseline, after three PRP sessions and after six PRP sessions 1 year after

2 years after

3 years after

Managing Hair Loss Platelet-Rich Plasma

in life cause an enhanced androgen action on the scalp, which drives follicular miniaturisation and hair thinning on the centre of the scalp.8 It was emphasised that treatments need to be sustained long-term to help stop or slow the progression of the condition.

The patient expressed a desire for non-surgical intervention, as she had no intention of pursuing hair transplantation. Various treatment options for female pattern hair loss were explained, including the licensed treatment of topical minoxidil 2% and off-licence treatments such as topical minoxidil 5%, oral minoxidil, oral spironolactone, oral finasteride, PRP and low-level light therapy. Each treatment’s mechanism, potential effects, adverse effects and regimen requirements were reviewed. The patient was then given time to consider the options, as any chosen treatment would need to be continued for at least six months (as a general rule of thumb) to assess its effectiveness.

Treatment plan The patient returned to the clinic after three months and expressed a desire to undergo a course of monthly PRP injections, as she felt this was the most natural method to support hair growth. She opted against oral treatments, preferring to avoid potential systemic side effects. She was also considering purchasing a home low-level light therapy device to complement the effects of PRP. A monthly PRP treatment regimen was initiated, and she attended her appointments as scheduled.

After her second PRP treatment, the potential addition of topical minoxidil 5% (Figure 3) was discussed, as combination therapies have been shown to yield better outcomes for female pattern hair loss compared with monotherapy.12 Notably, her hair density showed marked improvement after three sessions of PRP, even though she had not yet started using low-level light therapy or topical minoxidil 5%. She continued with three additional PRP sessions at monthly intervals, and commenced daily use of topical minoxidil 5% to enhance the treatment effects.

Over the following three months, she continued to experience improvement in hair density. She then transitioned to a maintenance regimen consisting of three- to four PRP treatment sessions per year (spaced at three to four-month intervals), along with daily topical minoxidil 5%. Her treatment results have remained stable and effective even after three years (Figure 7).

The procedure, using the RegenLab PRP system, involves the withdrawal of a 10ml blood sample directly into the PRP tube using a vacutainer system, which was then centrifuged for five minutes.

Around 5ml was PRP was obtained after centrifuge, and this was then injected into the scalp skin using a TSK 25G 4mm length needle using the nappage (micro-injection) technique. A total of 5ml were injected to the frontal and vertex scalp, where the hair thinning was worst. A consistent technique was used at each appointment to the same treatment areas.

Long-term efficacy of PRP

Figure 5-7: 64-year-old post-menopausal woman after one year, two years and three years of PRP treatment

Consultation After the clinical examination, the diagnosis of female pattern hair loss was discussed with the patient. It was explained that the condition is influenced by both hormonal and genetic factors (hence the medical term ‘androgenetic alopecia’) and tends to progress over time.8 This is because the sharp decline in oestrogen levels with menopause and a slow decline in androgen levels until later stages

PRP can be a potential effective treatment for patients who have female pattern hair loss, which commonly presents in the peri-menopausal or post-menopausal periods.1 The maintenance of PRP treatment has been shown, as demonstrated in this case, to be effective in stabilising the condition of female pattern hair loss even years after the initial treatment course.

Dr Nicole Chiang is a consultant dermatologist who subspecialises in hair disorders. She is experienced in treating non-scarring and scarring alopecia with medical and aesthetic treatments.

Qual: MBChB(Hons), FRCP, PG Cert Aesthetic Medicine

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49

Advertorial Crown Aesthetics

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Elevating skin health

Revolutionising Skin Rejuvenation: New SkinPen® Precision Treatment Procedure with BIOJUVE™ Introducing the new SkinPen® Precision treatment procedure with BIOJUVE™ for advanced biome boosted skin remodelling Crown Aesthetics stands at the forefront of a transformative movement in medical aesthetics by unveiling a new approach that synergises the award-winning SkinPen® Precision technology with the groundbreaking BIOJUVE™ Skin Biome Care. This approach is poised to redefine the paradigm of skin care, offering an integrative treatment that elevates skin quality and appearance, and fortifies skin health on a microbial level. The aesthetics specialty is unmistakably headed towards treatments that embrace a holistic perspective, and Crown Aesthetics leads this charge by pioneering a new standard in skin biome care. Their patented BIOJUVE™, in combination with The Aesthetics Awards 2024 Best Energy Device SkinPen® Precision, delivers a potent formula for optimal skin remodelling. This innovative pair works to accelerate the natural healing process while minimising downtime, and reducing redness, dryness, peeling, itchiness and swelling post-procedure, presenting a groundbreaking dual strategy.

A harmonious blend of innovation and care The treatment protocol seamlessly integrates Crown Aesthetics’ premier innovations: SkinPen® Precision skin remodelling and BIOJUVE™ skin biome care. The SkinPen® Precision, recognised for its pioneering role as the world’s first FDA-cleared microneedling device, excels in activating the skin’s natural regenerative processes, enhancing collagen and elastin production. The result is a noticeable improvement in skin tone, texture and elasticity to help improve the cosmetic appearance of fine lines, wrinkles, stretch marks, surgical scars, enlarged pores and pigmentation conditions (dyschromia).1 BIOJUVE™ marks a significant advance in the nurturing of the skin’s microbiome. It exemplifies Crown Aesthetics’ dedication to holistic skin health, promoting the beneficial bacteria that are the foundation for a robust and vibrant skin barrier. This dual-faceted approach quickens the healing process pre- and post-microneedling and bolsters the skin’s overall health and resilience.

A core component of this new approach is the Xycrobe™ Technology, encapsulated within BIOJUVE™.1 This cutting-edge system enhances skin health and quality by harnessing the microbes native to our skin.1 Utilising a unique strain of C.acnes defendens, Xycrobes optimise the skin’s microbiome by acting as a skin probiotic, fostering a balanced skin biome that visibly improves skin clarity, tone and texture.1 Integrating this living microbe into the skin’s existing ecosystem creates a conducive environment for these improvements, highlighting the pivotal role of microbiomes in aesthetic outcomes.

Clinical studies underscore the efficacy of this approach, revealing significant aesthetic enhancements and reduced downtime when BIOJUVE™ skin biome care is incorporated into pre- and post-SkinPen® Precision microneedling treatments.1

Comprehensive benefits This innovative approach allows for inclusive care, yielding immediate and enduring skin health and aesthetic improvements.

Patients can anticipate a diminution in skin imperfections and an enhancement in skin tone and texture.1 This holistic methodology accommodates all skin types and tones, embodying a significant leap forward in personalised, non-invasive skin rejuvenation solutions.1 By leveraging mechanical and biological innovations, Crown Aesthetics spearheads the development of therapies that promise profound and lasting benefits This initiative mirrors the specialty’s growing preference for natural, minimally invasive techniques. As our comprehension of the skin’s intricacy deepens, the need to support its processes and defences becomes evident. The SkinPen® Precision and BIOJUVE™ treatment procedure is emblematic of this evolution, offering a method that complements the body’s natural mechanisms.

This advertorial was written and supplied

by Crown Aesthetics

A vision for holistic beauty and health

“We’re thrilled to present our innovative SkinPen® Precision treatment procedure combined with BIOJUVE™. This isn’t merely a new treatment option; it represents our unwavering dedication to advancing holistic solutions that cater to the skin’s aesthetic and health needs. At Crown Aesthetics, our pursuit of sustainable beauty is driven by a profound comprehension of skin science. Our objective is to empower practitioners and patients with pioneering solutions that establish new benchmarks in the aesthetics sphere.

We’re honoured to lead this transformative journey in skincare and beauty,” says Andy Moulton, VP of International at Crown Aesthetics.

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For more details visit www.skinpenuk.com and www.biojuve.co.uk, or contact enquiries@crownaesthetics.com

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Clinical Papers Abstracts

A Summary of the Latest Clinical Studies The latest research highlight from Professor Sebastian Cotofana and The Harley Academy Research Group World-renowned anatomist Professor Sebastian Cotofana shares a key study influencing the world of medical aesthetics.

Title: The Relationship Between Glabellar Contraction Patterns and Glabellar Muscle Anatomy: A Magnetic Resonance Imaging-Based Study Authors: Rams D, et al.

Published: Aesthetic Surgery Journal, October 2024 Keywords: Melancholia, Glabellar Rhytids, Neuromodulator Treatments In 1872, Charles Darwin described a specific forehead wrinkle pattern when observing individuals suffering from depression and melancholia, which was labelled in 1878 by Heinrich Schuele as omega melancholicum or the omega sign. They thought that this specific upper facial expression was a clinical sign and indicator for the mental state of these patients. In 1985, however, the connection to other facial expressions and the involvement of specific muscles was established via electromyography, thereby linking facial expressions to the activity of specific facial muscles.

In 2010 and 2012, a Brazilian group centred around dermatologist Dr Ada Trinidade de Almeida claimed that the government regulatory board-approved injection algorithm for treating the

glabellar region with neuromodulators needed optimisation and individual adjustments. The authors suggested that a glabellar injection algorithm should be modified based on five specific contraction patterns which are visible when patients frown; this concept was termed glabellar contraction patterns. Subsequent publications evaluated whether this strategy was generalisable to other ethnicities or had any tangible clinical merit.

Based on the former findings, Rams and his colleagues from the Department of Anatomy of the Jagiellonian University Medical College in Kraków, Poland conducted an MRI-based study in young, toxin naïve individuals which they stratified into the previously described five glabellar contraction patterns. They investigated the length, width, thickness and surface area of the frontalis, procerus, orbicularis oculi and corrugator supercilii muscles through multiplanar measuring methods. Their analyses revealed that there were no statistically significant differences in the evaluated muscle parameters; independent of which contraction pattern the subjects displayed, no difference was visible via MRI in their underlying musculature.

Clinically, the results point out that the glabellar can be treated via the standard and approved injection neuromodulator algorithm, independent of which glabellar contraction pattern the patient has. Small adjustments in dosage, however, should be made to account for interindividual differences, but the injection points and depth of product placement should remain unaltered.

These findings are novel and change a 14-year-old concept which previously may have resulted in those patients receiving neuromodulator treatments that were positioned suboptimally.

This may have potentially caused an increased risk for adverse events and reduced efficacy. Future studies will be needed to further increase our knowledge of how to better treat glabellar rhytids.

Title: Case Reports on Hand Prejuvenation: Clinical Outcomes in Middle-Aged Women with Hyaluronic Acid Filler Plus Lidocaine

Title: Comparative Analysis of Cellulite Treatment Modalities: A Systematic Review

Authors: Siquier-Dameto G, Malgapo D.

Authors: Lim S, et al.

Published: International Journal of Women’s Dermatology, November 2024

Published: Aesthetic Plastic Surgery, November 2024

Keywords: Hand Rejuvenation, Hyaluronic Acid, Injectables Abstract: Hand rejuvenation with hyaluronic acid filler injections is gaining more attention for its ability to correct volume loss and improve skin quality. The hand dorsum is prone to loss of dermal elasticity and subcutaneous atrophy as individuals age, and administering hyaluronic acid fillers has become an option to restore the smoothness and youthful contour of the hand. The aim of this study is to demonstrate that injections with Definisse Touch Filler Plus Lidocaine are effective and safe for hand rejuvenation. Ten subjects underwent filler placement of 0.5 to 1.0 ml in the dorsal superficial lamina, which is devoid of sensory nerves and major skin vessels, using a blunt cannula via the fanning technique.

Measurements were done before, immediately after and one month after the treatment using validated aesthetic scales.

There was a significant correction of volume loss immediately after the first treatment, and an improvement in skin texture and topography one month after the procedure. Therefore, injecting a low G-prime hyaluronic acid along the dorsal superficial lamina via cannula was found to provide an effective and tolerable option for improving the appearance of aged hands.

Keywords: Aesthetic Devices, Body Treatments, Cellulite Abstract: Cellulite is a highly prevalent and aesthetically distressing skin condition. Whilst there are a variety of treatment modalities, none are definitively established. This systematic review aims to assess invasive and non-invasive treatment modalities for cellulite management. Overall, 753 studies were initially identified, of which 24 satisfied the eligibility criteria, with a total of 2,084 patients. Evaluated interventions included mechanical stimulation, topical therapy, shock wave therapy (SWT), laser and light-based devices, radiofrequency therapy, subcutaneous injectables and ultrasound. SWT emerged as a standout intervention, demonstrating a consistent cellulite reduction score of 2.07 ± 0.39 across four studies. Radiofrequency therapy exhibited a statistically significant reduction of thigh circumference and subcutaneous tissue thickness. Subcutaneous injectables, specifically collagenase clostridium histolyticum-aaes, demonstrated a statistically significant improvement in the clinician-reported photonumeric cellulite severity scale (17.0%) and patient-reported photonumeric cellulite severity scale (25.7%). SWT, radiofrequency therapy and subcutaneous injectables have shown promising findings in cellulite treatment.

Aesthetics | December 2024

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Staff In Practice Progression News Professional Reviews

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look at how I can support those goals.5

Utilising Professional Development Reviews Nurse prescriber Carla Mills outlines how business owners can use professional development reviews to enhance staff success Every business owner should have professional development reviews (PDRs) of their staff embedded within their business process. This underpins service delivery and care standards, as well as upholding your business’s reputation. Not having this process within your aesthetic practice could lead to unnecessary mistakes and staffing issues, which can damage the business reputation you’ve worked so hard to build.

Here, I outline the benefits of regular PDRs, and provide advice for getting the most out of your staff.

What are PDRs? PDRs are regularly adopted throughout all areas of industry. Their function is to summarise and reflect on progress against development opportunities, relevant professional standards, benefits and applications of professional learning, achievements and any factors which may have impacted the appraisee and their performance. They can also help to set objectives and key performance indicators.1

The benefits of PDRs PDRs are an opportunity to set employee goals, identify successful or poor performance, provide employees with additional support and look at any areas of progression.

Setting employee goals Just as it is important to set goals within your aesthetic business, practitioners need to keep staff motivated. Evidence shows that pay alone is not enough to retain good employees, keep them engaged and support their wellbeing.2 The goal setting theory suggests that setting goals can positively influence increased employee job satisfaction and performance.3 Allowing the individual to set their own goals increases satisfaction when they can attain or exceed them. A research study by Floyd stresses the importance of making the goal-setting process autonomous, as if not, there is a risk of creating a culture of performativity, whereby employees feel micromanaged rather than supported in meeting their goals.4 The research findings also highlight the importance of setting realistic goals, as setting over-ambitious ones could lead to a disengaged workforce.4 Within my aesthetic business, I carry out employee PDRs every six months, as this allows the employees to set smaller, more manageable and attainable goals. I allow the employee to use the PDRs to make autonomous decisions on what their goals should be, and I then 52

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One example of how this works well for both the employee and the business is a PDR I carried out with an employee, who wanted to understand the business processes, and take on more of the business functions I carried out. I suggested she attend a business and management course, following which I would review her progress at her next PDR. By the time this came about, she was completing weekly profit and loss accounts and evaluating business processes like patient software.

There were many different functions the employee was able to assist with within the business, and as a result, on her next PDR I gave her a pay increase. This illustrates how a PDR can both support the goals of the employee, as well as support the future innovation of the business.

Providing extra support and taking on feedback The power of PDRs combined with effective listening skills at the management level can help identify areas where employees need support, be it through further training modules such as skincare training, customer service or arranging for your employees to attend shadow shifts in other aesthetic clinics. Recognising this may lead to improved workforce performance, and therefore increased production, reduced rates of defects and increased business profits.6 This empowerment and inclusivity of staff supports the notion that employee feedback and those one-to-one interactions can be the difference between your business failing or becoming successful and increasing profits.

As an employer, it’s important to try to limit criticism and instead concentrate on solutions/advice Identifying poor performance One bad apple can damage the success of your business. So, it is important that you make time to regularly review all employee performance to identify any shortcomings and look at any negative patterns of behaviour. This means poor performance

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does not go undetected, negative work culture is not allowed to spread and you can carry out damage control before they either make a mistake, damage your business reputation or cost your business lots of money.7

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Staff In Practice Progression News Professional Reviews

Avoid ignoring professional development The high staff turnover and increased dissatisfaction from workers within the NHS is a good example of how ignoring the feelings and experiences of your workforce can lead to symptoms of burnout, high levels of job role dissatisfaction and disengagement.

If your employee is underperforming, this may be due to low morale or lack of skills. These issues can only be identified through PDR Data from YouGov found 47% of staff were actively searching activities – it is your opportunity to find out what the cause of poor for job roles outside of the NHS.8 Testimonials from staff found performance is. Is it that your employee just isn’t the right fit for reasons for the levels of dissatisfaction to be, “The public and your business, do they have gaps in training or are they having the government do not care about how desperate the people some health and wellbeing issues which are working in the NHS are for change and negatively impacting their work performance? it kills us,” and, “We are seeing talented Case study You won’t know until you ask the questions. and hardworking paramedics have mental During one of my rounds of Rewarding hard work breakdowns and quit on a daily basis. We performance reviews, an audit found see a consistent impact on patient care, As well as using a PDR to highlight any that one of my team member’s and every shift becomes more and more employee poor performance issues, from records were not up to standard. Of difficult.” These testimonials support the my own experience, PDRs also work well course, this is really important for validity and importance of listening to your your business in terms of medical, in keeping great members of staff – those legal and indemnity considerations. staff and providing them with sufficient who will help your business grow and Rather than getting annoyed, I used increase profits. support and guidance through PDRs. Not this opportunity to question why this only will this keep the great staff members You can use your PDR meeting as an might be happening. It turned out who make your business successful from opportunity to give praise – if they have met the employee was so busy carrying leaving, but it will underpin the service your their goals, or have some examples of really out services, they felt they didn’t team provides your patients.9 great work, it’s your time as a manager to make have enough time to do their notes. them feel appreciated and valued. You can This was the first time they had Improving performance also discuss growth plans in terms of their next expressed any concerns to me, and steps within the company, giving them a strong PDRs are a huge influencer towards without the performance review the sense of purpose and a clear pathway for employee productivity, engagement, issue may well have fallen under the career progression. morale, levels of excellence, staff wellbeing radar for longer. and happiness at work, as well as higher During the review, we discussed The role of the reviewer levels of success and growth in your what the action would be to improve It’s the role of the reviewer to ensure you business. They work well to identify their record keeping. We decided provide a supportive environment to promote that the employee would extend issues, celebrate any wins and help your an open discussion during the PDR. Celebrate the time allocated to each service, relationship with your employees grow their achievements and success, strengthen so they had more time to complete and develop. relationships, focus on how the management their patient notes and get ready The NHS workforce levels of feeling team can support the employee’s goal for for their next patient. Although underappreciated and ignored is a over the next 12 months, identify training and treatment times were extended, great example of how not engaging with developmental needs and share constructive the risk of potential legal action your staff at regular intervals and not feedback. This could be through reviewing and the associated costs due to listening or acting on their concerns can poor record-keeping outweighed patient feedback forms and looking for any lead to disengagement in their work, the benefits of trying to fit in more areas requiring improvement. As an employer, treatments. This could compromise psychological issues and ultimately staff it’s important to try to limit criticism and the time the employee had to wanting to leave. I advise any aesthetic instead concentrate on solutions/advice – complete all her tasks before the this will stop the interaction from seeming business owner to start implementing next patient. negative and instead be constructive. A good PDRs where possible, and witness change way to do this is to form a PDR template, and During the next PDR we audited the their to employee productivity grow! employee’s record keeping since compare these documents from the previous the last meeting, put that area of Carla Mills is a registered meeting. This way you can discuss what the general nurse and independent development down as completed goals were at the last PDR and whether the nurse prescriber who has and celebrated that employee’s win. employee has attained them. If they have not trained in aesthetics since The result: met those goals, why have they not, and how 2012. She holds a first degree could they have been supported to achieve · The employee felt supported and in Business and Management, and most them? It’s also a good way for the employee wanted to improve their records recently completed her post graduate diploma in Aesthetic Medicine with the University of to check their ongoing goals throughout the · We were able to check the South Wales and her assessors qualification year and ensure they are completing them progress of this action by with MapIQ. She is a KOL for InMode with a before the next review. auditing records special interest in women’s health, is BAMAN · We knew the records were being As a reviewer, it is important to manage the leader for the North Wales region and is a completed to a high standard reviewee’s expectations, and be realistic clinical research officer within her NHS Post.

Qual: RGN, INP, Dip HE in what you’re practically able to provide to · The business was meeting the them. All of these actions will contribute to requirements of our insurance your employee’s motivation, levels of work policy and regulatory bodies VIEW THE REFERENCES AT satisfaction and wellbeing, thus leading to AESTHETICSJOURNAL.COM higher staff retention rates.6 Aesthetics | December 2024

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References: * Such treatment decisions must be assessed and discussed as part of the healthcare professional–patient consultation prior to any treatment being administered. † Multimodal aesthetics treatment describes the use of more than one type of treatment modality that are administered as part of a patient’s treatment plan.

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Dr Edward Robinson explores the literature around polynucleotide use for hair loss

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The safety and efficacy of HArmonyCa™ has not been evaluated in patients treated with other filling implants.10 There is no data available regarding the safety of injecting a greater amount than 20mL of ALLERGAN dermal fillers per 60kg body mass per year.4 HArmonyCa™ Lidocaine is referred to as HArmonyCa™.

Special Feature: Examining Treatment Approaches to Manage Scars Treating Melasma: Discussing Various Treatment Modalities for Melasma

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Personal Branding Aesthetic Profile

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the skills and expertise of my team. By promoting my colleagues through the clinic’s platform (@thedoctorandcompany), we strengthened the clinic’s brand identity as a collective, rather than being solely tied to my personal reputation.

Becoming a reputable business

Standing Out as a Personal Brand Within Your Clinic Dr Natalie Haworth shares her insights on building a personal brand within your clinic You’ve completed the courses, honed your injection techniques, invested in your scrubs and taken your professional headshots. So, what’s the next step? In the world of aesthetics – a highly competitive and rapidly evolving landscape – standing out isn’t just about skill; it’s about strategy.

Marketing yourself effectively in the aesthetics field presents unique challenges, from legal and regulatory constraints on advertising procedures, to the sheer volume of competition.1,2 Building a strong, authentic personal brand can set you apart and attract the patients you’re looking to serve.

Personal branding I first recognised the importance of personal branding in 2022, during my eighth year as an injector. My journey to establishing a distinction between my personal brand and my clinic brand was unplanned; I learned through experience. After leaving a large clinic where personal branding was minimised in favour of promoting the clinic as a unified entity, I needed to develop a strong personal brand to strategically attract and retain previous patients. To start, I branded myself simply and effectively as Dr Natalie Clinics.

Brand identity Personal branding in aesthetics is crucial because it serves as a visual representation of your identity; it’s your professional ‘dating profile’. You attract patients who share your values, aesthetics and approach to treatments. By curating consistent and appealing content in all forms of media (website, blogs, social media, advertorials in local press/ aesthetic press/magazines), you can convey professionalism, knowledge, probity and care.

This differentiation allows you to stand out in an increasingly crowded market, drawing not just any patients but the right patients to your clinic, leading to long-term relationships and retention. There is research to show practitioners’ backgrounds having a strong correlation to being trustworthy (e.g. they hold a regulatory body).3 In 2022, I realised the lack of personalised branding was limiting growth. To facilitate business expansion and balance workload among staff, I needed to remodel the clinic’s branding to create a clear distinction between myself and the other injectors. This led to the creation of The Doctor & Company (Skin Clinic), establishing two distinct brands: one for the clinic and one for myself as an individual practitioner.

To support this transition, I launched a separate social media account for my personal brand (@drnataliehaworth), allowing me to step back from the clinic’s public-facing presence. This enabled me to strategically shift the focus of the clinic’s branding to highlight 56

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Credibility and reputation are fundamental to standing out as a personal brand within your clinic. Showcasing your medical background, certificates, titles and educational achievements can reinforce your professional identity and establish trust with patients. Additionally, partaking in educational activities reminds patients of your commitment to improvement, and the fact that this is being implemented in your practice regularly. In the aesthetics field, trust is paramount – patients are more likely to choose practitioners they connect with, especially for such personal treatments. Patients are much more likely to trust a provider with a clear identity, a recognisable face, a trusted name and, more importantly, links to regulatory bodies that ensure quality and safety such as General Medical Council (GMC), General Dental Council (GDC) and Nursing and Midwifery Council (NMC).

Tips for social media

1 2 3 4

Be aware of your regulatory body’s guidance and ASA rules2 Stay consistent and post regularly – daily if possible!

Keep things simple – no huge paragraphs on a post Show your face – people engage more with a person

Social media Social media is an excellent platform to educate and attract patients. In the UK, 34 million people have an Instagram account, and 23 million are on TikTok.4 It’s free, fairly easy to navigate and can be completely personalised. When I started in aesthetics, the algorithm on Instagram was easy to please and growth came quickly. More recently, trying to get your own followers to engage in your social media can be difficult due to algorithm changes and increase of accounts, making it a saturated platform.

I recently grew my personal Instagram account by 10,000 in six weeks as I found my ‘hook’. A social media hook is something that is used to get the attention of the viewer and encourage engagement.

For me, it was text overlaid on Reels about my personal growth; I had hundreds of direct messages from people who could resonate with my journey.

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I also find my engagement and followers increase when I post Reels about current affairs relating to aesthetics. It’s important to acknowledge current affairs, but in your own authentic way – using your own ideas and words. Taking inspiration from others online is fine, but never blindly copy content; your followers will see through it and it will stop them from resonating with you.

Tips for building an effective personal brand

1

Regular, professional headshots: Every publication will request a headshot. Invest in high-quality, professional photography that reflects the image you want to project

2

Develop a simple and recognisable logo: You can’t trademark one you created on an app, so invest in graphic design

3

Define your style: Pick your style and stick with it; mine is natural tweakments, myth busting and educational content

Public relations (PR) After establishing a strong social media presence on both Instagram accounts, this was at the same time with the government’s pessimistic budget announcement and I decided we needed a strategy for continual growth.4 I wanted to ensure that we retained current patients and continued the momentum of gaining new ones despite the tough economic climate that was predicted.

This prompted me to explore public relations (PR) agencies and social media strategists.

After meeting with a PR team, I agreed – albeit reluctantly – that our campaign should centre on me, rather than just the clinic, embracing a personal branding strategy to stand out and secure our clinic’s future.

I completed a six-month plan that combined using a PR consultant and social media content. They created a Dr Natalie Haworth logo (Figure 1), colour palette and a bank of images and videos to be used on the campaign that complemented the clinic brand for consistency so patients understood I was still representing the clinic (Figure 2). They reached out to complementary brands for collaborations, got articles published in magazines and gained coverage of attendances at events.

This was the perfect storm for media exposure; within a month I had articles in most press outlets and my social media reach trebled.

At the end of the six months, I analysed data and decided we could achieve the same results without a whole package and cherry picked the most cost-effective parts, which were PR and social media.

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Figure 1: Dr Natalie Haworth’s logo for personal brand image

To become more prominent within the specialty, contributing to articles and journal publications are important. You can do this directly, but to be time efficient it may be worth investing in PR on your behalf. You can work with PR companies on a retainer or ad hoc pay-per-article basis. Journalists are busy people and will often reach out to a list of PR agents rather than directly to you, so it’s worth having your name in someone’s phonebook.

Publishing your work is a great way to gain professional recognition and it sets you apart from others by providing you with credibility as an expert in your field. This can include blog posts, which are for website traffic, pulling in from Google using meta phrasing and professional journals, typically for peers.

Your Google hits will also increase because your name will appear alongside other metaphases used in the journal. It boosts your own professional development and counts towards the quality improvement section (QIS) of the Royal Statistical Society (RSS) – a forum that promotes the use of statistical methods to improve organisation performance and outcomes – of your appraisal, it’s a win-win.

Brand engagement A lot can be gained from contact with brands in terms of training and education. Events, whether online or in-person, can generate valuable visibility on social media. By tagging companies or brands as a collaborator, you can appear on the feeds of people who may not follow you. Participating in brand events also demonstrates to your patients your commitment to ongoing education and professional growth. Aesthetics can sometimes feel isolating, and networking with colleagues might seem intimidating.

However, events and professional groups offer the perfect opportunity to connect with peers and start building your reputation within the specialty.

Brands naturally want medical experts with good reputations and skills to deliver their training and act as key opinion leaders (KOLs) for them, and this is where you may find opportunity to increase your profile further. UK brands generally have structured faculty boards that will provide education and training, as well as assisting the brand in the development and delivery of their products. Backed by a strong personal brand with social proof of press coverage Aesthetics | December 2024

Personal Branding Aesthetic Profile

Figure 2: Dr Natalie Haworth’s company logo for clinic brand image

and online engagement, practitioners can confidently approach partners with requests to be KOLs. I would also recommend supporting this approach with financial evidence of in-clinic sales of the brand’s treatments and products.

Brand engagement associated with being a KOL has been an ongoing debate in recent years due to the inherent bias of being affiliated with and even paid by brands.

There are no defining criteria of experience or qualifications to be a KOL, which opens the conversation around the validity of treating a KOL as an accolade. Having said that, being a KOL certainly does invite further opportunity and exposure within the specialty, and it’s common for practitioners to be KOLs for multiple non-competing brands.

The title can add prestige and status within the specialty, proving that you and your work has been vetted by the company.

Building your personal brand in the clinic is more important than direct sales, as you serve as a ‘key opinion leader’ for your patients – similar to how influencer marketing operates. Influencers possess the ability to resonate with their audience on a personal level, fostering trust and credibility that traditional advertising often struggles to achieve. Combining that with knowledge and experience, it’s a hypnotic sales technique.

Standing out Establishing a strong personal brand in aesthetics is crucial for credibility and attracting the right patient. Utilising PR strategies and brand engagement, practitioners can enhance their visibility in the specialty and ultimately drive growth for their clinic. Before 2022, none of my decisions were based on strategy, but if I were to do it all again with the knowledge and wisdom I have today, I may be more efficient, not only with my time, but my money too.

Dr Natalie Haworth is a cosmetic physician with skin clinics in Lancashire, Cheshire and Manchester. She graduated from The University of Manchester in Medicine in 2011 and started speciality training in women’s health. She specialises in natural enhancements and menopausal skin.

Qual: MBCHb

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Management Style Coaching

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Federation found that 86% of companies saw a return on investment from coaching.5 Coaching establishes a closer connection between manager and employee when the manager makes the time to connect on a personal level, and has a clear strategy for understanding what genuine connection means and how to develop it.

In the context of medical aesthetics, coaching can lead to:

· Improved patient care: Well-supported

Exploring Coaching as a Management Style Business development coach Marcus Haycock explores how coaching can be an effective approach to management Running a medical aesthetic clinic has always been challenging but also very rewarding.

With fierce competition, constant technological advancements and increasing regulatory pressures, it’s critical to have an inspired, competent and highly skilled practice team.

This article will explore what coaching means for managers and how you can adopt a coaching approach in your management style to boost clinic productivity and success.

The importance of good management A 2023 survey of 2,500 managers across the UK found that 82% were characterised as ‘accidental managers’, meaning they had never received structured management training.1 These individuals have typically learned on the job, relying on their abilities and professional talents. The challenge here is that without structured training on leadership and coaching team members, there is a real risk of business underperformance and increasing interpersonal pressures, especially as the medical sector becomes progressively challenging to operate and compete in.

Your management style affects everything, from how smoothly your clinic runs to how happy your staff and patients are. Good management can make a huge difference in medical aesthetics, where patient experience is paramount. Indeed, a Harvard Business Review article and study found that participative management styles, like coaching, lead to better employee engagement and performance.2

The place for coaching as a manager Coaching as a manager is about guiding your team to find solutions through questions, feedback and support. It helps staff think independently and solve problems creatively. It also focuses on promoting employees’ innovative behaviour and work motivation.3 Traditional management styles involve telling, advising and directing. While there is a place for this, without mastering the art of coaching employees, there is a risk of lower employee engagement, higher staff turnover and long-term business underperformance. It’s all a question of balance and scheduling specific coaching meetings as part of an ongoing continual improvement process.

On the other hand, coaching moves away from a top-down approach to something more collaborative. It creates a culture of continuous learning through regular feedback.

According to workplace consulting company Gallup, employees who receive regular feedback are 3.6 times more likely to be engaged at work.4 The International Coach 58

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employees who are constantly learning can provide better care, boosting patient satisfaction and retention. · Higher employee satisfaction: Coaching makes employees feel valued, which can reduce turnover. That’s crucial in a field where skilled practitioners are in high demand. · Increased clinic profitability: Engaged, well-trained staff can improve efficiency and service delivery, boosting the clinic’s bottom line.

Barriers to practising coaching When speaking to managers across my career, many are unaware of their need to prove their authority and experience, and fear that a coaching approach could dilute their control and ability to achieve superior team results. They have experience in the specialty and naturally want to pass on their wisdom and insights. The challenge is that employees learn to always rely on the manager for advice and problem-solving, which can compound work pressures for the manager, making the clinic less efficient.

Coaching is not a one-off event and requires adequate training and continual practice. Restricted budgets sometimes prevent organisations from improving their management skills en masse. However, a practical workaround would be to focus on upskilling selective managers to spread best coaching practices throughout the business. In other words, enrol in a course to learn how to coach employees and, in the medium term, aspire to be a coaching trainer and attend train-the-trainer courses. A coaching approach requires additional time upfront and complies with the same principle as investing time in professional development. You take time out to upskill, but this investment in time pays off substantially in the long term. For a manager adept at coaching others, the benefits can be profound. Significantly more time is spent on strategic imperatives, lowering staff turnover, creating a more engaged and empowered team, improving organisational performance and fostering a less stressful work environment. This investment of additional time can be a barrier initially, but also a symptom of organisations that are constantly

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‘firefighting’ working in a reactive, inefficient and stressful work environment compared to a proactive, controlled and well-balanced one.

Tips for integrating coaching Invest in professional training Firstly, you must consider investing in or piloting the concept of upskilling your managers to become master coaches.

Reading books and articles is a starting point, but it can never replace having the support of experienced professionals who specialise in making managers great at what they do. I recommend the book The Coaching Habit by Michael Stanier Bungay, published in 2016.6 When looking for the right training for you and your team, contact your network to determine which providers have a robust track record and relevant experience.

Create a shortlist, then set up online meetings to interview them based on how they can support your training needs. Invite the most appropriate providers to deliver a comprehensive programme presentation and present a proposal.

Beware of providers who offer one-off training workshops for a day or two.

Coaching is an ongoing process, and selecting a provider that uses spaced repetition, continual feedback over a series of weeks/months, multi-sensory learning and on-the-job application increases the likelihood that this training will stick.

Go in with a plan When I coach and train managers to become master coaches, I follow a structured and comprehensive strategy that can achieve transformational results.

The GROW coaching model, developed

by Sir John Whitmore and his team over forty years ago, is a coaching framework that represents Goal, Reality, Options and Way Forward.7 Its origins came from performance coaching, blending techniques from the sports and business worlds to guide individuals in setting and achieving objectives.

It is the most well-known in the coaching industry. However, existing models are useful, but incomplete and simplistic. A structured programme is needed to walk managers through a process that reviews the science and the ‘why’ of coaching along with practical and pragmatic applications, exercises and development tools.

The C.O.A.C.H. model is one of the best I have encountered. It stands for Connect, Objective, Action Plan, Commitment and Help.8 It emphasises the critical importance of connecting with coaches first. It supports the upskilling of managers by following the five key steps:8

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C: Connection Develop a productive and engaged employee working relationship based on mutual trust and empathy by showing the team members that you genuinely care about them as individuals and are personally invested in their future career success.

O: Objective Help your team members define the direction they need to head in and the ultimate destination that symbolises success. For example, increase revenues by 25%.

A: Action plan Focus on nurturing your questioning skills and helping your team members learn when shaping their action plans to ensure they achieve their objectives.

C: Commitment Apply the S.M.A.R.T. (Specific, Measurable, Aligned, Realistic and Time-bound) framework to ensure employees fully commit to achieving the objective.

H: Help Provide meaningful support and feedback that empowers team members to grow confidently and independently.

Build your relationships Develop deeper connections with all your staff. You can’t coach someone until they trust you and know you care about their best interests. This is where some managers who have attempted coaching have failed – they haven’t dedicated enough time to achieve a solid personal connection. Connecting creates greater understanding and a strong sensitivity to their feelings and needs. It significantly improves communication between both parties by enabling better expression and recognition of others’ views and perceptions, even if they are not fully aligned. Developing a genuine interest, listening and understanding employees’ aspirations and concerns are key strategies to show you care for those you lead and coach.

A transactional manager/employee relationship may be characterised by a task-and-process-focused approach.

These managers are less likely to lead and empower because they are unaware of the importance of tapping into employees’ attitudes and intrinsic motivators, and thus connecting optimally.

Support open communication Once you are connected, developing a culture of open communication is essential.

Make sure your team feels comfortable sharing ideas and concerns; regular team meetings and one-on-one sessions can Aesthetics | December 2024

Management Style Coaching help. Creating a safe environment for staff to be open with their opinions, ideas and mistakes creates a more innovative and productive environment for all. Mistakes can be discussed ‘head on’ and used as valuable learning experiences for whole-team learning.

Individual communication surrounding your team members’ professional development and growth in your team is also indispensable. Work with your staff to set personal and professional goals that align with your clinic’s objectives. Then, provide them with continuous, constructive feedback so you both remain on top of their progression.

Challenges you might face Shifting to a coaching style can be challenging, but persistence, continual learning and time scheduling are the key.

Staff are probably used to a more directive style, always leaning on the manager for support and advice. Taking personal responsibility, thinking for oneself and taking ownership of one’s own development may be a paradigm shift for some, but this needs to happen over time if you are going to develop a world-class practice team.

Achieving mastery in coaching your team members can incur more expense, but the long-term benefits usually outweigh the initial costs. These benefits are not just linked to improved financial performance for your practice. They can also be associated with lower staff turnover, reduced costs of hiring, better communication, an empowering work culture, lower stress levels and a heightened level of staff wellbeing.

Investing in success Remember, staying ahead in this competitive field means embracing technological advancements and creating a supportive, empowering workplace for your team. By investing in coaching, you can unlock your clinic’s full potential and achieve lasting success.

Marcus Haycock, a leadership development coach, has more than 21 years of expertise in medical aesthetics. Holding a business studies degree, he has honed his accountancy, sales, marketing, training, coaching, business consulting, management and leadership skills. He now works with the Logistics Management Institute (LMI), supporting its total leader programme.

Disclosure: Marcus Haycock runs leadership programme Logistics Management Institute

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In The Life Of Dr Shino Bay Dr Shino Bay takes us through a typical day in his life balancing global leadership and innovation in medical aesthetics

In The Life Of Dr Shino Bay In addition, I am the director of both the Tell-All Tribune and the Genesis meeting – an annual event produced by Modern Aesthetics that focuses on innovations in regenerative and medical aesthetics. I also contribute to the scientific committee for Advanced Medical Solutions (AMS) and AestheticSafe, a hands-on workshop we developed for dermatology, plastic surgery, oculoplastic and facial plastic surgery residents and fellows.

Being involved in projects that impact my colleagues, residents, fellows and the specialty as a whole is something I truly love.

A typical working day…

I aim to begin my morning with intention and mindfulness. I wake up at 7am and the first thing I do is head to the bathroom, drink water and recite either a Hindu or Buddhist prayer, asking for blessings. I repeat this ritual to affirm my meditations, followed by a workout, which varies between gym, yoga or a calisthenics session at home. For me, starting the day with movement is essential, as it helps reduce cortisol levels, manage stress and keep my telomeres long.

I am also a keynote speaker for leading companies such as Allergan Aesthetics, Galderma, Merz Aesthetics, Beneve, Solta Medical, Revision Skincare, Toskani MD, Vivant Skin Care, SkinCeuticals and L’Oreal.

My involvement includes sharing research, clinical insights and innovative techniques with fellow professionals.

This routine takes about an hour and 20 minutes.

After that, I take a cold shower and get ready for the day. Fortunately, my commute is short – just 13 minutes – and during the drive I listen the Know Thyself podcast by André Duqum and his guests. This is another opportunity for reflection and setting intentions. I finish with a cup of coffee, as I practise intermittent fasting, which keeps me going until noon.

On Tuesdays, I usually start work at 10am, but for the rest of the week, I arrive between 9 and 9:30am. Upon arrival, my patients are typically already numbed and prepped for injectable treatments or energy device procedures. I often have dermatology residents, fellows and visiting physicians shadowing me to learn, and I have a library of pre-recorded lectures for them to review when I’m occupied.

The treatments I enjoy performing most are those that blend science and artistry, allowing me to deliver natural, regenerative results for my patients. I take great pride in using bioregenerative techniques like Sculptra to enhance and maintain facial bone structure.

There is something incredibly rewarding about helping my patients age beautifully by leveraging their bodies’ own regenerative potential. I also use Renuva to restore facial fat in a way that looks natural and revitalised. For skin quality, I favour hyperdiluted Radiesse, as it helps support the skin’s structural integrity by stimulating collagen and elastin.

Most days, I bring my Paleo meals with me, but when I want a change, there’s a lovely Thai restaurant called Sky Thai on Fort Lauderdale Boulevard next to my clinic, Shino Bay Cosmetic Dermatology and Laser Institute. My go-to order is a beef noodle soup. If I’m feeling stressed, I tend to crave something sweet, so I’ll take a walk to get some frozen yoghurt and sneak in a few extra steps for the day.

In between the hustle of clinic duties, I peer review articles for dermatology journals, work on my own publications and prepare PowerPoint presentations for upcoming lectures.

Tuesdays are particularly long as I finish around midnight to catch up on work while my partner, Alejandro, is out. During this time, I focus on training session for Allergan Aesthetics, Galderma or dermatology residents and fellows. On other days, I stop seeing patients around 5:30pm and work from home until 7pm.

After work, I like to stay active. Physical activity is my favourite way to release stress, so I go to the gym for CrossFit on Mondays and Wednesdays, and pilates on Thursdays. After these workouts, I unwind by watching Netflix – preferably a comedy – with my partner. I am currently watching Acapulco and Pedaço de Mim!

Other work commitments…

I serve as a co-director of the Beauty Through Science conference in Stockholm, Sweden. It’s a year-round process to collaborate with my fellow co-directors, dermatologists Dr Ofir Artzi and Dr Patricia Ogilvie, as we curate content, select speakers and plan the event.

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I focus on merging science with practical applications to enhance patient outcomes.

Each of these collaborations allow me to bridge the gap between product development and real-world results, while also educating physicians, dermatologists and plastic surgeons on the latest trends and technologies. It’s an honour to be a trusted voice within the specialty.

Most memorable day in your career…

The most memorable day in my career was when I was asked by the Beauty Through Science Congress to step in as the director of the non-surgical track. I gave my all to the project, and with the incredible collaboration of my dear colleagues, we were able to create something truly special. The first meeting, both as a director and keynote speaker, is one of my proudest moments.

What is the best advice you’ve received?

If you have the choice to be right or kind, always choose kindness.

What is your favourite hobby?

It would have to be creative writing!

What is your life goal?

To elevate the consciousness of humanity.

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The Last Word Hair Loss and BDD

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The Last Word: BDD in Patients with Male Pattern Hair Loss Mr Greg Williams and psychologist Kimberley Cairns argue why some patients with BDD should still be entitled to hair loss treatment Body dysmorphic disorder (BDD) is a psychological condition where an individual has a pathological relationship with their appearance, which results in intrusive and obsessive thoughts that interfere with self-esteem and daily life.1 Individuals diagnosed with BDD experience a disconnect between their perception of reality and actual reality, which for male patients can be attributed to hair loss.2 In such patients, even if the hair loss is observable to the consulting practitioner and others, it is recommended by the National Institute for Health and Care Excellence (NICE) and the British Association of Aesthetic Plastic Surgeons (BAAPS) to avoid offering hair transplant surgery if the patient is exhibiting signs of BDD.3,4 However, we argue that male patients whose BDD does not focus on hair may still benefit from hair transplant procedures.

The root of hair loss insecurities Male pattern hair loss is extremely common – with an estimated 50% of 50-year-old men presenting with symptoms – and most men will experience some degree of it during their lifetime.5 Hair transplant surgeons are seeing increasing numbers of young men with very high levels of anxiety regarding relatively minor degrees of hairline thinning and frontal-temporal angle recession, and who are seeking surgery to restore their previous appearance or to create a ‘stronger’ hairline.6,7

Hair loss and BDD BDD is often linked to obsessive compulsive disorder (OCD). The International OCD Foundation ranks hair loss among the three most commonly disliked body parts.8 Individuals may feel significant anxiety over minor hair loss, even without BDD, complicating the distinction between normal distress and pathological anxiety for healthcare professionals. Many without a BDD diagnosis may still show behaviours resembling BDD, like social difficulties and excessive grooming. This lack of understanding could hinder access to treatments for those whose BDD is not actually linked to their hair.

The NICE guidance applies to hair transplant surgeons in the same way it applies to cosmetic surgeons in that, to achieve best 62

practice, hair transplant surgeons must develop and implement clear, structured referral pathways and work in partnership with specialist mental health professionals.2 We feel that hair loss practitioners often encounter individuals for whom they intuitively suspect BDD by a ‘gut feeling’.

However, they may hesitate to broach this topic with patients, fearing a lack of expertise in addressing it professionally and compassionately.

By definition, men requesting hair transplant surgery are dissatisfied with their appearance and are motivated to do something about it. They will present with both varying degrees of hair loss and associated distress and anxiety, and we believe this necessitates a screening to discern whether BDD may be present.

Assessing the severity We believe that all patients should have a psychological screening, but this can be informal or formal, simple or complex, accommodating diverse needs and scenarios.9,10 We argue for the use of an integrative, psychologically informed pathway in the treatment of hair to ensure thorough evaluation and appropriate management, promoting holistic wellbeing.

In cases where clinicians suspect BDD, a comprehensive approach is essential.

Patients should be promptly referred for evaluation by a specialised mental health professional. If the assessment concludes that the patient’s distress primarily stems from heightened anxiety related to hair loss without a BDD diagnosis, hair transplant surgery may be considered as an option.

However, when a definitive diagnosis of BDD specifically related to hair is established, non-surgical or surgical interventions should generally be avoided.

Balancing insecurities Hair loss is common, posing a clinical challenge when assessing patients with a history of BDD. If their BDD is unrelated to hair and they have a ‘normal’ attitude toward hair loss, we believe they should be managed similarly to those without BDD. However, defining a ‘normal’ attitude is difficult.

The International OCD Foundation recommends that since cosmetic treatments Aesthetics | December 2024

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for BDD rarely resolve symptoms of BDD, and in some cases, may make symptoms worse, cosmetic treatments are not recommended for this disorder.11 Whilst we agree in principle, we think this widely accepted position does not address patients who have objective appearance defects that are not the focus of their BDD but which they would like to have addressed.

Specifically, individuals with male pattern hair loss and a BDD diagnosis should not face discrimination solely due to their label.

However, it is essential for BDD patients and the practitioners to consider the risks of hair transplant surgery, recognising that it may inadvertently reinforce the notion that physical appearance defines self-worth.

Only deny treatment when necessary Hair restoration must not be considered a cure for BDD in patients whose obsessive focus is their hair loss. However, the authors argue that, for male patients with a diagnosis of BDD whose hair is not the central fixation of their BDD, offering hair transplant surgery may be a reasonable approach providing they have comprehensive psychological consultations, pre-care and aftercare.

This principle could extend to cosmetic surgical and non-surgical interventions addressing legitimate appearance defects in BDD patients.

To find out how you can support patients with body dysmorphic disorder or donate to the Body Dysmorphic Disorder Foundation, scan the QR code.

Mr Greg Williams is the only member of the British Association of Aesthetic Plastic Surgeons who performs hair transplant surgery on a full-time basis in the UK. He has over 20 years’ experience in hair restoration and is the past president of the British Association of Hair Restoration Surgery.

Qual: FRCS (Plast) Kimberley Cairns is a psycho-aesthetic consultant who founded the Integrating Psycho-Aesthetic Wellness in Practice (IPAW) consultancy service. Cairns works as a clinical advisor throughout the UK. Qual: BSc, MSc (Psychology), GMBPsS

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