Tanya Albin offers advice on carrying out elective filler dissolving treatment ◆ David Moatazedi discusses the rationale behind marketing to millennials Special Feature: Key Considerations When Treating Skin of Colour Lips Using Polynucleotides for Eye Dermatitis and Eczema Treatment
Dr Rehanna Beckhurst outlines the rheology and
The Resource for Medical Aesthetic Professionals
Discover, network & celebrate medical aesthetics
Entries open soon, become an Elite member of Aesthetics to enter
The UK’s leading resource for medical aesthetic professionals
Uniting the specialty to shape the future of medical aesthetics
Headline Sponsor
Midface, jawline and jowl lift using countourel ® Ultra + / Nose reshaping with countourel ® jamber tanxing
Images courtesy of Dr Rita Poddar
Dip MJDF, MFDS RCS(Eng)
Contents • August 2024
08 News
The latest product and specialty news
19 News Special: Younger Generation Still Pursuing Perfection
A new study has highlighted how views on aesthetics vary across generations
CLINICAL PRACTICE
21 Special Feature: Treating Skin of Colour Lips
Practitioners outline considerations for SOC lip enhancements
25 Performing the Non-Surgical Rhinoplasty with VIVACY
Dr Thuha Jabbar offers a guide on NSRs using STYLAGE dermal fillers
27 CPD: Discovering the Properties of HA Dermal Fillers
Dr Rehanna Beckhurst outlines the properties of dermal filler products
30 Treating the Platysmal Bands
Miss Harmony Ubhi discusses age-related changes in the neck
34 Master the Newest Injection Techniques at CCR
Injectable learning like you’ve never seen before at CCR 2024
36 Treating TMD with Botulinum Toxin
Practitioners discuss how toxin can be used to treat TMD
39 Maximising Patient Satisfaction with EXION and EMFACE
Embrace the regenerative shift with BTL’s treatment offering
41 Case Study: Using Polynucleotides for Eye Dermatitis
Practitioners discuss polynucleotide treatments around the eyes
46 Examining Elective Filler Dissolving
Tanya Albin offers advice on elective filler dissolving treatment
48 Case Study: Multi-Modality Approach to Facial Ageing
Dr Priya Verma presents a full-face case study addressing facial ageing
53 Abstracts
A round-up and summary of useful clinical papers
IN PRACTICE
54 Targeting Your Company to a Specific Age Demographic
David Moatazedi discusses the rationale of marketing to millennials
56 Creating Trust In Your Team
Kevin Riley shares advice on how to create trust in your team
58 Optimising Your Aesthetic Practice With AI
Rick O’Neill explores how clinic owners can utilise AI in their practice
61 In The Life of Dr MJ Rowland-Warmann
Dr MJ Rowland-Warmann shares a day treating patients and addressing complications
62 The Last Word: Filler’s Place in Medical Aesthetics
Dr Tristan Mehta provides thoughts on why fillers belong in aesthetics
Special Feature: Treating Skin of Colour Lips Page 21
Clinical Contributors
Dr Rehanna Beckhurst is a dental surgeon and co-founder of ifab Clinic in Barnstaple, Devon. She is a key opinion leader for Church Pharmacy and Beamwave technologies, and specialises in full-face harmonisation.
Miss Harmony Ubhi is a full-time specialist registrar in oral and maxillofacial surgery. She is a member of the Royal College of Surgeons and the clinical director of Dr Harmony Aesthetics in Amersham, London.
Dr Elle Reid is an aesthetic practitioner and dental surgeon with a background in maxillofacial surgery, hospital and practice-based dentistry. She holds the positions of clinical lead for Acquisition Aesthetics in Newcastle and director of Paragon Aesthetics medical aesthetics clinic.
Dr Bryony Elder is an aesthetic practitioner and educator. She is the founder of Ametrine Aesthetics in Newcastle upon Tyne, the Aesthetic Director for Pre- Salons in London and the Level 7 lead for Acquisition Aesthetics.
Dr Sonakshi Khorana is a GP in medical and cosmetic dermatology. She serves as a dermatology specialist for renowned skincare brands and holds memberships at the Royal College of GPs, British Medical Laser Association and Aesthetic Complications Expert (ACE) Group World.
Dr David Eccleston qualified in medicine and undertook postgraduate dermatology training at the Birmingham Skin Centre. He has worked in the field of cosmetic dermatology and is a global trainer and key opinion leader for Evolus, DermaFocus and Cutera.
Tanya Albin has worked in the aesthetic field for 14 years, while also continuing to work in the NHS, with a background in acute care within A&E, theatres, ITU and prison nursing. She owns her own CQC-registered clinic in Canterbury, Kent.
Dr Priya Verma is an aesthetic doctor at PHI Clinic in London, and a GP with a background in primary care research. She is a key opinion leader and global faculty member for Eufoton, and is an international trainer for EndoliftX.
As we welcome August, I hope many of you are managing to get some well-deserved rest and are going somewhere sunny for a holiday! I’m excited to share some fascinating developments in the world of medical aesthetics with you this month. Our news section highlights a significant update from the Royal Society of Medicine (RSM), which has just, for the first time, recognised medical aesthetics as a specialty! It’s the first new section for the RSM in 35 years and is big news for our field. I commend the individuals who have strived to make the RSM Section of Aesthetic Medicine and Surgery happen – read more on p.9. If you’re interested in hearing more from the new RSM Section, make sure to register for CCR on October 10-11 where there will be a whole full-face agenda in the Aesthetics Journal Arena – it’s not to be missed!
Our theme for this issue is injectables, so we have a lot of injectable-themed content for you to read. Our Special Feature this month focuses on treating the lips of skin of colour (SOC) patients.
Clinical Advisory Board
This topic is crucial as it addresses the unique considerations and techniques necessary to achieve optimal results in diverse patient populations. Turn to p.21 to dive into these expert insights. Continuing with our commitment to professional development, our CPD article explores the rheology of dermal fillers. Understanding the science behind the materials we use can profoundly impact treatment outcomes, so be sure to read this comprehensive piece on p.27
Don’t miss our Aesthetics Awards Highly Commended full-face case study, showcasing a masterful application of techniques on p.48! If you want to enter your own case studies into The Aesthetics Awards, entry opens on August 5, so head to the website to find out more.
Our Last Word this month tackles the ongoing relevance of fillers in aesthetic practice. Despite evolving trends and new treatments, fillers remain a cornerstone for our specialty, and we explore why they continue to be indispensable on p.62
Finally, are you taking your journal with you on holiday? Take a picture and tag us on Instagram via @aestheticsjournaluk and we will reshare your photos from around the world! Enjoy this issue!
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.
Sharon Bennett, Clinical Lead
Mr Naveen Cavale has been a consultant plastic, reconstructive and aesthetic surgeon since 2009. He has his own private clinic and hospital, REAL, in London’s Battersea. Mr Cavale is the national secretary for the ISAPS, president of the Royal Society of Medicine, and vice-chair for the British Foundation for International Reconstructive Surgery.
Miss Elizabeth Hawkes is a consultant ophthalmologist and oculoplastic surgeon. She is the lead oculoplastic surgeon at the Cadogan Clinic, specialising in blepharoplasty and advanced facial aesthetics. Miss Hawkes is a full member of the BOPSS and the ESOPRS, and is an examiner and fellow of the Royal College of Ophthalmologists.
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.
PORTFOLIO MANAGEMENT
Alison Willis • CEO | T: 07747 761198 alison.willis@easyfairs.com
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.
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 Souphiyeh Samizadeh is a dental surgeon with a Master’s degree in Aesthetic Medicine and a PGCert in Clinical Education. She is the founder of the Great British Academy of Medicine and Revivify London Clinic. Dr Samizadeh is a Visiting Teaching Fellow at University College London and King’s College London.
ADVERTISING & SPONSORSHIP
Judith Nowell • Head of Sales T: 0203 196 4352 | M: 07765 407629 judith@aestheticsjournal.com
HELP PROGRESS MEDICAL AESTHETICS! WRITE FOR THE JOURNAL
Do you have any techniques to share, case studies to showcase or knowledge to impart?
Email: editorial@aestheticsjournal.com
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.
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
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.
ARTICLE PDFs AND REPRO
Material may not be reproduced in any form without the publisher’s written permission. For PDF file support please email, contact@aestheticsjournal.com
BACN HQ are at the Conference & Events Awards nominated for Best Association Event for the Autumn Aesthetic Conference!
#Conference
Dermaroller
@dermaroller_theoriginal
Our team had an incredible experience at IMCAS in Bangkok, Asia’s largest aesthetics and cosmetic conference!
#Media
Dr Sarah Jenkins
@dr.sarah.jenskins
So privileged to have been invited onto This Morning on ITV and raising awareness about women’s health issues!
#Training
SJ Partnership
@sjpartnership
We had an incredible weekend in Edinburgh supporting the Evolus UK team with their Anatomy and Dissection training!
Innovation Mia Femtech unveils first ever injectable breast implant
Aesthetic treatment company Mia Femtech has introduced the Mia minimally invasive injectable breast implants.
The company explains that the injectable implants can be delivered in 15 minutes without the need for general anaesthesia or a scalpel, with the total appointment taking only 90 minutes. They use biocompatible surface technology to promote a low inflammatory response, low friction and low bacterial attachment. The implants can provide one or two cup enhancement with smaller sized implants, with the company saying the goal is a more natural look. According to Mia Femtech, patients experience some post-operative pain and leave with a small scar, but can resume normal activities quickly. The company explains that the procedure must still be delivered by a surgeon.
Plastic and cosmetic surgeon Mr Paul Banwell commented, “I am thrilled to be one of the first surgeons in the UK to help introduce Mia to the country. Mia complements our existing surgical offering as we continue to provide our patients with innovative treatments that are underpinned by clinical excellence, greater accessibility and peace of mind. This represents a new paradigm in breast aesthetics, offering patients the opportunity to replace a push up bra with a revolutionary local aesthetic technique.”
Advertising
ASA issues warnings about supplement menopause claims
The Advertising Standards Authority (ASA) has upheld rulings against two supplement companies after they claimed their products could treat symptoms of menopause.
A Facebook ad for the first company stated, “It’s the most comprehensive menopause support supplement that’s out there, it also works for perimenopause, it also works for post-menopause,” before listing a set of menopause symptoms which could be addressed. Indeed, the second advert stated that its product, “Reduces bloating and fluid retention in 1 to 3 days; Eliminates hot flashes [sic] in as little as 4 to 7 days; Induces deep, uninterrupted sleep in 5 to 7 days; Starts shifting hormonal weight in 15 to 30 days.”
#Launch
Dr Preema Vig
@drpreema
So much fun at the launch of JetPeel UK with such dear friends!
In both cases, the ASA’s AI Active Ad Monitoring system challenged whether the ads stated and implied that the supplements could help to prevent, treat or cure the symptoms of the menopause and perimenopause. The CAP Code states that claims which imply that a food could prevent, treat or cure human disease are prohibited.
In response, the first company said its advertisement did not use the words ‘treat’, ‘cure’ or ‘prevent’ in relation to symptoms of menopause or perimenopause, and were listing the product’s ingredients as beneficial for general health and wellbeing. The second company declined to comment.
The ASA concluded that neither advert should appear in the same format again, and that any future advertising should only make health claims which comply with GB Register conditions.
Awards
Entry for The Aesthetics Awards 2025 opens
Entry for The Aesthetics Awards 2025 will open on August 5, marking a chance for the specialty’s best and brightest to be recognised for their achievements.
The 2025 ceremony will applaud aesthetic professionals across 26 categories, covering practitioners, clinics, results, companies, products and much more. It is an unparalleled opportunity to recognise the field’s achievements over the past year.
As a prize-winner at the Awards Awards two years running, and the recipient of an Independent Awards Standards Council Trust Mark, The Aesthetics Awards’ stringent judging process and glamorous ceremony make it the most recognised and respected in the UK specialty.
Shannon Kilgariff, editor and event manager at Aesthetics, said, “Anyone who has attended The Aesthetics Awards before knows that it is truly the highlight of the aesthetics calendar. There is nothing like gathering the entire specialty together for a night of celebration. We received almost 500 entries of the highest quality last year, and we cannot wait to celebrate another year of outstanding entrants.”
The Aesthetics Awards 2025 ceremony will be held at Grosvenor House, London on March 15, 2025 following the second day of the Aesthetics Conference & Exhibition. Go to aestheticsawards.com to enter.
Specialty Advancement
Aesthetics recognised as a medical specialty by RSM
The Royal Society of Medicine (RSM) has created its first new section in 35 years, formally recognising aesthetics as a medical specialty.
The society explains that the RSM Section of Aesthetic Medicine and Surgery (RSM SAMAS) will promote best practice in the specialty by hosting regular educational events for doctors and dentists, and establishing a forum for scientific debate in the field to elevate standards.
Consultant dermatologist and first president of the RSM SAMAS Dr Christopher Rowland Payne said, “This is a historic moment for our field of aesthetic medicine and surgery. RSM SAMAS is dedicated to applying the principles of clinical medicine and evidence-based practice in a collegiate and inclusive manner. The aim is to help elevate standards and promote education in the field of aesthetics by sharing research and techniques, all for the ultimate benefit of patients.”
RSM Aesthetics Congress, taking place at the RSM on September 6 and 7, is the inaugural congress held to celebrate the birth of the RSM SAMAS. The agenda is set to welcome speakers from around the world to provide talks on anatomy, aesthetic technologies and treatment approaches. Dr Rowland Payne commented, “Come and join us on Friday September 6 for a programme of non-promotional scientific talks given by internationally acclaimed speakers, which will be followed by a Networking Cocktail event. Later in the evening, come to the Founders' Gala Dinner at the Travellers Club. On Saturday 7 September, Devonshire Dermatology will host a rotation of 50 specialised workshops led by a faculty of 40 experts.”
Representatives from RSM SAMAS will also be presenting a clinical agenda at CCR 2024, chaired by Dr Rowland Payne. Turn to p.34.to register free now.
Vital Statistics
Out of 2,500 people, 6 in 10 women in the UK are worried about being judged for having dermal fillers
(Teoxane, 2024)
A survey of 2,000 people aged 16-65 years old found 35% admitted to breakouts impacting their mood and wellbeing
(47 Skin, 2024)
The UK town of Bolton was found to be the most interested in weight loss medication, with 2,159 monthly searches per 100,000 people
(NHS, 2024)
Over the last four years, non-surgical aesthetic procedures performed by plastic surgeons have increased by 57.8% (ISAPS, 2024)
More than half of the 2,000 women questioned agreed that hyperpigmentation requires more than just skincare to treat
(Cynosure Lutronic, 2024)
Over the past year, there has been a 97% rise in people opting for facelift procedures in the UK
(The Beam Room, 2024)
Events diary
6th-7th September
RSM Aesthetics 2024
21st September
BCAM Annual Conference 2024
26th-27th September
BACN Autumn Conference 2024
10th-11th October
CCR 2024
Dr Sarah Jenkins talks skin rejuvenation on This Morning Aesthetic practitioner Dr Sarah Jenkins has appeared on ITV’s This Morning to discuss vaginal rejuvenation and why women are turning to this type of treatment. Dr Jenkins sat beside mum-of-three Gina Sigobodhla who, after struggling with low libido and incontinence, is back to her best self after using platelet-rich plasma (PRP) injections.
Dr Jenkins explained the procedure saying, “You’re injecting PRP which in turn causes growth factors to come along and cause collagen and elastin to be reformed; rejuvenating the skin.” She reiterated that this treatment is not an indulgence, but rather a solution to managing medical symptoms and “empowering women to have a good quality of life post-childbirth or menopause.”
Aesthetic Today Podcast interviews Dr Andrew Weber on holistic approaches
In a recent episode of the Aesthetics Today Podcast, TV presenter
Anthea Turner discusses an holistic approach to aesthetic treatment and skincare with aesthetic practitioner Dr Andrew Weber. The episode explored the significance of hormonal health, particularly during menopause, noting it has become a key topic of discussion.
Dr Weber says the incorporation of hormone replacement therapy (HRT) into treatment plans is due to his experience in general practice. He highlights the benefits of HRT, stating, “HRT on its own has immense benefits, including stabilising your sugar and preventing osteoporosis and cardiovascular problems.”
Nursing
NMC culture condemned as toxic in damning independent report
An independent culture review of the Nursing and Midwifery Council (NMC) has uncovered bullying, racism and incompetence.
The review heard from 1,000 current and former NMC nurses, along with more than 200 fitness-to-practise hearing panel members. “Virtually every level” of the NMC was concluded to be dysfunctional, with the report stating, “We saw staff break down in tears as they recounted their frustrations over safeguarding decisions that put the public at risk.”
A backlog of nearly 6,000 fitness-to-practise cases was found, with six nurses under review having taken their own life this year alone. The report says that some serious cases were dropped, including those that concerned racism, because of time constraints.
Chair of the NMC Sir David Warren responded, “This is a profoundly distressing report to read. I express my condolences to the family and friends of anybody who has died by suicide while under fitness-to-practise investigation. Our safeguarding lead is urgently revisiting those cases and examining the impact of our processes on all those involved in them.”
Aesthetic device company BTL Aesthetics has released the new EMFACE Submentum application to complement its EMFACE device.
The company explains that the Submentum aims to target the double chin and jawline area by treating both skin and fat. Synchronised RF remodels collagen and elastin to improve skin texture and reduce saggy skin under the chin, while HIFES stimulates the digastric muscle to selectively tone laxity and lift the submental area, according to BTL.
Aesthetic practitioner Dr Suha Kersh commented, “The submental area and double chin are a major concern for nearly half the patients that we see, and this new treatment has allowed us to address the area directly. We use this in combination with other BTL technologies such as EXION Face and FRF to achieve a superior lift and tightening of tissues, as well as promoting collagen production and regeneration.”
BTL Aesthetics will be exhibiting at CCR 2024. Turn to p.34.to register free now.
GetHarley begins offering selection of skin supplements
Skincare platform GetHarley has announced it will provide its first range of supplements, curated by functional medicine specialist Dr Sohere Roked. The company shares that a range of supplements will be available through the platform, including Altrient, Pure Encapsulations, Barebiology and many more.
Dr Roked commented, “Supplements are unregulated in the UK and it’s a minefield. I completely understand that for those who are not nutritionists or functional doctors, they will not necessarily have the knowledge to give their patients with regards to the right supplementation, and knowing which brands to recommend is an even harder feat! I was thrilled to be asked to curate a collection for GetHarley practitioners. I am a true believer in helping and supporting my peers, and ultimately giving each patient a holistic service.” GetHarley will be exhibiting at CCR 2024. Turn to p.34 to register free now.
Trends in medical longevity to be revealed at CCR
The latest statistics and trends in regenerative medicine and wellness will be unveiled at CCR 2024’s Medical Longevity Summit. Ben Pask from market research company RARE: Group will explore how the medical longevity market has evolved in the past year. He will share how the company’s RARE Monitor system has tracked how many UK aesthetic clinical are offering longevity treatments compared to last year, as well as the most popular treatments offered.
The Medical Longevity Summit will also showcase a host of top speakers looking into subjects such as gut testing, the effects of diet, menopause solutions, hormone testing and much more.
CCR will also offer delegates the opportunity to connect with companies including Roseway Labs, Dotolo, Erchonia Lasers, Hifas de Terra UK, L-Nutra Health, NAD+ at Home, Nature’s Plus, Nuchido, Oxford Healthspan, Totally Derma and Yotsuba Japan.
Pask commented, “Over the past few years, we have seen that medical aesthetics is driving the medical wellness and longevity agenda in the UK. We can see how much this has changed in the last six months in our system RARE Monitor, which tracks what every clinic in the UK is doing. CCR is the perfect platform to share the latest news with the specialty on the topic.”
The Medical Longevity Summit will take place at CCR 2024. Turn to p.34 to register free now.
Patient Safety
WHO issues warning over counterfeit Ozempic
The World Health Organization (WHO) has issued a global warning regarding fake versions of weight loss injection Ozempic.
The organisation has stated that the semaglutide product, the legitimate version of which is manufactured by pharmaceutical company Novo Nordisk and originally intended for type 2 diabetics, could pose a danger to health if falsified.
This warning comes after the Medicines and Healthcare products Regulatory Agency (MHRA) seized batches of pre-filled pens falsely labelled as Ozempic from two UK wholesalers in October 2023.
Dr Yukiko Nakatani, WHO assistant director general for essential medicines and health products, said, “[We advise] healthcare professionals, regulatory authorities and the public to be aware of these falsified batches of medicines. Patients who are using these products can take actions such as buying medicines with prescriptions from licensed physicians, and avoiding buying medicines from unfamiliar or unverified sources such as those that may be found online.”
Dr Alison Cave, MHRA chief safety officer, said, “Buying semaglutide from illegally trading online suppliers significantly increases the risk of getting a product which is either falsified or not licensed for use in the UK.”
BACN UPDATES
SCOTTISH PARLIAMENTARY MEETING
In June 2024, representatives from the Scottish Medical Aesthetics Safety Group, BCAM and BACN met with a cross-party group of MSPs at the Scottish parliament.
The roundtable was set up to address concerns such as cross-border issues and under-18s seeking procedures in Scotland.
Jenni Minto, minister for public health and women’s health, declared that action was urgently required and that a decade has been lost since the government created the Scottish Cosmetic Intervention Expert Group to advise on regulation.
Minister Minto agreed to convene a cross-party group in September, after the parliamentary recess, to fast-track an effective solution. We are extremely proud of Scottish members Jackie Partridge, Linda Strachan, Frances Turner-Traill and Jackie Cooney for representing the BACN in Scottish parliament. The BACN believes action needs to be taken now, even if that requires interim measures.
PRESENTATION SKILLS
The first BACN presentation skills day took place on June 14. It was set up for regional leaders and the education and training committee, aiming to empower them to effectively guide local events and foster engagement within their communities.
The event took place at Alma studios in London and was led by communication coach Nicky Curran. A huge thank you to Circa Skin for sponsoring this event. It is a great step towards building a stronger network and enhancing the overall experience for BACN members.
AUTUMN AESTHETIC CONFERENCE
This year’s BACN Autumn Aesthetic Conference are on sale and selling fast! The award-nominated conference returns on 26-27 September at the Eastside Rooms in Birmingham.
The refreshed and re-imagined event is an excellent opportunity for nurses in the aesthetics speciality to engage in learning, networking and professional development. Get your ticket now by using the QR code below or email us at admin@bacn.org.uk
This column is written and supported by the BACN
Event Spotlight: Innovative Developments with Galderma
Aesthetics speaks to Dr Ana Mansouri about what we can expect from Headline Sponsor Galderma at CCR 2024
What are you collaborating on with Galderma at CCR?
I am excited to collaborate with Galderma at CCR to showcase the transformative potential of Sculptra in medical aesthetics. Our collaboration focuses on highlighting Sculptra’s unique ability as a biostimulator with a 25-year heritage in generating collagen type 1, stimulating adipocyte stem cells and rebalancing the extracellular matrix. Through live demonstrations and discussions, we aim to educate practitioners on the advanced techniques and personalised approach of the A.A.R.T (Assessment, Anatomy, Range, Treatment) methodology, ensuring optimal outcomes for patients.
What are you most looking forward to at CCR?
I am very excited to demonstrate live Sculptra injections on the big stage. I’m also looking forward to engaging with esteemed colleagues and exchanging insights on the latest advancements in medical aesthetics. CCR provides a platform for networking, learning about cutting-edge technologies and exploring innovative approaches that enhance patient care. I am eager to contribute to these discussions and collaborate with colleagues who share a passion for advancing the field.
Why are events like CCR important for the specialty? CCR plays a pivotal role in advancing our specialty by fostering collaboration, education and innovation. It provides a forum for practitioners to stay updated on emerging trends, exchange best practices and deepen their understanding of new treatments and technologies. Additionally, these events promote networking opportunities that strengthen professional relationships and inspire continuous improvement in patient care standards. By attending CCR, specialists can enhance their skills, broaden their perspectives and contribute to the growth and evolution of medical aesthetics.
Top speakers and agenda revealed for CCR 2024
World-renowned speakers and a topquality educational agenda for CCR 2024 have been revealed, including injectable techniques, anatomy insights and business tips.
The Aesthetics Journal Arena will be the prime location for the latest in clinical research, techniques and discussions. The stage will focus on creating holistic results using injectables and will highlight agendas on toxin, injectable considerations, best practice for skin and regenerative aesthetics, with talks from some of the field’s top practitioners. Some of the speakers taking to the stage will include aesthetics practitioners Dr Kate Goldie, Dr Tapan Patel, Dr Munir Somji, and Dr Nestor Demosthenous and more.
The In Practice Theatre will be host to leading business experts, covering topics such as opening multiple clinics, mental health practices, artificial intelligence, aesthetic regulation and more. The agenda will include an insightful Women In Business Panel featuring Dr Olha Vorodyukhina, Dr Bonny Armstrong, Dr Maryam Zamani, chaired by Tatler’s Health and Beauty Editor-at-Large Francesca Ogiermann-White.
Some of the top brands in the aesthetics specialty will be appearing on other stages throughout the event, including DermapenWorld and Mastelli by DermaFocus, presenting product insights.
Aesthetic doctors will have access to an exclusive networking opportunity at the British College of Aesthetic Medicine (BCAM) Breakfast, sponsored by Crown Aesthetics. At 9:15am on Friday October 11, BCAM members and newer practitioners alike will be invited to the Crown Aesthetics stand to enjoy refreshments together.
CCR 2024 will take place at ExCeL London on October 10 and 11, 2024. Turn to p.34.to register for free now.
Revision Skincare releases new post-procedure product
Skincare distribution company AestheticSource has announced the launch of Revision Skincare CMT Post-Procedure Cream.
The company explains that the product contains a patent-pending neurocosmetic technology which targets skin-brain communication to aid recovery after peels, microneedling and laser treatments. The technology suppresses receptors such as TRPV1, which send discomfort signals to the brain if they detect heat or distress, thus reducing post-procedure pain.
Revision Skincare says the product also contains pre- and post-biotics, ceramides and THD ascorbate to restore skin biome health, minimise moisture loss and reduce downtime.
Lorna Bowes, CEO at AestheticSource, said, “With clinically proven results to help the skin recover better and faster, CMT Post-Procedure Cream improves the overall treatment experience while also increasing the likelihood of completing the recommended number of treatments. With the CMT standing for its post-healing for chemical, mechanical and thermal procedures, it makes for a pioneering addition to the Revision Skincare lineup.”
Skin Health
Toxin
Study reveals more toxin needed in hotter climates
A new study published in Plastic and Reconstructive Surgery has found that higher doses of botulinum toxin are required to achieve results in ‘high-sun’ climates. The research compared outcomes of glabellar Botox treatment in a ‘high-sun’ group of 292 women in Malta and a ‘low-sun’ group of 231 women treated in London, with the Malta group treated in the summer and the London group in the winter. The optimum results showed a higher average Botox dose in the high-sun group: 29.2 vs. 27.3 units. They also received a higher average top-up dose: 2.24 vs. 1.98 units. The researchers speculate that higher temperatures or direct sunlight might affect the body’s response to the toxin. Alternatively, as the glabellar muscles are more active in summer weather due to squinting, this may have had an effect.
Lead author and surgical trainee Dr Kim Borsky concluded, “Our results suggest that practitioners may need to adjust their toxin dosing protocols to account for the effects of climate on the results of this cosmetic treatment.”
Training
The Expert Mentorship Program training scheme announced
The Expert Mentorship Program training scheme has launched in the UK, led by aesthetic nurse Fiona McInnes. McInnes explains that the programme is designed to provide a comprehensive curriculum in medical
aesthetics. This is set to include cadaver dissections with dental surgeon Dr Lee Walker and consultant plastic surgeon Mr Taimur Shoaib. The course will also incorporate seven modules on treating different areas of the face, live demonstrations to illustrate techniques and personalised mentorship for support during the learning process.
McInnes commented, “Join me – with 20 years of experience and more than 100,000 treatments – for The Expert Mentorship Program. Master the expert approach to full-face rejuvenation, boosting your skill level and confidence. Enhance patient outcomes and their confidence, and driving practice growth. Sculpt your success with world experts boasting more than 100 years of combined experience.”
Skin Treatment
Sun Protection AlumierMD unveils reformulated sunscreens
Skincare company AlumierMD has reformulated Clear Shield and Sheer Hydration sunscreens to provide even broader protection.
The company says that the products now protect against six environmental aggressors: infrared radiation, blue light, pollution, free radicals, and UVA and UVB rays. The products also contain zinc oxide, titanium dioxide, vitamin C, physavie, glutathione and resveratrol to further protect the skin.
Aesthetic practitioner Dr Sonia Khorana commented, “Patients can control up to 90% of how their skin ages. AlumierMD’s upgraded sunscreen formulations contribute towards the protection of the skin in so many important ways: shielding against extrinsic factors including pollution, the sun’s rays, IR and HEV. Daily use of such a hard-working, hybrid sunscreen is my essential advice to all patients.”
Jan Marini Skin Research debuts new hydrating mask
Skincare company Jan Marini Skin Research, distributed in the UK by Healthxchange, has released a new Hyla3D hydrating face mask.
The company explains that the product combines multiple forms of hyaluronic acid, antioxidants and ceramides to enhance moisture retention in the skin. The aim of the product is to reduce the appearance of fine lines and wrinkles, plump the skin and protect against free radicals.
Simone Shoffman, head of education at Healthxchange, said, “The innovative Jan Marini Skin Research Hyla3D Face Mask has now launched and is available in the UK. Hydrating and revitalising effects can be seen on the skin due to the advanced Hyla3D technology; the formulation includes various types of hyaluronic acid, peptides and antioxidants. This mask visibly reduces fine lines, boosts elasticity and results in plump, more youthful looking skin.” Healthxchange will be exhibiting at CCR 2024. Turn to p.34 to register free now.
Key Opinion Leader
Alma announces new brand ambassador
Aesthetic device company Alma has unveiled aesthetic practitioner Dr Cemal Kavasogullari as the newest member of its Alma Ambassador lineup.
The company explains that the Alma Ambassadors are the company’s key opinion leader collective, delivering advanced training to other professionals in the field to enhance results.
Dr Kavasogullari commented, “Alma’s innovative technology, backed by clinical research and proven outcomes, aligns perfectly with Est-Ethics Wellness Clinic’s mission to enhance natural beauty through cutting-edge solutions. We are excited to represent Alma’s global presence and expertise both locally and to the wider UK market. I look forward to this exciting collaboration and the incredible opportunities it brings to both our clinic and the aesthetic community at large.”
Alma will be exhibiting at CCR 2024. Turn to p.34.to register free now.
Skincare
Dermaroller unveils New Natural Line
Medical aesthetic device and skincare company Dermaroller has launched its New Natural Line, a range designed to enhance skin health.
The range contains five products: Hyaluron Acid, Skin Cleanser, Moisturiser ACE, Hyal C Serum and Lipopeptide as well as Intensive Hyaluronic Mask, Hyaluron Amploules and a Home Roller – all containing natural ingredients, says the company.
The New Natural Line includes ingredients such as hyaluronic acid to plump up fine line and wrinkles, niacinamide and vitamin C to protect your skin from cell damage, and vitamin C in the form of retinyl palmitate to promote firm skin, Dermaroller explains.
Raffi Eghiayan, CEO at Wigmore Medical – exclusive UK trade distributor of Dermaroller – said, “We are very excited to introduce Dermaroller’s New Natural Line, a collection of skincare products designed to enhance patient’s skin health through the power of nature. With seven products in the new range, as well as the Home Roller, the new line is ideal for delivering radiant and healthy skin to your patients.”
Wigmore Medical will be exhibiting at CCR 2024. Turn to p.34. to register free now.
Skin Health
IMAGE Skincare releases post-treatment skincare system
Skincare company IMAGE Skincare has debuted three Post-Treatment Kits designed to prolong results and aid recovery following aesthetic treatments.
The company explains that the Recovery kit is aimed towards soothing sensitive skin, making it ideal for recovery after chemical peels. The Post Resurfacing kit is geared towards skin following treatments like microneedling and laser to provide hydration and sun protection. Finally, the Post Injectables kit contains ingredients to plump and protect the skin after injectable procedures. Each kit will contain a cleanser, along with a tailored range of serums, creams and SPFs, according to the company.
Michele Snyder, IMAGE Skincare chief marketing and innovation officer, commented, “As a professional brand at our core, developing these skincare systems was a natural extension for our community. By leveraging the expertise of IMAGE’s renowned physician partners, we’ve ensured that these new at-home care solutions are both highly effective and user-friendly, helping support the results of in-clinic treatments like no other products on the market today.”
Training provider Acquisition Aesthetics has released a new programme, designed for aesthetic practitioners looking to elevate their career.
The pathway offers a step-by-step guide to mastering medical aesthetics, according to the company, providing different levels from foundation training to advanced techniques.
The key steps include core training, future proofing, upskilling, diversifying and becoming business ready. The clinical development workshop provides one-to-one training opportunities and simulates real-life clinical practice.
Dr Lara Watson, co-founder and CEO of Acquisition Aesthetics, commented, “The Ultimate Practitioner Pathway has been built on the backbone of 10 years of experience in aesthetic training and a detailed analysis of the needs and ambitions of the thousands of delegates we have supported to date. The pathway provides a uniquely continuous and holistic programme of learning that safeguards the validity of training against future regulatory change, and delivers a range of clinical and business skills to help guarantee success in medical aesthetics.”
Acquisition Aesthetics will be exhibiting at CCR 2024. Turn to p.34.to register free now.
On the Scene
The Aesthetics Journal out and about in the specialty this month
Alastin Skincare officially launches
Pharmaceutical company Galderma has launched new skincare brand Alastin at a grand launch event at Frameless London.
On June 24, 100 guests were invited to hear all about the new range, before a networking dinner and drinks at the eye-catching location.
Speakers Dr Tapan Patel, Dr Sophie Shotter and Dr Sabrina Fabi from the US shared insights into the range, including the science behind it, how to use it post device treatments and how to integrate skincare into all procedures. They also shared that the range is available to purchase through GetHarley, Medfx and Wigmore Medical.
Joanna Neal, senior brand manager UK&I for Alastin, said, “We were delighted to be joined by so many industry professionals at the official launch event for Alastin skincare. The science and data behind this brand as published and presented by Dr Fabi is truly unique and we were thrilled that so many people were able to hear this from her first hand. To have esteemed KOLs such as Dr Shotter and Dr Patel sharing their experience so far is testament to the performance of the products.”
Galderma will be exhibiting at CCR 2024. Turn to p.34 to register.
Sciton introduces new BBL HEROic device
Medical device company Sciton unveiled its new pulsed light device, BBL HEROic, on July 11 at the Westin London City Hotel.
David Percival, vice president and general manager, welcomed delegates to the event before revealing the device.
Dermatologist and key opinion leader for Sciton Dr Anjali Mahto took to the stage to discuss how the device can be used by providers in clinics for optimal results, with a focus on safety and consistency when treating patients.
Data scientist, physicist and lead engineer for the new device Andy Balk presented a virtual demonstration on the BBL HEROic, showing delegates the different angles and movements of the handpiece during treatment. The event concluded with David Higham, northern Europe regional leader at Sciton, who informed guests about the opportunity to test out the new device.
Lindsey Whelan, territory manager for Sciton, commented, “It is very exciting to have BBL HEROic finally launched! We can safely treat dark skin types in a corrective mode due to the safety and cooling mechanisms. You can reach your clinical endpoint and provide new rejuvenation options for those with darker skin types. BBL HEROic is the only device that has the safety protocols in place to treat those skin types.”
Sciton will be exhibiting at CCR 2024. Turn to p.34.to register.
Eden Aesthetics hosts debut event for JetPeel
Distribution company Eden Aesthetics held an event on June 18 at Home House to announce its appointment as UK distribution partner for skin rejuvenating treatment, JetPeel.
The evening commenced with welcome drinks and a Bridgerton-themed string quartet during the dinner service.
Lindsay Gray, Eden Aesthetics managing director, opened her presentation discussing the advancements at the distributing company before handing over to Tim Cranko, CEO at JetPeel. Cranko spoke about the patented technology of JetPeel that uses jet-pressure energy to generate high-velocity jet streams of liquid micro-droplets to penetrate the skin.
Aesthetic practitioner Dr Nisha Menon concluded the presentation by enlightening delegates on the practical application in a non-surgical practice.
Gray commented, “We are delighted with the outcome as the attendance was phenomenal and beyond what we had initially anticipated. The energy was magical, and it created a huge buzz about Eden Aesthetics. We look forward to the next event!”
Eden Aesthetics will be exhibiting at CCR 2024. Turn to p.34 to register.
InMode unveils Lift and Light technologies
Aesthetic device company InMode introduced its new Life and Light procedures at a launch event on July 5 at The Door W4.
UK managing director Victoria Voysey was joined by key opinion leaders Dr David Jack, Dr Dev Patel, Neelam Holmes, Lisa Franklin and Eavanna Breen for a series of podcast recordings and panel talks introducing the technologies.
They explained that InMode Lift is a three-step treatment protocol designed to target fat and tighten skin in the jaw line. The protocol combines bio-polar radiofrequency (RF), high voltage pulse (HVP) RF and lymphatic massage to achieve results.
InMode Light combines intense pulsed light (IPL) from the Lumecca and Diolaze XL handpieces to target both skin rejuvenation and vascular lesions, the company explains.
Voysey explained, “We have taken our hero technology and developed a suite of treatments offering optimised results which can be tailored for the patient. We are delighted to launch InMode Lift and InMode Light.”
InMode will be exhibiting at CCR 2024. Turn to p.34 to register.
DermaFocus introduces four new practitioner ambassadors
Aesthetic manufacturer DermaFocus has welcomed dental surgeon Dr Yusra Al-Mukthar and aesthetic practitioner Dr Bibi Ghalaie to its faculty.
The company adds that two new expert trainers will also join, with nurse prescriber Amanda Demosthenous delivering Plinest polynucleotides training courses in Edinburgh, and nurse practitioner Kerry Hanaphy leading Plinest training in Dublin. Milad Bemana, executive director of DermaFocus, commented, “With trainers based in each region across the UK and Ireland, practitioners have access to high-level education in regenerative aesthetics, without having to travel to London. They can also access support on a local level from our clinic success partners, who will guide them on successfully integrating products into their clinics while attracting patients who will benefit from these impressive treatments.”
DermaFocus will be exhibiting at CCR 2024. Turn to p.34.to register free now.
Skin Treatment
EndoliftX collaborates with Lutronic for new combination
BabyFace, a laser treatment by aesthetic device company Lutronic, is being used in harmony with the cosmetic procedure EndoliftX to create the BabyLift protocol. EndoliftX, manufactured by Eufoton, aims to increase collagen production by retracting the connective tissue and activating the skin cell’s metabolic, says the company. Lutronic states that BabyFace works by vaporising water molecules in the skin and creating microchannels, which allow hydrating and brightening ‘nano’ serums to penetrate deeper under the skin. Combining the two treatments to create BabyLift, patients will need a single treatment, with a session lasting an hour and 15 minutes and requiring minimal downtime, according the EndoliftX.
Aesthetic practitioner Dr Luke Simmonds commented, “The patient is now able to address every skin concern in one appointment, with an immediate filler-like improvement to the skin and results continuing to improve over time. With minimal downtime and discomfort, I am confident that this combination treatment will become the go-to for those wanting to maintain looking and feeling their best.”
Lutronic will be exhibiting at CCR 2024. Turn to p.34.to register free now. Ambassadors
Dermalogica releases eye cream
Skincare brand Dermalogica has released the Phyto Nature Lifting Eye Cream that aims to firm and lift the region, according to the company.
Some of the products key ingredients include quinoa seed extract, multi-peptides, squalane and vitamin E, among others.
Victoria Evans, education manager at Dermalogica, commented, “This new product visibly lifts and firms the eye area to help reduce skin’s visible age as it revitalises thinning skin, and works to undo years of exposomic damage. This advanced, highly sensorial cream is formulated with potent peptides, botanical blends and CoQ10 that deliver a fast lifting, firming and tightening affect to smooth eyelid folds. Ultra-moisturising ingredients reawaken the eye contour area as it densifies and hydrates thinning skin, restores the effects of ageing skin and safeguarding this delicate area from future damage.”
Device 4T Medical unveils Eve device
Aesthetic technology supplier 4T Medical has introduced Eve – a multi-platform device for skin rejuvenation.
The company explains that the device incorporates hydradermabrasion, diamond peeling, microcurrent therapy and electro muscle stimulation (EMS) which can be used individually or in synergy.
4T Medical says that the hydradermabrasion and peeling are designed to cleanse, resurface and hydrate the skin, the microcurrent therapy uses electrical currents to activate essential skin processes, and the EMS stimulates muscle contraction and relaxation for lifting and toning.
Julien Tordjmann, managing director of 4T Medical, commented, “We are very proud to introduce the Eve to the UK market. This device takes several well-proven aesthetic technologies to the next level. Its four distinct functions allow for bespoke treatment plans tailored to each patient’s unique skin concerns.”
4T Medical will be exhibiting at CCR 2024. Turn to p.34.to register free now.
HydroPeptide debuts serum
Skincare company HydroPeptide has announced the launch of the new Clear Rescue Serum. The serum contains 0.5% salicylic acid aiming to exfoliate the skin, remove excess oil and destroy acne-causing bacteria, according to HydroPeptide. The product also contains cellrenew-16, acne peptide complex and acne probiotic. The company states that these key ingredients work to stimulate the production of growth factors for proteins and keratins, work synergistically with other actives to enhance efficacy and protect and balance the skin’s microbiota.
Anna Baker, aesthetic nurse prescriber, commented, “The new Clear Rescue Serum is formulated with clinically proven acne-fighting ingredients. This probiotic serum delivers a host of advanced anti-ageing benefits with anti-inflammatory peptide boosting ingredients.”
Skincare
Eyecare
Conference
A List educational event to take place in Northern Ireland
The A List conference, International Takeover, will take place at Titanic Belfast on September 8.
The organisers explain that the full-day event will welcome worldwide speakers to talk on treatment techniques and optimal patient care. The keynote speaker for the day is Norwegian aesthetic nurse Julie Horne, who will appear alongside Dr Kay Durairaj and Dr Gideon Kwok – both practitioners from California. Also appearing on the lineup include Mr Jeff Downie, Dr Zunaid Alli, Dr Kam Lally and more.
The day will be rounded off with an evening soirée, offering the chance to further share expertise.
Registered nurse and organiser Lisa Waring said, “As a medical professional, I am so passionate about educating and supporting fellow aesthetic practitioners. The International Takeover conference is the first of its kind to take place in Northern Ireland, and provides an invaluable opportunity for practitioners to gain unique insights from global experts who are at the forefront of medical aesthetics.”
Education
Hydrafacial hosts first UK Physician’s Summit
Aesthetic treatment company Hydrafacial has held its first UK Physician’s Summit, ‘Masters at the Machine’, at the Belton Woods in Grantham.
The event commenced with a welcome dinner, inviting delegates to network before a training session the following morning. Hydrafacial covered the technology behind its treatments and introduced the Wet Diamond tip, with aesthetic practitioner Dr Ana Mansouri leading the hands-on practice. The device enhances treatment results allowing practitioners to personalise treatments based on patient needs, according to the company.
Erin White, vice president of sales performance at EMEA and country manager at Hydrafacial UK and Ireland, commented, “We are delighted to have hosted our first Masters at the Machine event. This summit offered participating doctors a first-hand look at what Hydrafacial can achieve for their practices, helping them elevate patient outcome. This summit marks a significant milestone, highlighting the company’s commitment to advancing medical aesthetics.”
Hydrafacial will be exhibiting at CCR 2024. Turn to p.34 to register free now.
CosmoPro
hosts icoone showcase
Aesthetic device manufacturer and training academy CosmoPro hosted a VIP icoone spa day at Medi-Spa 28 in Stafford.
The event aimed to introduce the laser technology icoone – a device that combines laser and LED light sources, working by stimulating the connective tissue – and allow delegates the opportunity to experience the treatment.
CosmoPro director Rachael Turner-Percy introduced the event before country manager for CosmoPro Zara Tyers led a presentation alongside icoone UK trainer Kelly Singleton. They discussed the laser device and its application to the medical and beauty businesses. Following the presentation, delegates changed into their robes and were offered a drink while waiting for their icoone treatment.
Miss Tyers commented, “When brainstorming our next event myself and Rachael discussed the idea of a spa day. We wanted to introduce and educate our clinics into icoone in a relaxing setting. It was a great day and we all enjoyed it.”
News in Brief
Aesthetics launches group to support aesthetic professionals affected by job loss
After the dissolution of SK:N Group clinic chain, Aesthetics has set up a LinkedIn group – the Aesthetics Recruitment Support Network – to help support the 800 individuals affected with potential employment opportunities. The group conveys regular job postings from industry partners, recruitment agencies and aesthetic clinics. Tips for searching for jobs, honing your CV, interview preparation, networking and more will also be shared to provide optimal support for those seeking employment.
Crystal Clear Clinical appoints
Miss Jennifer Doyle as KOL
Skincare company Crystal Clear has announced consultant oculoplastic surgeon and aesthetic practitioner Miss Jennifer Doyle as a key opinion leader (KOL) to launch new device SKINSTORM across the UK. Having practised for more than 11 years and serving as head of aesthetics and chief operating officer at Clinic Holland Park, Miss Doyle specialises in eyelid surgery and advanced facial aesthetics. Sharon Hilditch, founder of Crystal Clear Clinical, commented, “We are delighted to work with such an incredible, reputable doctor on SKINSTORM. We are confident that her expertise and knowledge will help grow awareness and trust in SKINSTORM.”
Medica Forte announces launch of PRFKT chemical peels
Medical distribution company Medica Forte has unveiled its new chemical peel brand PRFKT, alongside two new website launches. PRFKT is the parent brand for The Perfect Peel and The Perfect Peel Superblend. The corresponding website – PRFKTPro.com – aims to provide an informative platform for practitioners. The company adds that it has also launched a consumer-focused website – PRFKT.com –that aims to enhance customer experience by proving comprehensive resources.
Clinical Skin unveils two new SPF 50 sunscreens
Skincare brand Clinical Skin has launched two new broad-spectrum SPF 50 products – the Clinical Skin Matte Sunscreen and the Clinical Skin Matte Tinted Sunscreen. The products aim to prevent UV damage, reduce inflammation and irritation from free radicals and guard against signs of premature ageing. Dr Laurence Dryer, chief scientific officer at Clinical Skin, said, “Our new sunscreen products represent the next evolution in sun protection, offering unparalleled mineral, broad-spectrum SPF 50 coverage.”
Study Reveals Younger Generation is Still Pursuing Perfection
Aesthetics looks into a new study which highlights varying views on aesthetics across generations
Research has found that while self-care is the top driver for female dermal filler patients, the younger generation is still preoccupied with aiming for perfection.1
The Age of Wellness report from aesthetic manufacturer Teoxane surveyed 2,500 female respondents across the UK, and of the cohort aged 18-25, a third said they are likely to undergo filler treatment in the future.1 This is a firm indication that dermal fillers are retaining their popularity, and people remain interested in receiving treatment.
This younger age range did, however, answer differently when asked their motivations for treatment. Figure 1 shows that while wanting to feel better about themselves is the biggest motivation across the board, 56% of those over 55 prioritised this in comparison to 42% of 18-25-year-olds.1 In contrast, 2% of those over 55 prioritised conforming to beauty standards, while 13% of 18-25-year-olds gave this primary importance.1 The youngest age group also gave the highest priority to wanting to look perfect (11%).1 The study authors suggest these figures show the younger generation still associates aesthetic interventions with seeking a societally acceptable idea of beauty.
Aesthetic practitioner and contributor to the report Dr Bonny Armstrong believes the younger demographic’s expectations are often influenced by social media, filters, AI images and societal pressures. “I take extra care to educate them about realistic outcomes and the importance of subtle enhancements that complement their natural features and individualism,” she says.
She continues, “Practitioners have a responsibility to protect young patients from unnecessary or premature treatments, ensuring their decisions are well-informed and not driven by fleeting societal pressures.”
Aesthetic practitioner Dr Sophie Shotter adds, “Perfection doesn’t even exist, so if someone’s motivation to receive treatment is to aim for that, treatment might not be the best thing for them.” Both practitioners say it is essential to prioritise young patients’ wellbeing and long-term physical and psychological development when deciding which treatments, if any, are best.
Treatments improving selfesteem
The factors of self-care and self-esteem remain the highest across the board. The research found that 93% of 518 respondents believe dermal filler treatments can help improve self-esteem.1 In the same group, 89% said they would recommend filler as a way to boost confidence in areas of insecurity.1
Dr Armstrong has seen this, saying, “We are seeing treatments fuelled by improvements to self-esteem and confidence rather than changes in the mirror. Patients used to seek big visual changes in their appearance, but now I find they feel empowered by seeing natural enhancements.” Dr Shotter also mentions that her patients’ biggest concern at the moment is looking unnatural and having treatment that is ‘detectable’. This is why it is so important for practitioners to publicise their natural results, and identify natural enhancement as a priority during consultations, she says. Moreover, of the aforementioned 518 respondents, 61% said they felt more comfortable with their appearance after dermal filler treatment, and 74% reported feeling more confident
appearing in photos after treatment.1
Dr Shotter reflects, “The most notable trend I’ve observed in my clinic recently is the increasing emphasis on prioritising self-esteem.” She says her patients frequently mention that their peers ask if they are tired or angry based on lines or wrinkles, which significantly impacts their mood. For this reason, Dr Shotter looks at the face holistically and thinks how injectables can improve the whole appearance rather than focusing on facial features in isolation. “These treatments can help patients feel their best,” she says, adding, “The happier we feel, the happier we become.”
Stigma still remains
Nevertheless, the study highlighted a continuing concern for the specialty –stigma surrounding aesthetics. Of all respondents, one in four women said they have researched dermal filler as a potential treatment, but only one in 10 are actually getting treatments.1 Six in 10 reported being worried about being judged for having filler, suggesting this is a barrier to patients opting to go ahead with treatment.
Dr Shotter, however, remarks that she feels the stigma around procedures has improved in recent years across all demographics. “Among my patients, I see they are less secretive about their treatments than 10 or 15 years ago. People may not broadcast it publicly, but they are more likely to share with friends and family that they have had help. I do feel that if public figures were more open about what they have had done, this would help massively too,” she says.
Dispelling the myth of perfection
The report advocates for an ‘accepting culture that acknowledges that everybody’s definition of beauty is different’.1 The report states, ‘it is entirely possible to empower people to make their own choices that make them feel their most beautiful’.1
Dr Armstrong and Dr Shotter agree that emphasising personal empowerment and wellbeing through dermal filler treatments is the key to happy patients. Dr Armstrong says, “Improving confidence can totally change the trajectory of a person’s life, and I have seen firsthand how these treatments can be transformative for my patients’ personal and professional lives.”
Figure 1: Graph depicting patient motivations
@sinclair_uk
www.sinclair.com/uk
Special Feature
Skin of Colour Lips
Creating bespoke treatment plans
Regardless of patients’ ethnicity, Saynor advises we should always be creating individualised treatment plans. “The UK is a really trend-led nation. We look to Instagram for advice on skincare, makeup and now even filler treatments,” she says. “This means we often see patients asking for a particular volume of filler or technique approach. Following these trends can make us lose sight of how to make a lip look unique to that person. It’s important to remember that there will be something different with every anatomical ethnic variation, so bespoke treatments are essential.”
Treating the Lips of Black Patients
Practitioners outline anatomy and treatment considerations for lip enhancements in skin of colour individuals
Taking care to understand anatomical variations and beauty standards in different ethnicities is an essential part of being an inclusive and leading practitioner. Doing so ensures your aesthetic treatments are accessible and appropriate for every patient you see. Historically, education focused on treatments for dark-skinned patients has been limited. A 2024 literature review examined the use of cosmetic injectables in skin of colour (SOC). For the review, researchers identified 503 publications on PubMed published between 1960 and 2020, which either had more than 20% SOC study participants or dedicated article content commenting on the safety and efficacy of injectables in SOC participants.1 Whilst the research drew positive conclusions that highlighted how botulinum toxin and dermal fillers are well tolerated in SOC patients, it emphasised that most studies focused on Asian patients, meaning there ‘remains a paucity of research on Black and Latinx populations’, and ‘more high quality, randomised controlled trials in Black and Latinx populations are warranted’.1
Furthermore, in 2020, the Aesthetics Journal published an article on improving diversity in aesthetics. Results from surveys
included in the piece revealed that seven out of 10 Black patients had difficulties finding practitioners confident in treating their skin, while the consensus suggested that better training and guidance on treating darker skin was needed.2 While we have seen improvement in recent years, it’s important to continue the conversation. In this article, aesthetic practitioner Dr Carol Mastropierro, plastic surgeon Mr Osman Bashir Tahir and nurse prescriber Kelly Saynor share guidance on how to achieve a consistently high standard of result for every patient through treatment, technique and risk considerations.
Understanding ethnic differences
“For many years, teaching has focused on how ‘aesthetically beautiful’ lips should have a ratio of 1:1.6 between the upper and lower lip, with the lower being larger,” explains Dr Mastropierro. While research has found this to be most attractive in Caucasian patients, 3 it does not consider how this presents in and is perceived by Black patients.
An insightful study published in 2023 focused on aesthetic considerations when treating patients of African descent. While acknowledging the importance
The practitioners advise that to balance patient requests with clinically-appropriate treatment, you should first and foremost make your patient feel heard. “You should actively listen as the patient describes what kind of lips they think are beautiful. Ask for photographs of lips they like the look of and ask them why they think they’re so good,” says Mr Tahir. From here he explains that you can gently advise them whether a similar look is achievable for them and how their ethnicity and facial features may or may not suit this look, before outlining your recommended approach.
“The border is more rounded in a SOC lip, so overstretching it can change the way it’s inherently supposed to look. Determine if treating it is necessary in each individual patient”
Kelly Saynor
“When treating Black patients I look beyond their face – at their hands, chest and ears in particular – to see if I can see any evidence of previous keloid scarring”
Dr Carol Mastropierro
of recognising different genetic and phenotypic influences, it highlighted that a ratio of 1:1 is generally considered most beautiful in Black patients. The research further explained that Black patients of African descent generally desire restoration of lost volume rather than augmentation. Researchers said, ‘Volume loss due to ageing is generally more evident in the upper versus the lower lip, and treatment is most often restricted to management of the upper lip and upper lip rhytids, with treatment of the lower lip directed more toward providing adequate structural support’.
The practitioners highlight that while this is true in older patients who have lost volume, anecdotally, younger Black patients seek treatment to improve balance and harmonise the shape of their lips. Mr Tahir adds that the fullness of lips in Black patients tend to carry out laterally, rather than being focused medially, so it’s important to consider where and how you are adding volume in your treatments.
Avoiding risks associated with Black skin
The previously mentioned 2024 literature review identified three studies that investigated the safety and efficacy of dermal fillers in the Black population. They found that hyaluronic acid filler had a ‘favourable safety profile, transient mild to moderate adverse events, a lack of immunogenicity, and no incidence of keloid formation in Black subjects’.1
Despite this, the practitioners warn that we should be aware Black patients are more prone to keloid scarring due to increased melanin in Black skin, so care should be taken to minimise this risk.5 The likelihood of keloid scarring can vary from patient to patient, says Dr Mastropierro, explaining, “When treating Black patients I look beyond their face – at their hands, chest and ears in particular – to see if I can see any evidence of previous keloid scarring in these commonly-affected areas. I ask them specifically if they’ve had keloid scarring in the past to work out if they’re prone to it. Together we can then discuss the risk of it developing post-filler treatment and decide if, based on the risk, they still want to go ahead.”
Saynor adds, “Although the risk is low when you’re doing a pinprick injection, we should do all that we can to avoid damaging the skin and thoroughly inform the patient of what could happen. Emphasise the importance of not touching or applying makeup to the injected area by highlighting how this can lead to infection and, afterwards, scarring.” She notes that, in her experience, using a cannula rather than a serial puncture technique can also reduce risk.5
Similar guidance is also recommended in the literature review regarding the risk of post-inflammatory hyperpigmentation (PIH).1 PIH occurs after skin inflammation or injury as a result of excessive
production or irregular dispersion of melanin, which occurs more frequently in Black patients.6 After lip filler injection, Mr Tahir explains that PIH can form around the corners and on the border of the lips.
The research highlights that overall rates of PIH in SOC patients following filler injection were low, but were most notably observed in patients who had undergone treatment with fast injection rates and multiple puncture techniques.1 To minimise the risk of PIH in SOC patients, the authors advise to ‘inject sub-dermally, use slower injection rates and utilise injection techniques that minimise the number of punctures, such as linear threading’.1
If PIH does occur, the practitioners recommend treating with a skin lightening agent such as a 10% vitamin C serum first. “Q-switched laser is also good for hyperpigmentation, and I sometimes use CO2 laser on a very low setting,” says Mr Tahir, explaining, “I use the Lutronic Hollywood Spectra which, in my experience, provides just enough energy to break up the melanocytes and reduce the appearance of PIH.”
Choosing products and adapting techniques
In Dr Mastropierro’s experience, most SOC patients seek lip filler treatment to enhance the shape of their lips rather than to add volume. “Because of this, I tend to prefer products that have a slightly higher G prime as they are better at helping lips retain their shape,” she explains.
Figure 1: Patient before and immediately after treatment with 0.3ml Juvéderm Volift to the upper lip. Lower lip untreated. Images courtesy of Dr Carol Mastropierro.
Dr Mastropierro’s products of choice are Juvéderm Volift and Teosyal Puresense Kiss. “When used properly, Volift can give soft yet effective results, creating much better lip shape. Similarly to Volift, Puresense Kiss is a product with a medium G prime – both are ‘harder’ products to work with as they are quite thick, but in my experience, they hold the shape better and we can use smaller volume than their lower G prime counterparts,” she says.
In terms of technique, Dr Mastropierro notes that she rarely injects the vermillion border in SOC patients, as they tend to already have good definition. “We know that disrupting the vermillion border, even with the finest needle, can predispose the patient to filler migration,” she says, adding, “I always want to stay right underneath the vermillion border and create a little definition if needed with an extremely small retrograde linear thread of product.”
Dr Mastropierro also highlights how she prefers using a needle when performing treatments that require balancing or changing the lip shape. “A cannula is great at minimising bruising and swelling, but when you want to be precise, you’re better off using a needle in my experience. I prefer smaller needles with a 30 or 32G, using vertical linear threads to create practical height to balance lips,” she says.
For Saynor, who has been practising aesthetics for 20+ years, filler suitability for Black patients has come a long way. “The products we began with were very bulky and thick. You just couldn’t address ethnic concerns with these fillers – the volume was too much. It wasn’t fair for patients,” she says. Now, however, she shares that there is a much better range of products that can treat multiple concerns. “I love using Belotero Lips, Belotero Balance and Belotero Intense for lips,” says Saynor, adding, “From my experience, they’ve got a really great safety profile, are soft and add excellent hydration.”8
When administering filler, Saynor advises to always be mindful of lip ratio and how Black upper and lower lips are more even in size compared to Caucasian lips. She also recommends treating Black patients’ lips through two treatment sessions. “While you won’t usually do this for Caucasian patients, it can help reassure Black patients who may be nervous about excessive swelling post treatment. By taking a gradual approach, you can always add filler in a second treatment session,” she says, adding, “Remember, less is always more!”
As Dr Mastropierro highlights, Saynor agrees that being mindful of the vermillion border in Black patients is important. “The border is more rounded in a SOC lip, so overstretching it can change the way it is inherently supposed to look. Determine if treating it is necessary in each individual patient and do so in a way which suits their natural anatomical structure,” she advises.
Mr Tahir values Restylane and FILLMED products for his lip treatments.
As with all patients, aftercare is vital to maintain results and avoid complications. The practitioners all advise patients to avoid exercise and alcohol for 24 hours post-treatment to reduce the risk of bruising and swelling. Dr Mastropierro says, “For me, the most important
“We need to understand what makes a face beautiful for all ethnicities, remembering that it is not the same approach for everyone"
Mr Osman Bashir Tahir
thing is not to touch the lips for the rest of the day to help avoid infection that can lead to PIH and scarring which, as discussed, SOC patients have an increased risk of. To help with this, I apply mesolips protector by mesoestetic, which creates a thin protective film and adds moisturisation, which is very beneficial post treatment.”
The importance of individualism and inclusivity
By now we all know that tailoring treatments to each patient is essential for safe and successful results. The practitioners emphasise this is only achievable if we receive well-rounded education that considers every ethnicity that practitioners may see in clinic.
Dr Mastropierro encourages all practitioners to review their understanding of SOC and invest time into filling any knowledge gaps. “I teach a cosmetic dermatology course at Harley Academy, where we have a hyperpigmentation and SOC workshop. We also have a section dedicated to addressing lips on SOC patients as part of our lip masterclass. Both provide an excellent foundation for understanding how to treat dark skin and how to make your practice more inclusive,” she says.
Equally, Saynor highlights there does need to be more awareness on how to adapt techniques and treatment protocols to effectively enhance Black patients’ lips. “Understanding ethnic beauty ideals, how lip ratios vary in Black patients and how lips age differently is so valuable in enabling you to deliver results that respect your patients’ ethnicity, as well as their individuality,” she says.
Mr Tahir concludes, “We should remember that our goal is to create facial harmony. We need to understand what makes a face beautiful for all ethnicities, remembering that it is not the same approach for everyone.”
Make sure to attend CCR 2024 on October 10-11 to receive the latest education on aesthetic injectables. Register for free on p.34
Figure 2: Patient before and immediately after treatment with 0.5ml of Revanesse Outline injected to upper lip and 0.5ml injected to lower lip. Images courtesy of Dr Carol Mastropierro. Before After
Performing the Non-Surgical Rhinoplasty with VIVACY
Aesthetic practitioner Dr Thuha Jabbar offers a guide on NSR procedures using STYLAGE dermal fillers
Traditionally, rhinoplasty has been the gold standard for correcting nasal asymmetry, bumps and other cosmetic concerns. However, surgery carries inherent risks and requires significant downtime. Non-surgical rhinoplasty (NSR) offers a compelling alternative for patients seeking subtle improvements without the commitment of surgery. Having conducted more than 1,000 NSRs to date, here I will explore the principles, procedures and outcomes, and why Stylage XXL is my product of choice for this highly demanding area.
Principles of the NSR
The NSR relies on injectable dermal fillers to achieve temporary reshaping of the nose. Dermal fillers are composed of various substances, most commonly hyaluronic acid (HA) – a naturally occurring polysaccharide found in the skin. HA fillers function by attracting and binding water molecules, adding volume and smoothing irregularities in the targeted area. By strategically injecting fillers into specific regions of the nose, practitioners can achieve various aesthetic improvements, including:
· Camouflage of bumps: Fillers can be strategically placed to camouflage a dorsal hump, creating a straighter bridge appearance.
· Lifting a drooping tip: Injections into the anterior nasal spine and the columella can elevate a drooping nasal tip, creating a more refined profile.
· Refining the nasal tip: Fillers can be used to define the nasal tip, creating a sharper or more projected appearance.
· Correcting asymmetry: By strategically injecting filler into one side of the nose compared to the other, minor asymmetries can be balanced.
· Correcting failed surgical rhinoplasties: Certain complications post-surgery, such as a poly-beak deformity, can be corrected using dermal fillers.
Procedure and recovery
The typical NSR process is as follows:
1. Consultation: A thorough consultation is crucial. The nose is a high-risk area and must only be treated by an experienced practitioner. The practitioner discusses desired outcomes, assesses the nasal anatomy and ensures the candidate is suitable for the procedure.
2. Anaesthesia: Topical numbing cream may be used to minimise discomfort.
3. Planning and product selection: The practitioner plans injection points with the desired outcome in mind. It is crucial to select the appropriate dermal filler not only to enhance the outcome, but also the longevity.
4. Injection: Using a fine needle, the dermal filler is injected into specific areas of the nose to achieve the desired pre-planned outcome. The amount of filler used depends on the desired correction and individual anatomy.
5. Recovery: Downtime following NSR is minimal. Patients may experience mild swelling, bruising or tenderness at the injection sites, which typically resolves within a few days.
The success and longevity of NSR hinges on selecting the appropriate dermal filler. Different fillers have varying consistency, particle size and lifting capacity. In the nose, a thicker filler with a high g-prime but low hydrophilic capacity is desirable to create contour and definition without drawing too much water into the area. Furthermore, a highly cross-linked filler will offer longer-lasting results but may be less forgiving if improperly placed. It is important that all practitioners have a comprehensive understanding of various fillers and their
characteristics to select the most suitable option based on the area being injected. At the forefront of non-surgical rhinoplasty innovations lies Stylage XXL, a premium dermal filler specifically designed for facial volumisation. Unlike traditional fillers, Stylage XXL boasts a unique IPN-like technology combined with antioxidant mannitol. This advanced formula offers several advantages:
Long-lasting Results: Stylage XXL boasts impressive longevity, with results lasting up to 12 months. This allows for a refined profile for a significant period without requiring frequent touch-up procedures. The mannitol also acts as an antioxidant, potentially protecting the integrity of the gel immediately post-injection.
· Natural-Looking Enhancements: The unique consistency and lifting capacity of Stylage XXL enables skilled practitioners to achieve subtle yet impactful corrections. Whether it’s smoothing a dorsal hump, refining the tip or balancing minor asymmetries, Stylage XXL allows for natural-looking contour improvements that complement existing features. This is why Stylage XXL has been my product of choice for many years. The patented IPN-like technology has created unique viscoelastic properties which allows it to create excellent projection with minimal volume.
Diversifying treatment options
The NSR offers an effective, minimally invasive approach for patients seeking subtle improvements to the shape and appearance of their nose when delivered by an experienced practitioner. It is crucial for patients to have realistic expectations and understand the limitations of this technique. I have found that VIVACY dermal fillers are optimal for this treatment, and thoroughly recommend their use during NSR procedures.
This advertorial was written and supplied by VIVACY Laboratories For more information, please contact contact@vivacylabs.co.uk
Dr Thuha Jabbar has been practising cosmetic dentistry and facial aesthetics for more than 15 years, during which she founded Almás Dentistry and Aesthetics. She is a KOL for VIVACY and regularly runs training courses and workshops Qual: BDS, MJDF, RCS (Eng.), MSc (Rest Dent), PgCert (ClinEd)
Figure 1: 31-year-old patient before and immediately after NSR procedure using Stylage XXL
CPD
Filler Rheology
Discovering the Properties of HA Dermal Fillers
Dr Rehanna Beckhurst outlines the manufacturing process and physico-chemical properties of dermal filler products
Hyaluronic acid (HA) injectable fillers are the most widely used dermal fillers to treat facial volume deficits.1 Appreciating the physico-chemical properties of dermal fillers is crucial for making well-informed choices in product selection. HA fillers exhibit different characteristics depending on their manufacturing process technologies, which are designed to fine-tune the mechanical properties to achieve desired biological outcomes post injection.1
Once augmented, fillers undergo both shear stress and vertical compression/elongation forces, leading to the deformation of the filler.1 In states of low stress, dermal fillers manifest gel-like properties. However, as shear stress increases, they exhibit varying degrees of flow, influenced by the specific manufacturing conditions and composition.1 Understanding these dynamic properties is instrumental in the optimisation of dermal filler applications, ensuring that the selected product aligns effectively with the intended use and desired results.1
What is HA?
HA is a naturally occurring polymer found in the extracellular matrix, the vitreous humor and the cartilage.4 The total quantity of HA found in a 70kg person is approximately 15g, and its average turnover rate is 5g/d.4 Approximately 50% of the total quantity of HA in the human body is concentrated in the skin, and it has a half-life of 24-48 hours.4 HA fillers have gained immense popularity, surpassing their predecessors, thanks to several advantages. HA is a naturally occurring linear polysaccharide, comprising of repeating disaccharide units of N-acetylglucosamine and D-glucuronic acid, linked together linearly by a β-1,4 glycosidic bond.5 These glycosaminoglycan chains coil back on themselves, contributing to an elastic and viscous matrix.
One of HA’s remarkable features is its uniformity throughout nature, rendering immunogenic reactions exceptionally rare.6 Additionally, its relatively stable molecular composition allows for non-refrigerated storage for up to two years.6 Beyond longevity, HA’s highly hydrophilic nature plays a pivotal role in skin hydration, adding to its allure in cosmetic applications.7 Despite its distinctive biological
characteristics, native HA has limited residence time and a very short half-life in the skin – approximately two to four days – due to rapid degradation of glycosidic bonds by natural hyaluronidase and reactive oxygen species.8,9,10
Additionally, its inherent lack of elastic properties prevents direct use as a filler since it cannot effectively lift tissues in its natural state.11 Therefore, these limitations could be overridden by altering the structure of HA chains. The goal is to develop HA gels characterised by prolonged residence time and improved viscoelastic properties.11
An ideal HA gel should have the capacity to lift tissues consistently over the long-term, seamlessly adapt to dynamic facial expressions and exhibit effective tissue integration and cohesiveness, all while maintaining ease of injection and biocompatibility.11 This can be achieved through chemical modifications and crosslinking during the manufacturing process, resulting in a more viscous and stable material than the original polymer.11 Importantly, they retain the biocompatibility of the raw material and remain resorbable. Among the various methods to synthesise a HA gel, the use of crosslinkers stands out as the most widely employed. These crosslinkers, typically small molecules with a spacer and two functional groups, bridge HA chains and play a pivotal role in providing clinically important properties.12
The manufacturing process of HA Crosslinking
The raw HA polymer used to produce dermal fillers is usually supplied to the manufacturer in dry powder form.13 Mixing this powder with water creates a viscous liquid that has the look and feel of egg white. The higher the concentration of HA (more HA powder added to a given amount of water), the thicker and more viscous the solution will become.13
Such a solution is known as free HA, native HA, un-crosslinked HA or non-modified HA. If this solution were to be used as a dermal filler, the product would be rapidly eliminated from the injection site in a few days.13 Enzymes such as hyaluronidase and
free radicals that are naturally present in the skin can quickly degrade un-crosslinked HA, breaking down the polymer chains.13
To ‘clip’ those chains together and improve longevity and performance, manufacturers use crosslinkers.14 The crosslinkers bind HA polymer chains to each other, creating a polymer ‘network’ and transforming the viscous liquid into a gel.14
Commercially used crosslinkers are: 1,4-butanediol diglycidyl ether (BDDE), poly (ethylene glycol) diglycidyl ether (PEGDE), divinyl sulfone (DVS), 1-ethyl-3-(3 dimethylaminopropyl) carbodiimide (EDC), 1,2,7,8-diepox-yoctane and glutaraldehyde (GA).14 Some of these are no longer sold due to failure to meet specifications conditioning the design of safe HA-based fillers.7,14-17
The first crosslinker to be used in commercially available HA-based filler was 1,4-butanediol diglycidyl ether (BDDE, the first linker from the bisepoxide family). It was introduced in 1996, and the US Food and Drug Administration approved in 2003.18 Most fillers used in the UK have a BDDE crosslinker, as well as Europe, where about 30 international filler product lines use BDDE as a crosslinker.7
Nowadays, BDDE is the standard crosslinker of HA for its use in fillers and has important advantages. It is crucial that manufacturers establish the biocompatibility of crosslinked HA gels through comprehensive biocompatibility and safety studies to meet regulatory approval requirements.18 BDDE-crosslinked HA has undergone extensive validation, demonstrating safety over a period exceeding 25 years, supported by a growing number of injections administered globally each year.18 Treatment-related side effects following HA filler injection are linked to the procedure rather than to the presence of BDDE.18 Indeed, adverse events are relatively rare regarding the invasiveness of the procedure and the growing number of procedures carried out every year.19
The degree of crosslinking is also important. When reacting with HA polymers, crosslinkers can be fully reacted (linked to the HA chains at both ends), pendant type (linked at one end), hydrolysed (inactive, removed during purification process and, therefore, harmless) or residual (highly
reactive and potentially harmful in quantities above the established safety threshold).20,21 The degree of crosslinking is the ratio of the crosslinker molecules that form links to the number of HA disaccharides.21 Higher crosslinked fillers tend to be stiffer, and intake less water (less swelling) as chains are held tightly together; crosslinkers themselves are not hydrophilic, unlike HA molecules.21 It is worth mentioning that crosslinking of native HA isn’t the only method of modification. It is possible to modify HA prior to crosslinking to reveal new reactive functional groups, or to use milder crosslinking conditions to better preserve HA chains.18 It is also possible to employ a crosslinker-free approach using the conjugation technique, as crosslinking two samples of HA that are previously derivatised with different groups can then react with each other under mild conditions.18
Purification
The next step after modification is purification. Details regarding this process are frequently confidential and vary among manufacturers. Nonetheless, it is of utmost importance to ensure product safety. Dialysis stands out as the gold standard technique for purifying HA gels.19 This method employs a semipermeable membrane to selectively separate undesirable molecules, including traces of crosslinkers. This ensures the removal of impurities and enhances the overall purity and safety of the end product.22
Fragmentation
Injection experience depends on the extrusion force, which is affected by the size of particles and the distribution range of the particles. Particle fragmentation and homogenisation are a part of the manufacturing process.
A high crosslinking rate can make the gel stiff, hence some manufacturers add un-crosslinked HA to lubricate the gel and allow smooth passage through the needle/cannula.14 Some manufacturers will insist that uniform particle size will be ideal for extrusion, as this can decrease interruptions in the flow and prevent ‘stop and go mode’, as well as provide a comfortable injection experience.14 Therefore, it is important to check HA filler particle size and distribution rate so you can choose appropriate gauge needles and cannulas.11
Water intake/swelling ratio
This property is affected by HA concertation and degree of crosslinking. The highest swelling ratio is observed for non-crosslinked HA with high molecular weight. The crosslinking technology used in manufacturing highly impacts in vitro swelling rate. This depends on the crosslinking density, as chains are held more tightly together. Besides, crosslinkers, unlike HA polymers themselves, are not hydrophilic.21
Rheological properties
After injection, HA fillers undergo exposure to different forces, including relative movement (shear) between tissue layers such as skin, muscles, fat pads and bone.23 Other impacting factors include gravitational forces and compression exerted by overlying tissues or external pressure.23 Rheological properties of fillers can be described by different parameters.
Elastic modulus
Also known as G’, G prime or elasticity, this measures the elastic properties of the gel, its hardness and its ability to recover
its shape after shearing stress is removed.11
The most common parameter used for HA fillers, G’ is a measure of the strength (firmness).11 G’ is influenced by the degree of crosslinking and total HA concentration.11 Shear stress (lateral gliding) causes low G’ fillers to spread; higher G’ fillers will recover their shape better (Figure 1).24 When an HA gel is placed between two plates and the upper plate is quickly moved horizontally while keeping the lower plate still, a force will be required to hold the deformation in place.14
G’ is defined as the ratio of the shear stress (the force per unit area of plate) to the shear strain imposed (the ratio of the horizontal displacement to the vertical distance between plates).14
In a gel with a low degree of crosslinking, where the HA polymer chains are loosely linked to one another, the force required for displacement is low, so the gel hardness or G’ is low.14 As the degree of crosslinking is increased, but at the same overall HA concentration, the network formed by the HA polymers becomes more tightly connected, and a greater force is required to displace the gel, and the gel hardness or G’ increases.14 Traditionally, G’ is considered an indicator of a filler’s lift capacity, as supported by numerous references.1,26-32
However, it’s crucial to note that the relationship between G’ and lift capacity is not always linear, as it depends on many other parameters and manufacturing technologies.26 These include HA concentration, particle size and homogeneity, degree of crosslinking, technology and the crosslinker used.26
Viscous modulus
G”, or loss modulus, measures the viscous properties of the gel and its inability to recover its shape. HA fillers tend to have low G”. It describes the flow characteristics of a gel; used to define gel thickness, and it is clinically related to injectability.25
In summary, G’ and G’’ are not opposite measures but complementary components of the complex modulus. Together, they provide insights into the viscoelastic behaviour of fillers.33
The ratio of G’’ to G’ can be used to characterise the material’s
Upper Face
High G’ for temporal fossa with medium to high cohesivity for filling and volume restoration
Medium to high G’ for forehead contour, with low to medium cohesivity for moulding and some degree of spread
Lips
• Low to medium G’ (sufficient elasticity for smoothness and moldability)
Low cohesivity for spreadability
• Low water uptake for natural results
Medium to high cohesivity for volumisation and projection
Lower Face
Medium G’ to respond naturally to facial movement
Low to medium cohesivity with moderate lifting capacity
• Used to correct severe folds, gel with higher cohesivity recommended, but may be harder to mould
Mid-face
• Infraorbital area/tear troughs: low to medium G’ and low cohesivity to be spreadable to prevent overcorrection, lumps and bumps
Zygomatic and submalar areas: medium to high G’ to resist shearing
Medium to high cohesivity to resist compression and maintain projection
Nose, jawline and chin
• High G’ and medium cohesivity to enhance contour and provide structure
High resistance to deformation and high lift capacity
• Fine lines and improvement in skin quality
Low to medium G’ combined with low cohesivity for spreadability and to perform well with dynamic movement and avoid palpability
Figure 2: Recommended parameters for different facial areas. 34
Shear
Fillers
Figure 1: How G’ is measured and calculated. 25
behaviour: a low ratio indicates more solid-like behaviour, while a high ratio suggests more liquid-like behaviour.33
For HA filler to be effective it has to be viscoelastic, meaning it possesses both of these properties.34 It must be viscous enough to be injected and initially moulded, but elastic enough to resist shear deformation forces and provide a durable correction once implanted into soft tissues.34
The term that better describes rheology of HA filler is complex viscosity (η*) – a measure used in rheology to describe the behaviour of complex fluids. They don’t follow simple Newtonian behaviour (where viscosity remains constant regardless of the applied stress). Instead, these materials display a relationship between stress and strain that is more complex.25
In simple terms, viscosity is a measure of a fluid’s resistance to flow. Complex viscosity extends this idea to materials like HA fillers which show both elastic and viscous properties.1
Gel cohesion (cohesivity)
Cohesivity characterises how a filler behaves as a gel deposit once it is injected and subjected to forces (stretching skin or laying on a pillow). It is described as internal adhesion forces holding together the individual crosslinked HA particles. Gel cohesion is influenced by HA concentration and the crosslinking and sizing/ homogenisation of the gel.1
Cohesivity is important because HA fillers are made of multiple units of crosslinked HA chains, adhered through non-covalent bonds. Adhesion of those units is critical when choosing a filler for deep facial volumisation.34 Highly cohesive fillers are better suited for deep facial volumisation, while fillers with low cohesivity are easy to mould and tend to form thin, even layers in the skin.34
High cohesivity helps fillers maintain vertical projection, while soft tissues apply vertical stress.34 Medium cohesivity provides versatility by keeping a balance between vertical projection and relatively easy mouldability.34 Low cohesivity helps the filler to form a sheet by spreading evenly upon injection and makes it easy to mould initially, however, when affected by pressure or tension, particles can detach and result in migration.34 When affected by compression or stretching, filler with higher cohesivity will keep projection longer than filler with lower cohesivity, even with the same G’ value.34
Achieving effective tissue integration requires careful consideration of both these parameters. In cases where the treated tissue has a firm structure, like cheekbones or the jawline, a high viscosity gel with high cohesivity is preferable.5 Such a gel can be manipulated by massaging the area post-injection, without the risk of fragmentation. Conversely, for superficial indications such as fine lines and wrinkles, a HA gel with low viscosity may be more suitable.5 This type of gel has the propensity to flow and spread, blending and integrating into the treated tissue.5
It is interesting to note that all soft tissue filler gels have higher viscosities when the shear force is low. Viscosity decreases (the filler ‘thins out’) as shear force increases – a phenomenon known as ‘shear thinning’. 33 The relationship between applied shear force and viscosity is non-linear. There is little change in viscosity up to a certain level of applied shear force, whereas beyond this level, there are significant changes in viscosity as shear force is increased. 33 A level of shear force that is insufficient to cause shear thinning of a high-viscosity gel may be sufficient to cause shear thinning of a low-viscosity gel. 33
Practical applications
When selecting an appropriate product, it becomes crucial to take into account the injection site, specifically targeting the distinct anatomical facial layers. Varied regions and layers of the face experience diverse types of forces. These factors must be meticulously considered to attain the most favourable and effective
outcome. For example, when planning upper-face treatment, medium to high cohesivity and high G’ fillers would be suited for volumisation, but for contouring, low cohesivity is preferable, as this will allow the filler to spread.34
Fillers with high G’ are able to resist outside forces and provide better structure than fillers with low G’. For this reason, high G’ fillers are well suited to mid- and lower-face volumisation (Figure 2).34
Optimising outcomes with your choice of filler
The key factors distinguishing various HA products encompass the particle size, type of crosslinking agent, level of crosslinking, percentage of crosslinked HA, amount of free HA and the elasticity modulus (G’). The choice of crosslinking technology, uniformity and particle size, along with the concentration of HA, collectively shape the viscoelastic properties of the product, consequently influencing its clinical effects.
These physical and chemical attributes, in turn, dictate essential characteristics such as clinical indications, ease of injection, tissue filling capacity, longevity, overall clinical appearance and the likelihood of side effects for each filler. Understanding and navigating these nuanced distinctions is vital for practitioners in optimising outcomes and tailoring treatments to individual patient needs.
Test your knowledge!
Complete the multiple-choice questions and go online to receive your CPD certificate!
Questions
1. What is the half-life of HA in the skin?
2. From a physical point of view, what type of materials are HA fillers?
Possible answers
a. 24-48 hours
b. 48-72 hours
c. One week
d. One month
a. Elastic
b. Viscous
c. Plastic
d. Viscoelastic
a. G prime and cohesiveness
b. Molecular weight
3. What affects filler’s swelling ratio/water intake?
4. What fillers are best suited for lower face volumisation?
5. What is crosslinking?
c. HA concentration and degree of crosslinking
d. Complex viscosity
a. Fillers with high G’
b. Fillers with low G’
c. Un-crosslinked HA fillers
d. HA fillers with high molecular weight
a. Linking different HA types together
b. Clipping the coined chains together with small molecules
c. Mixing up HA with high and low molecular weight
d. Purification of HA
Answers: A,D,C,A,B
Dr Rehanna Beckhurst is a dental surgeon and co-founder of ifab Clinic in Barnstaple, Devon. With more than 20 years in dentistry and 12 years in aesthetics, she is a KOL for Church Pharmacy and Beamwave technologies, a public speaker and an aesthetic tutor. Qual: MDS, MBA, PgDip ANSI
Treating the Platysmal Bands
Miss Harmony Ubhi discusses age-related changes which occur in the platysma and appropriate treatment options
The platysma is a thin, sheet-like muscle which spans the anterior neck. Its function is to aid in facial movement and expression. The platysmal bands are one of the main signs of an ageing neck, alongside reduced skin quality (thinning or loose skin with loss of elasticity and collagen producing a sagging appearance).1 Addressing these concerns is an important consideration when it comes to neck rejuvenation. Understanding the anatomy and senescent process of the neck is essential for practitioners providing treatment in both surgical and non-surgical domains. This article aims to describe the platysma, assess the ageing process and explore the treatment modalities in addressing platysmal bands.
Anatomy of the neck
The platysma is a thin, superficial muscle in the neck, separating it into superficial and deep spaces. It lies as a broad sheet, arising from the fascia surrounding the pectoralis major muscles and anterior deltoids laterally. It converges obliquely and medially, inserting mainly on the border of the mandible, as well as the orbicularis oris complex ( Figure 1 ).1 Despite being traditionally believed as separate, the platysma can extend significantly superiorly into the face, and is generally described as continuous with the superficial musculoaponeurotic system (SMAS) above.1
The platysma lies superficial to the skin and subcutaneous fat in the neck, and has a free anterior border in the anterior neck (midline) and posterior border. Platysma fibres can interdigitate with its contralateral side in the midline, up to 1-2cm below the chin. Several less common variations have been described, ranging from interdigitation down to the thyroid cartilage, to none at all. 2
Procerus muscle
Orbicularis oculi muscle
Zygomaticus major muscle
Orbicularis oris muscle
Mentalis muscle
Depressor labii inferioris muscle
Depressor anguli oris muscle
Function of the platysma bands
The platysma is a muscle of facial expression, supplied by the facial nerve and receiving its blood from the submental (branch of the facial artery) and suprascapular arteries. Its function is to pull the corners of the mouth down and back to produce platysma ridges beneath the skin.1
Ageing
There are several theories for the proposal of platysmal band formation. Traditionally, this was considered to be due to muscle separation from the underlying structures, resulting in thinner, atonic muscle while the overlying skin becomes laxer. 3
A recent proposal suggests that the platysma becomes hyperkinetic with increased age, resulting in platysmal band prominence. 2 This has been well supported by the Trevidic and Criollo-Lamilla observational study, in which 25 patients with unilateral facial palsy were unaffected by platysmal bands on the paralysed side. 3 Labbe et al. also describe the cervicomental angle suspensory ligament, which acts to fixate the platysma and skin to deeper structures which may play a key role in the formation of the cervicomental angle alterations in the ageing process.4
This research supports the action of denervating the bands with less invasive measures, although further research may need to be explored.
Assessment
Treatment of the neck and décolleté is a frequently requested procedure in aesthetic clinics, with 3,412 patients seeking a face/neck lift in 2022.5
The treating practitioner should be confident in obtaining an appropriate medical history and conducting a thorough examination of the patient’s neck to determine the best course of treatment. This should include the assessment of the platysmal bands, as well as other senescent neck changes, including skin laxity, lipodystrophy, nasolabial jowls and submandibular salivary gland ptosis.6
Platysmal bands should be assessed with the patient sitting up, asking them to perform an exaggerated frown using their neck to activate platysmal movement. Platysmal bands are identified along the line of muscle insertion, i.e. they can appear vertically in the neck. The lines which appear horizontally as neck creases are those that are present from birth. These are often associated with retaining ligaments of the neck, rather than platysmal bands.1,2
Frontal belly of occipitofrontalis muscle
Platysma muscle
Investlin layer of (deep) cervical fascia
Parotid fascia
Occipital belly of occipitofrontalis muscle
Risorius muscle
Figure 1: Anatomy of the face and neck 1
Further studies in the form of randomised control trials are needed to compare treatment
methods of platysmal bands
Geiseter et al. have developed a five-point photonumeric assessment scale for platysmal bands on forced contraction to aid the practitioner’s assessment, providing both frontal and lateral views on a scale ranging from minimal (1) to severe (5) banding.4 This may be a useful reference in assessing the severity of banding both pre- and post-treatment. At present, there is no current consensus guidance in terms of dosing or treatment planning based on this scale alone.
Treatment options
Botulinum toxin
Botulinum toxin (BoNT), produced by clostridium botulinum bacteria, prevents the release of acetylcholine at the motor end plate. Injections of BoNT into the platysma reduce the appearance of platysmal bands, allowing a lifting effect to the jawline and potentially correcting some drooping of the corners of the mouth and jowls.7
Ideal patients have a slim neck, with platysmal band activity upon facial expression, for example while speaking. Horizontal neck lines are likely to be addressed with a combination of biodegradable injectables and ablative treatments such as laser or microneedling, rather than BoNT alone.7
Patients are treated while in a sitting position and asked to perform the exaggerated frown. The clinician can identify the platysmal bands through gentle isolation with the non-injecting hand, which should be continued while injecting. It can be recommended to avoid the use of topical anaesthetics in the platysmal bands, even for the anxious patient, as these have the potential to inactivate the muscle prior to treatment.5 BoNT placement should be performed very superficially in the contracted platysma muscle to minimise the risk of product migration into neighbouring musculature.7 There have been reported cases of product migration resulting in difficulty
swallowing (dysphagia), change in voice (dysphonia) and an asymmetrical smile.7 The use of ultrasonography may be supportive in injection guidance, but the technique is practitioner- and experience-dependent. Therefore, one should consider a lower dosage with precise injections from a background of anatomical appreciation. The amount depends on product used. For example, if using type A ona-botulinum toxin, two units (U) can be injected per point, and five points can be injected for each band, approximately 2cm from each other along the muscular band.7 A total of 40 units may be used on both sides of the medial and lateral bands.7 There will be variations with other brands of BoNT, so the user should consult the product literature. It’s important to identify the major superficial vessels of the neck, as well as the external and anterior jugular veins, prior to injection. There can be significant anatomical variation and their avoidance is crucial to minimise bruising or hematoma post-treatment.6 Similarly, patients may develop antibody production due to repeated BoNT injections and therefore become immune to further treatment. The commonality of this varies from 0.3%-6%.8 There is limited literature to suggest a consensus on the most beneficial and least risk-associated BoNT treatment of platysmal bands. Sugrue et al. performed a literature review which identified three prospective studies using the validated five-point assessment scale at baseline and subsequent follow-up.9 In these, a total of 78 patients were treated. All injections were placed intramuscular, spaced 1-2cm apart and the number of injections ranged between two to six points, placed in the most prominent part of the band. All three studies used a standard injection technique, with a maximum 20 IU of incobotulinumtoxin A and 5 U abobotulinumtoxin A administered per band. Improvements were reported in 91% of subjects, with the authors concluding that botulinum toxin is a highly effective treatment for isolated platysma bands.9
Surgical options
There are a variety of surgical techniques used to rejuvenate the neck, including platysma resection, platysma midline plication and reattachment of platysma to the underlying fascia. For platysmaplasty, the common approach is via an incision below the submental fold to access the platysma.10 Redundant tissue can then be excised or plicated at the anterior border, and the platysmal bands resected.10 Additionally, the platysma can be lifted and tightened superoposteriorly and fixed to the preauricular, peri-mastoid tissue and posterior cervical region via a lateral neck incision. This may occur in combination with a facelift procedure.10
A surgical intervention is considered appropriate for those patients with associated skin laxity, as they are likely to have suboptimal results with BoNT alone.6 However, these come with their own surgical risks including scarring and prolonged recovery time, without eliminating the risk of recurrence.
Platysmotomy has been suggested as an alternative, less-invasive technique, where marginal resection is performed on platysmal bands through multiple small incisions, however its long-term results are to be determined.11,12 There have yet to be high-quality trials comparing different surgical modalities for platysmal bands.
Implementing further research
Clinicians must be well-versed in eliciting the aim for treatments and assessing patient suitability for both surgical and non-surgical options, as both come with their own risks and benefits. Further studies in the form of randomised control trials are needed to compare treatment methods of platysmal bands in order to determine the long-term outcomes and patient satisfaction in the evolving landscape of neck rejuvenation treatments.
Miss Harmony Ubhi is a full-time specialist registrar in oral and maxillofacial surgery. She has dual qualifications in both medicine and dentistry and is a member of the Royal College of Surgeons. Miss Ubhi is the clinical director of Dr Harmony Aesthetics, providing a harmonised approach to minimally invasive medical aesthetics in Amersham, London.
Qual: MBBS, BSc, BDS, AKC, PCME, MRCS (Eng)
Help unlock your patients’ ultimate aesthetic versatile portfolio that supports a multimodal
* 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. The safety and efficacy of HArmonyCa™ has not been evaluated in patients treated with other filling implants. 3 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.4-12
ONE PRODUCT. DUAL EFFECT.
A dual effect Injectable designed for a potential instant lift and sustained collagen stimulation3,14,20,‡,¶,¥,#
Providing a true instant and maintained lift 20,¥
HA , hyaluronic acid; CaHA , calcium hydroxyapatite. HArmonyCa™ Lidocaine is referred to as HArmonyCa™. HArmonyCa™ Lidocaine is a dermal filler intended for facial soft tissue augmentation and should be injected into the deep dermal and sub-dermal layers. The lidocaine in the product is for reducing pain during treatment.3
Individual treatments and patient results may vary.
Please consult the HArmonyCa™ IFU (instructions for use) for the full list of contraindications, warnings and precautions prior to use.
‡ Results from a prospective and non-randomised interventional study where HArmonyCa™ was injected in the preauricular region of 15 women. The primary endpoint was the volumetric changes at Day 180. Secondary endpoints included changes in facial tension vectors, time to filler tissue integration and safety profile.14
¶ Ultrasound and elastography examinations were performed using the Samsung HT 30 ultrasound machine and the ElastoScan HS30/XH30 respectively (Samsung Healthcare Global). When compared to baseline, an increase in density, viscoelasticity, and firmness of the tissue was observed at 60 days and then confirmed at 90 days after treatment. At 180 days after treatment an increase in collagen in the treated areas was confirmed.14
¥ Results from a pre-clinical animal study of HArmonyCa™ with results demonstrated over 12 weeks which showed that HArmonyCa™ lead to an instant lift following injection. 20
# Vectra® H2 (Canfield Scientific, Inc.) was used to assess skin lift and tightening by measuring the changes in FTV at 60, 90, and 180 days after treatment. As compared to pre-treatment values, FTV significantly increased at all timepoints with a median (interquartile-range) increased by 2.2 (1.6– 2.2) mm and 2.0 (1.7–2.2) mm in the right and left side, respectively p < 0.0001 each, 180 days after treatment.14
Delivering sustained collagen stimulation by supporting the body’s own collagen production14,‡,¶ Adverse events should be reported. 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.
Model treated with JUVÉDERM®. Individual treatment and patient results may vary.
aesthetic goals with a diverse and multimodal treatment approach2-19*,†
CRAFT THEIR EXTRAORDINARY
Long lasting
The longest lasting collection of hyaluronic acid facial fillers on the market, 21,π with results lasting 9-24 months22-24,§,¥¥
High quality
High quality product design and manufacturing that comes with every syringe25,26
Embracing individuality
Our commitment to embracing patients’ individuality and helping them achieve an individual look 27,28
Patients may experience potential side effects after treatment with JUVÉDERM® facial filler, which include inflammatory reactions (redness, oedema, erythema, etc.), haematomas, induration or nodules, staining or discolourations at the injection site.4-12
Rare but serious adverse events associated with intravascular injection of dermal fillers in the face and tissue compression have been reported and include temporary or permanent vision impairment, blindness, cerebral ischemia or cerebral haemorrhage, leading to stroke, skin necrosis and damage to underlying structures. Please refer to the Directions for Use (DFU).4-12 § Juvéderm® VOLUMA has been shown to last up to 24 months in the malar region of the face. 23,24
π Based on a search of published clinical studies of hyaluronic acid facial fillers in November 2019. A duration of 24 months was established in Juvéderm® VOLUMA with lidocaine, depending on the treatment area chosen. 21
¥¥ Results lasting from 9 months up to 24 months depending on the product used and facial areas treated. 22-24
Adverse events should be reported. 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.
Book a call with a VIRTUAL PRODUCT SPECIALIST to find out more
ORIGINAL BOTOX®29,30**
Predictable
• Mechanism of action and manufacturing quality 2,31-33
Proven
• 30+ years of manufacturing experience29,30,**,††
• More peer-reviewed publications and clinical studies than any other toxin34,35,††,ø,œ
• Demonstrated clinical outcomes36,∑
> Significant improvement in FHL up to 180 days P≤0.002 (vs placebo from Day 7)36,∑
BOTOX® (botulinum toxin type A) is indicated for the temporary improvement in the appearance of: moderate to severe vertical lines between the eyebrows seen at maximum frown (glabellar lines) and/or
• moderate to severe lateral canthal lines (crow’s feet lines) seen at maximum smile and/or moderate to severe forehead lines seen at maximum eyebrow elevation when the severity of the facial lines has an important psychological impact in adult patients. 2
SAFETY INFORMATION
COMMON ADVERSE REACTIONS: Common (≥1/100 to <1/10) Glabellar lines: Nervous system disorders (common): Headache. Eye disorders (common): Eyelid ptosis. Skin and subcutaneous tissue disorders (common): Erythema. Musculoskeletal and connective tissue disorders (common): Localised muscle weakness. General disorders and administration site conditions (common): Face Pain. Crow’s Feet Lines with or without Glabellar Lines: General disorders and administration site conditions (common): Injection site haematoma (procedure- related adverse event). Forehead Lines and Glabellar Lines with or without Crow’s Feet Lines: Nervous system disorders (common): Headache. Eye disorders (common): Eyelid ptosis (The median time to onset of eyelid ptosis was 9 days following treatment). Skin and subcutaneous tissue disorders (common): Skin tightness, Brow Ptosis (The median time to onset of brow ptosis was 5 days following treatment). Musculoskeletal and connective tissue disorders (common): Mephisto sign. General disorders and administration site conditions (common): Injection site bruising, Injection site haematoma (procedure-related adverse events). 2
PREGNANCY AND LACTATION: BOTOX® is not recommended during pregnancy and in women of childbearing potential not using contraception. There is no information on whether BOTOX® is excreted in human milk. The use of BOTOX® during breast-feeding can not be recommended. 2
CONTRAINDICATIONS: Known hypersensitivity to botulinum toxin type A or to any of the excipients. Presence of infection at the proposed injection site(s). 2 Please refer to the BOTOX® Summary of Product Characteristics (SmPC) for further information on Adverse Events and Safety Information and the Prescribing information for contraindications, warning and precautions. 2
CFL , crow’s feet lines; FDA , Food and Drug Administration; FHL , forehead lines; FWS, Facial Wrinkle Scale; GL , glabellar lines; mITT, modified intention-to-treat; U, unit.
** First medical approval for therapeutic use was granted in the United States of America by the FDA in 1989. 29,30
†† Therapeutic and cosmetic use. 29,30,34,35
ø Data as of July 2022.34
œ Data as of December 2021.35
∑ Simultaneous treatment with BOTOX® (64 U = GL (20 U) + FHL (20 U) + CFL (24 U), co-primary endpoint, P≤0.002, n=235, investigator assessed). This 12-month, Phase 3 study, (N=787) consisted of two treatment periods to evaluate the safety and efficacy of BOTOX® for the treatment of FHL distributed between the frontalis (20 U) and the glabellar complex (20 U), with or without simultaneous treatment of CFL (24 U). Two treatment periods: 6-month, randomised (BOTOX® 64 U, BOTOX® 40 U and placebo in a 2:2:1 ratio). Period 1 (Days 1–180), double blind, single treatment, placebo controlled, parallel group, followed by a 6-month, open-label (BOTOX®) treatment period 2 (Days 180–360).
Before treatment on Day 1, subjects must have had moderate-to-severe FHL at maximum eyebrow elevation, investigator and subject assessed using the Facial Wrinkle Scale with Photonumeric Guide (FWS; 0 = none, 3 = severe); moderate-to-severe GL at maximum frown and moderate-to-severe, bilaterally symmetrical CFL at maximum smile investigatorassessed, using the FWS. Follow-up assessments were conducted at Weeks 1 and 2 and on Days 30, 60, 90, 120, 150 and 180. The co-primary end points were the proportion of subjects (EU analysis, mITT population, n=568) achieving an investigator- and subjectassessed FWS rating of none/mild for FHL severity at maximum eyebrow elevation at Day 30 of the double-blind period.36
BOTOX® (botulinum toxin type A) Forehead lines, Glabellar and Crow’s Feet Lines Abbreviated Prescribing Information
PRESENTATION: Botulinum toxin type A (from clostridium botulinum), 50 or 100 or 200 Allergan Units/vial
INDICATIONS: Temporar y improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at maximum frown (glabellar lines) and /or; moderate to severe lateral canthal lines (crow’s feet lines) seen at maximum smile and/or; moderate to severe forehead lines at maximum eyebrow elevation when the severity of the facial lines has an important psychological impact in adult patients.
DOSAGE and ADMINISTRATION: See Summar y of Product Characteristics for full information on dosing and administration. Do not inject into blood vessels. Botulinum toxin units are not interchangeable from one product to another. BOTOX must only be reconstituted with sterile sodium chloride 9 mg/ml (0.9%) solution for injection. Doses recommended in Allergan Units are different from other botulinum toxin preparations BOTOX should only be administered by an appropriately qualified healthcare practitioner with expertise in the treatment of the relevant indication and the use of the required equipment, in accordance with national guidelines This product is for single use only and any unused solution should be discarded. The most appropriate vial size should be selected for the indication Not recommended for patients <18 years. The recommended needle: Sterile 30 gauge needle Glabellar lines seen at maximum frown: Recommended dose is 0.1ml (4 units) administered in each of the 5 injection sites (2 injections in each corrugator muscle and 1 injection in the procerus muscle for a total dose of 20 Units) In order to reduce the risk of eyelid ptosis, the maximum dose of 4 Units for each injection site as well as the number of injection sites should not be exceeded Crow’s feet lines seen at maximum smile: A volume of 0.1 ml (4 Units) is administered in each of the 3 injection sites per side (total of 6 injection sites) in the lateral orbicularis oculi muscle, for a total dose of 24 Units in a total volume of 0.6 ml (12 Units per side). For simultaneous treatment with glabellar lines seen at maximum frown, the dose is 24 Units for crow’s feet lines seen at maximum smile and 20 Units for glabellar lines (see Administration guidance for glabellar lines) for a total dose of 44 Units in a total volume of 1.1 ml In order to reduce the risk of eyelid ptosis the maximum dose of 4 Units for each injection site as well as the number of injection sites should not be exceeded Forehead Lines seen at maximum eyebrow elevation: A volume of 0.1 ml (4 Units) is administered in each of the 5 injection sites in the frontalis muscle, for a total dose of 20 Units in a total volume of 0.5 ml The total dose for treatment of forehead lines (20 Units) in conjunction with glabellar lines (20 Units) is 40 Units/1.0 mL For simultaneous treatment with glabellar lines and crow’s feet lines, the total dose is 64 Units, comprised of 20 Units for forehead lines, 20 Units for glabellar lines and 24 Units for crow’s feet lines. When treating adult patients for multiple indications, the maximum cumulative dose should not exceed 400 Units in a 12-week interval.
CONTRAINDICATIONS: Known hypersensitivity to botulinum toxin type A or to any of the excipients. Presence of infection at the proposed injection site(s).
SPECIAL WARNINGS AND PRECAUTIONS : The recommended dosages and frequencies of administration of BOTOX should not be exceeded due to the potential for overdose, exaggerated muscle weakness, distant spread of toxin and the formation of neutralising antibodies. Initial dosing in treatment naïve patients should begin with the lowest recommended dose for the specific indication Prescribers and patients should be aware that side ef fects can occur despite previous injections being well tolerated. There are reports of side effects related to spread of toxin distant from injection site, sometimes resulting in death. The risk of symptoms is probably greatest in patients who have underlying conditions and comorbidities that would predispose them to these symptoms Patients treated with therapeutic doses may also experience exaggerated muscle weakness Elderly and debilitated patients should be treated with caution. Consideration should be given to the risk-benefit implications for the individual patient before embarking on treatment with BOTOX. BOTOX should only be used with extreme caution and under close supervision in patients with subclinical or clinical evidence of defective neuromuscular transmission e.g. myasthenia gravis or Lambert-Eaton Syndrome in patients with peripheral motor neuropathic diseases (e.g. amyotrophic lateral sclerosis or motor neuropathy) and in patients with underlying neurological disorders. Such patients may have an increased sensitivity to agents such as BOTOX, even at therapeutic doses, which may result in excessive muscle weakness and an increased risk of clinically significant systemic ef fects including severe dysphagia and respirator y compromise The botulinum toxin product should be used under specialist supervision in these patients and should only be used if the benefit of treatment is considered to outweigh the risk. Patients with a history of dysphagia and aspiration should be treated with extreme caution. Patients or caregivers should be advised to seek immediate medical care if swallowing, speech or respirator y disorders arise. As with any treatment with the potential to allow previously-sedentary patients to resume activities, the sedentar y patient should be cautioned to resume activity gradually. The relevant anatomy, and any alterations to the anatomy due to prior surgical procedures, must be understood prior to administering BOTOX and injection into vulnerable anatomic structures must be avoided. Pneumothorax associated with injection procedure has been reported following the administration of BOTOX near the thorax Caution is warranted when injecting in proximity to the lung (par ticularly the apices) or other vulnerable
anatomic structures. Serious adverse events including fatal outcomes have been reported in patients who had received off-label injections of BOTOX directly into salivary glands, the oro-lingual-phar yngeal region, oesophagus and stomach. Some patients had pre-existing dysphagia or significant debility If such a reaction occurs further injection of BOTOX should be discontinued and appropriate medical therapy, such as epinephrine, immediately instituted. Caution should be used when BOTOX is used in the presence of inflammation at the proposed injection site(s) or when excessive weakness or atrophy is present in the target muscle There have been reports of adverse events following administration of BOTOX involving the cardiovascular system, including arrhythmia and myocardial infarction, some with fatal outcomes New onset or recurrent seizures have been reported, typically in patients who are predisposed to experiencing these events The exact relationship of these events to botulinum toxin injection has not been established. Formation of neutralising antibodies to botulinum toxin type A may reduce the ef fectiveness of BOTOX treatment by inactivating the biological activity of the toxin. Clinical fluctuations during the repeated use of BOTOX (as with all botulinum toxins) may be a result of different vial reconstitution procedures, injection intervals, muscles injected and slightly differing potency values given by the biological test method used
PREGNANCY AND LACTATION: Pregnancy: BOTOX is not recommended during pregnancy and in women of childbearing potential not using contraception. Breastfeeding: There is no information on whether BOTOX is excreted in human milk. The use of BOTOX during breast-feeding cannot be recommended. Fertility: There are no adequate data on the ef fects on fertility from the use of botulinum toxin type A in women of childbearing potential. Studies in male and female rats have shown fertility reductions
DRIVING: No studies on the ef fects on the ability to drive and use machines have been performed. Botox may cause asthenia, muscle weakness, somnolence, dizziness and visual distur bance which could af fect driving and operation of machiner y.
INTERACTIONS: Theoretically, the effect of botulinum toxin may be potentiated by aminoglycoside antibiotics or spectinomycin, or other medicinal products that interfere with neuromuscular transmission
ADVERSE REACTIONS: See Summar y of Product Characteristics for full list of adverse events In controlled clinical trials for glabellar lines seen at maximum frown, adverse events considered by the investigators to be related to BOTOX were reported in 23% (placebo 19%) of patients. In treatment cycle 1 of the pivotal controlled clinical trials for crow’s feet lines seen at maximum smile, such events were reported in 8% and 6% of patients compared to 5% for placebo. In treatment cycle 1 of clinical trials for forehead lines seen at maximum eyebrow elevation, adverse events considered by the investigators to be related to BOTOX were reported in 20.6% of patients treated with 40 Units and 14.3% of patients treated with 64 Units, compared to 8.9% of patients that received placebo. Adverse reactions may be related to treatment, injection technique or both In general, adverse reactions occur within the first few days following injection and, while generally transient, may have a duration of several months or in rare cases, longer Local muscle weakness represents the expected pharmacological action of botulinum toxin in muscle tissue However, weakness of adjacent muscles and/ or muscles remote from the site of injection has been reported As is expected for any injection procedure, localised pain, inflammation, paraesthesia, hypoaesthesia, tenderness, swelling/oedema, er ythema, localised infection, bleeding and/or bruising have been associated with the injection. Needle-related pain and/or anxiety have resulted in vasovagal responses, including transient symptomatic hypotension and syncope Fever and flu syndrome have also been reported after injections of botulinum toxin. Adverse reactions reported in the clinical trials is defined as follows: Common (≥1/100 to <1/10) Glabellar lines: Nervous system disorders (common): Headache Eye disorders (common): Eyelid ptosis. Skin and subcutaneous tissue disorders (c ommon): Er ythema Musculoskeletal and connective tissue disorders (common): Localised muscle weakness General disorders and administration site conditions (common): Face Pain. Crow’s Feet Lines with or without Glabellar Lines: General disorders and administration site conditions (common): Injection site haematoma (procedure-related adverse event) Forehead Lines and Glabellar Lines with or without Crow’s Feet Lines: Nervous system disorders (common): Headache Eye disorders (common): Eyelid ptosis (The median time to onset of eyelid ptosis was 9 days following treatment) Skin and subcutaneous tissue disorders (common): Skin tightness, brow ptosis (The median time to onset of brow ptosis was 5 days following treatment) Musculoskeletal and connective tissue disorders (common): Mephisto sign General disorders and administration site conditions (common): Injection site bruising, injection site hematoma (procedure-related adverse events).
NHS Price: 50 Units: £77.50, 100 Units: £138.20, 200 Units £276.40. Marketing Authorization Number: 50 Units: PL 41042/0059, 100 Units: PL 41042/0057, 20 0 Units PL 41042/0058 Marketing Authorization Holder: AbbVie Ltd, Maidenhead, Berkshire, SL6 4UB, UK Legal Category: POM. Date of preparation: May 2023
Further information is available from: AbbVie Ltd, Maidenhead, Berkshire, SL6 4UB, UK
UK-PI-BOTOX-Aesthetics 02
Adverse events should be reported. 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 GBPV@abbvie.com.
REFERENCES: 1. Unpublished Data – Allergan Medical Institute International – August 2020. 2. BOTOX® 100 Units Powder for solution for injection - Summary of Product Characteristics (SmPC). June 2023. Available at https://www.medicines.org.uk/emc/product/859 (Accessed July 2024). 3. Allergan Aesthetics. HArmonyCa™ Lidocaine IFU. M032 V01. 2021. 4. Juvéderm® VOLITE DFU. 73655JR10. Revision 2019-09-09. 5. Juvéderm® VOLBELLA with lidocaine 32G DFU. 73363JR10. Revision 2020-07-10. 6. Juvéderm® VOLIFT with lidocaine DFU. 73652JR10. Revision 2019-09-09. 7. Juvéderm® VOLUMA with lidocaine DFU. 73650JR10. Revision 2019-09-09. 8. Juvéderm® VOLUX DFU. 73651JR10. Revision 2019-09-09. 9. Juvéderm® ULTRA 2 DFU. 73661JR10. Revision 2019-09-09. 10. Juvéderm® ULTRA 3 DFU. 73662JR10. Revision 2019-09-09. 11. Juvéderm® ULTRA 4 DFU. 73663JR10. Revision 2019-09-09. 12. Juvéderm® ULTRA SMILE DFU. 73664JR10. Revision 2019-09-09. 13. Sadick NS, et al. Aesthetic Plast Surg. 2013;37:266–76. 14. Urdiales-Gálvez F et al. J Cosmet Dermatol. 2023;00:1–12. 15. Niforos F, et al. Clin Cosmet Investig Dermatol. 2019;12:791–8. 16. Carruthers JDA et al. Plast Reconstr Surg. 2008;121(5 Suppl):5S–30S. 17. Kurtti A et al. J Drugs Dermatol. 2022;21(1):37-42. 18. Raspaldo H et al. J Cosmet Dermatol. 2012;11(4):279-89. 19. Black JM et al. Dermatol Surg. 2016;42 (Suppl 2):S161-4. 20. Allergan Aesthetics. Data on File. HArmonyCa™ Lidocaine Lift Capacity. October 2023. REF-84448. 21. Allergan Aesthetics. Data on File. JUVÉDERM® VYCROSS – longest duration in clinical trials. January 2020. REF-74194. 22. Pinsky MA et al. Aesthetic Surg J. 2008;28:17–23. 23. Callan P et al. Clin Cosmet Investig Dermatol. 2013;6:81–89. 24. Jones D and Murphy DK. Dermatol Surg. 2013;39:1602–1612. 25. Allergan Aesthetics. Data on File. JUVÉDERM® Centre of excellence. August 2023. REF-71205. 26. AbbVie. Product Quality and Safety. Available at: https://www.abbvie.co.uk/societal-impact/for-the-resilience-of-our-business/quality-and-safety.html (Accessed July 2024). 27. Liew S et al. J Cosmet Dermatol. 2020;19:296–302. 28. Gutowski KA. Clin Plast Surg. 2016;43:489–496. 29. Brin MF. Medicine. 2023; 102(Suppl ): e32370. 30. Brin, M. F., & Blitzer, A. (2017). History of onabotulinumtoxinA therapeutic. In Botulinum Toxin: Procedures in Cosmetic Dermatology Series (pp. 7-13). Elsevier. https://doi.org/10.1016/B978-0-323-47659-1.00002-3. 31. Brin MF, et al. Biologics. 2014; 8:227–241. 32. Allergan Aesthetics. Data on File. Botulinum toxin type A manufacturing process. October 2022. REF-104400. 33. Schantz EJ, et al. Perspect Biol Med. 1997;40(3):317–27. 34. Allergan Aesthetics. Data on file. BOTOX® number of peer-reviewed articles vs competitors. August 2022. REF-100250. 35. Allergan Aesthetics. Data on file. BOTOX® number of patients treated in clinical trials. August 2022. REF-124128. 36. De Boulle K, et al. Dermatol Surg. 2018;44(11).1437-1448.
We are
Our ambition is to support you throughout your career, to help realise your professional aspirations.
by Allergan Aesthetics
Helping the next generation of aesthetics professionals to thrive.
Access peer-to-peer content, including articles, webinars, videos, training and advice from experts in the field.
Spark by Allergan Aesthetics is an educational website that contains promotional materials available to healthcare professionals only. Allergan Aesthetics supports training of appropriately qualified healthcare professionals. We define this as individuals who hold a recognised and valid Medical Doctor, Dental Surgery or Human Nursing qualification, allowing them to practice independently as a Doctor, Dentist or Nurse in the UK.
*Data captured in 2020.1
Celebrating over 10 years of empowering excellence in medical education. Bringing together the best of the best – leading practitioners, cuttingedge technologies, and comprehensive medical education – AMI helps providers pursue optimal patient outcomes through clinical excellence.
More than 78,000 healthcare practitioners around the world1,* have access to evidence-based, expert-led, on-demand medical education.
The Allergan Medical Institute (AMI) Digital World is a promotional website produced and funded by Allergan Aesthetics, an AbbVie Company. It is intended for use by UK Healthcare Professionals.
JOIN THE CONVERSATION
Follow us on instagram @allerganaestheticsuki
Adverse events should be reported. 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 GBPV@abbvie.com.
Facilitating 1:1, in-clinic learning to support injectors
Business Consulting Team
Providing entrepreneurial support to help build your business. Our Business Consulting Service is a non-promotional, paid for service offered to owners of medical aesthetic practices
Sales Team and Medical Affairs
Extensive customer and medical service support every step of the way, to help get the best from our products
Master the Newest Evidence-Based Injection Techniques at CCR
Injectable learning like you’ve never seen it before
In the constantly evolving world of medical aesthetics, new products and techniques are always unveiled. But how do you know what will work best for your patients?
The Clinical Cosmetic Regenerative (CCR) Congress invites you to explore all the latest injectable innovations on 10 & 11 October, from dermal filler techniques to key strategies for injecting the mid-face, and everything in-between.
Hear from top key opinion leaders (KOLs) to help understand the benefits of offering a multi-treatment approach to your patients and learn the best ways to communicate this.
Secure your spot today to bring the latest clinical expertise, advanced technology and innovative approaches to your practice.
Uncover the latest injectable techniques with Galderma
Enhance your knowledge as Headline Sponsor Galderma delivers exclusive injectable education on how to perform bespoke, patient-centric assessment and treatments in the Aesthetics Journal Arena.
Over the course of two days, Galderma and the team will deliver unmissable new insights and live demonstrations, focusing on the regenerative approach to individualised treatments. It all takes place in the Aesthetics Journal Arena – here’s what you can expect.
Galderma will return to CCR with its demonstration area providing a chance to get hands-on with the Galderma product portfolio using their state-of-the-art training mannequins. Talks will be hosted on the stand by Galderma speakers taking part in their symposiums over the two days.
“Galderma is delighted to be back at CCR as Headline Sponsor for 2024 following our most successful show to date in 2023. CCR is the perfect platform for us to showcase what’s new with our brands and engage with practitioners and colleagues. This will be our fourth year in a row working with Easyfairs on this fantastic event, and we can’t wait to see everyone in October!
Joanna Neal, senior brand manager
Day 1
Optimising Outcomes with Restylane: Addressing Current Patient Trends & Expectations
Delve into the latest trends and expectations of patients, and how Restylane optimises treatment outcomes while addressing the needs of individual patients.
Key learning outcomes:
• To equip practitioners with the knowledge to meet current patient demands effectively with the right consultation
• To enhance technical skills with AART – Facial Assessment, Anatomy (nose, chin and lips) and Range of Restylane portfolio and treatment
• Application of Restylane in balancing profile and achieving natural-looking results
Speakers include:
• Dr Zoya Awan
• Jackie Partridge
• Dr Munir Somji (performing live injection)
Day 2
A.A.R.T of Sculptra: One Product, So Many Possibilities
Start your regenerative patient journey with Sculptra, the first clinically-proven biostimulator. Learn how to adopt the AART approach during patient consultations and leverage its regenerative pathway to transform your patients’ results.
Key learning outcomes:
• Learning how to unlock the many possibilities of Sculptra treatment for patients
• Understanding the AART of Assessment, Anatomy, Range, Treatment methodology – a systematic yet personalised approach to creating a patient journey
Speakers include:
• Dr Ana Mansouri (performing live injection)
• Dr MJ Rowland-Warmann
• Dr Kathryn Taylor-Barnes
Enhance your skills and patient satisfaction
The Aesthetics Journal Arena is the place to be for independent content. Curated by the Aesthetics editorial team and broken down into four mini agendas, expect exciting live demonstrations and engaging panel discussions on key topics. Leading practitioners will inspire you to adopt new treatments and techniques as you advance your aesthetic practice. Over the two days, you can explore effective off-label uses of botulinum toxin, discover the latest injectable techniques for full-face rejuvenation, learn how to enhance skin quality and hear from the experts about how regenerative treatments can transform patient results.
Speakers include:
Dr Kate Goldie, Mr Dalvi Humzah, Dr Anjali Mahto, Dr Christopher Rowland Payne, Dr Catherine Fairris, Dr Nestor Demosthenous, Dr Rashpal Singh, Alex Mills, Dr Tapan Patel and many more.
The
injectable
education doesn’t stop there
The Symposium Stage brings together the specialty’s leading brands to showcase their latest injectable techniques through one-hour live treatment demonstrations. Led by esteemed KOLs over a two-day agenda, these sessions are designed to elevate your knowledge, skills and confidence to safely deliver outstanding results. Confirmed companies presenting include DermaFocus and DermapenWorld.
NEW to 2024 – Injectable Avenue
Wondering where you can find the injectable companies at CCR 2024? The Injectable Avenue of course! Dedicated to reshaping the narrative and restoring confidence in injectables like HA fillers and toxins, this new feature is your pathway to extended injectable knowledge. In this area of the event you’ll find leading manufacturers and distributors of injectable products showcasing their latest innovations, as well as the associations we recommend aesthetic practitioners join for that all-important wider support.
Discover formal injectable training with Harley Academy
Located at our In Practice Theatre, listen to advice on Getting Started in Aesthetics. CEO and Founder of Harley Academy, Dr Tristan Mehta, will discuss everything you will need to stand out in the ever-evolving field of aesthetics and ensure you are practising at the best level. Learn about the latest standards in the specialty, advanced injectable techniques and the importance of continuous professional development.
Further your skills and career at CCR
Attending CCR will not only provide you with the skills to enhance patient satisfaction, but you will also gain 14 CPD points to use in your appraisal. In addition, CCR will give you the special opportunity to create valuable connections for career growth and to exchange ideas with your peers. Secure your free place today and continue your journey to achieving excellence in aesthetics.
Please note, some sessions at CCR are restricted to practitioners on certain medical registers only. Full information will be on the website and agendas. CPD points are automatically gained by attending CCR sessions however you must be an Elite member of Aesthetics to receive a personalised CPD certificate. Please visit aestheticsjournal.com to become a member.
Treating TMD with Botulinum Toxin
Dr Elle Reid and Dr Bryony Elder discuss the presentation of temporomandibular disorders and how they can be treated using botulinum toxin
Temporomandibular disorders (TMD) encompass a group of conditions affecting the temporomandibular joint (TMJ) and surrounding musculature, leading to pain, dysfunction and impaired quality of life for affected individuals. The diagnosis and management of TMD poses significant challenges for medical professionals due to the complex aetiology and diverse clinical presentations of these disorders. In recent years, botulinum toxin (BoNT) has emerged as a promising therapeutic option for managing TMD, offering targeted relief of symptoms and improving patient outcomes.1,2
Overview of TMD
TMD encompass musculoskeletal conditions characterised by discomfort and/or impairment in the muscles used for chewing, the TMJ and related structures. This category represents the predominant form of non-tooth-related facial pain, often manifesting as facial pain/ headaches, TMJ discomfort, dental pain, restricted jaw movement and audible TMJ sounds during jaw actions. Additionally, individuals with TMD frequently experience concurrent painful and non-painful conditions elsewhere in the body, such as neck and back pain, as well as gastrointestinal symptoms.3 Those with painful symptoms indicate how symptoms have a notable impact on quality of life and are a significant driver for seeking treatment.4,5
Recent studies indicate that the pathophysiology of painful TMD is biopsychosocial, with no single factor being responsible for its development.3,6,7 A prospective cohort study with more than 6,000 participants showed a twofold increase in TMD in persons with depression, and a 1.8-fold increase in myofascial pain in persons with anxiety. Factors consistently associated with TMD include other pain conditions (e.g. chronic headaches), fibromyalgia, autoimmune disorders, sleep apnea and psychiatric illnesses.6,7
Symptoms and presentation
When considering patients who present with painful symptoms, a large population study using the Research Diagnostic Criteria (RDC) TMD estimated that painful symptoms (arthralgia and myalgia) affected 36% of adults aged 20-49, and a combination of both arthralgia and myalgia form the most common presentation (73%).8,9 Painful symptoms may present as a persistent episode (19% of cases), recurrent (65% of cases) or a single episode (12% of cases) with the average duration of symptoms being six years.8 In population studies of both adolescent and adult patients, the presence of any RDC/TMD diagnosis is more prevalent in females, with some studies showing the male-to-female ratio as being 1:2.10,11 The condition affects all age groups, particularly young adults, with the highest prevalence rate being between 20-and-40-years-olds.12
Diagnosis
Diagnosis of TMD must be carried out by a suitably qualified professional, such as a dentist or maxillofacial colleague. A dental assessment is required to assess dental causes of TMD, such as occlusal discrepancies, signs of parafunction, tooth wear or appliance interference. It is also essential to assess the patient’s periodontium, general dental health to ensure a holistic overview of the potential dental-related causes of TMD. The diagnosis of TMD is primarily based on the patient’s history and physical examination findings.7 TMD symptoms often relate to jaw movements (e.g. opening and closing the mouth, chewing) and pain in the preauricular, masseter or temple regions. If pain is not influenced by jaw movement, another source of orofacial pain should be considered.13 While adventitious jaw sounds (e.g. clicking, popping, grating, crepitus) may be present in TMD, they also occur in up to 50% of asymptomatic individuals.7
When history and physical examination findings are equivocal, imaging can assist in subcategorising the type of TMD, as well as any aetiological factors. Plain radiography, in the form of a panoramic radiograph, which can demonstrate severe degenerative diseases, acute fractures or dislocations, should be considered as an initial study.7 Computerised tomography (CT) examinations offer a superior evaluation of subtle bony changes.7
However, they both have a limited view of soft tissue changes.10
Magnetic resonance imaging (MRI) is considered to be the optimal diagnostic examination for comprehensive joint evaluation for patients presenting with signs and symptoms of TMD. This is because it has a high soft tissue resolution and is able to demonstrate joint structure as well as the shape and position of the articular disc, in addition to being non-radiating.10,14 However, false positive reading can occur in as many as 20-34% of asymptomatic patients.7 Magnetic resonance imaging (MRI) is typically reserved for patients with severe functional impairment or those with suspected internal joint derangement.14
Differential diagnosis
Practitioners should be vigilant when diagnosing TMD in patients presenting with pain in the TMJ area. Several conditions can mimic TMD, including dental caries or abscess, oral lesions, conditions due to muscle overuse, trauma or dislocation, maxillary sinusitis, salivary gland disorders, trigeminal neuralgia, postherpetic neuralgia, glossopharyngeal neuralgia, giant cell arteritis, primary headache syndrome and cancer-associated pain.15,16 Additionally, TMD symptoms may appear in autoimmune diseases such as systemic lupus erythematosus, Sjögren’s syndrome and rheumatoid arthritis.15,17
Traditional treatment modalities
The literature favours conservative multidisciplinary interventions for TMD. Reversible therapies are first-line treatments but lack specific evidence for TMD types.17 Intraoral appliances offer short-term relief and are as effective as physical therapy and acupuncture.18,19 Physical therapy aims to improve muscle function, with weak evidence suggesting it may surpass intraoral appliances in effectiveness.20,21 Acupuncture is effective for short-term pain relief.22,23 Pharmacological treatments include NSAIDs, with naproxen proven effective for pain.24,25 Benzodiazepines, tricyclic antidepressants like amitriptyline, muscle relaxants and corticosteroids are used for severe cases, though evidence varies. Corticosteroids are reserved for severe joint issues.3,7,26
Using botulinum toxin
BoNT, particularly type A (BoNT-A), inhibits the release of acetylcholine at neuromuscular junctions. This blocks muscle contraction, reducing hyperactivity and tension in the masticatory muscles, a critical factor in TMD pain. BoNT-A achieves this by cleaving SNARE proteins involved in vesicle fusion, thus preventing neurotransmitter release.27 Additionally, BoNT-A may reduce pain by modulating inflammatory mediators
Study Protocol Dosing guidelines Outcomes
Schwartz and Freund (2002)30 Describes treatment with BoNT, emphasising correct injection techniques and appropriate dosing.
Bogucki and Kownacka (2016)1 Use of BoNT-A for TMD, highlighting the importance of correct dosing and injection technique.
Lima et al. (2021)33
Li et al. (2023)2
Low doses of BoNT-A were injected into each masseter and temporalis muscle.
Meta-analysis indicates higher doses are associated with greater pain reduction.
and neurotransmitters in the central nervous system.28
The use of BoNT in managing TMD is based on its ability to reduce muscle hyperactivity and associated pain. By relaxing the overactive masticatory muscles, BoNT can alleviate the tension and spasms contributing to TMD symptoms. This therapeutic approach has shown efficacy in patients who do not respond adequately to conservative treatments, providing a new avenue for managing chronic and refractory TMD pain.1
Summary of evidence
1. Efficacy:
· Pain reduction: Multiple studies have demonstrated that BoNT-A injections significantly reduce pain intensity in TMD patients compared to placebo ( Table 1)2,29,30
· Improved function: BoNT-A treatment has been shown to improve jaw function and increase mouth opening in TMD patients31
2. Safety:
· Adverse effects: BoNT-A is generally well-tolerated with a low incidence of adverse effects. Common side effects are mild and may include temporary weakness of the injected muscles32
Patient selection
Assessment and discussion surrounding expectations are vital for appropriate case selection for patients with TMD, ensuring a detailed discussion outlining functional or aesthetic goals and the realistic outcomes. Patents must be informed regarding potential risks such as transient muscle weakness, asymmetry or temporary changes in bite force. Practitioners must also ensure the patient understands the need for repeated treatments for optimal success, all of which constitute informed consent.31 The optimal number of treatments with BoNT for TMD typically involves initial treatment followed by re-evaluation and potential re-treatment every three to six months.31 This helps maintain symptom relief and manage chronic pain effectively. Individual patient responses should guide the exact frequency of treatments to ensure optimal outcomes.
Aesthetic outcomes
BoNT-A treatment of the masseters can be utilised for functional treatment of TMD and
Not specified
Not specified
20 U of BoNT-A bilaterally
60-100 U bilaterally
aesthetic concerns. Masseter hypertrophy can result in an increased mandibular width. Typically in a masculine appearance, the bi-gonial width should be equal to the bi-zygomatic width, therefore a treatment goal of a female-presenting patient may be to reduce this with ‘jaw slimming treatment’.28 BoNT-A can be used in an aesthetic consideration to cause atrophy of the masseters, resulting in a more feminine appearance. Patients must be educated that in hypertrophic masseters, BoNT-A will take time to cause atrophy, so treatment is not ‘instant’ and will require repeated treatments, dependent on severity of the hypertrophy and the potential desired outcomes.
Caution should be taken when treating a male-presenting patient, as a reduction in the masseter muscles can lead to an overly feminised face, which might not align with their desired aesthetic goals. Careful assessment and a balanced approach to muscle reduction are crucial to avoid undesired changes in facial structure and maintain a natural appearance.
Requirements to practise
According to the Care Quality Commission (CQC) guidelines, the premises and regulations under which practitioners can operate in the UK must clearly define the treatment of TMD and jaw slimming.34 TMD is recognised as a ‘disease or dysfunction’ under CQC recommendations, and thus, treatment for TMD must be
Successful reduction in TMD symptoms.
Effective symptom relief with BoNT-A when appropriately administered.
Significant pain decreases after 15 days, effects lasting up to 180 days.
Effective pain reduction and improved muscle function over several months.
provided in CQC-registered premises, such as a CQC-registered clinic, dental practice or hospital. However, treatment for purely cosmetic reasons is permitted under different CQC regulations. Therefore, if masseters are treated solely for cosmetic purposes and not for dysfunction, this treatment can be conducted in non-CQC-registered premises.34
An emerging treatment option Managing temporomandibular disorders (TMD) is complex, but botulinum toxin (BoNT) offers promising relief by reducing muscle hyperactivity and pain. BoNT improves jaw function and patient satisfaction, making it valuable for chronic and refractory TMD. Proper injection techniques and monitoring for adverse effects are essential for safety and efficacy. Long-term benefits are sustained with regular reassessment and re-injection. It’s important for non-dental professionals to work collaboratively with the dental community in order to provide patients with optimal outcomes.
Dr Elle Reid is an aesthetic practitioner and dental surgeon graduating from Newcastle University. Dr Reid has a background in maxillofacial surgery, hospital and practice-based dentistry. She holds the positions of clinical lead for Acquisition Aesthetics in Newcastle and director of Paragon Aesthetics medical aesthetics clinic.
Qual: BDS, MFDS
Dr Bryony Elder is an aesthetic practitioner and educator, graduating with a Bachelor’s in Dental Surgery from Leeds University. She is the founder of Ametrine Aesthetics in Newcastle upon Tyne, the Aesthetic Director for Pre- Salons in London and the Level 7 lead for Acquisition Aesthetics. She also is an Aesthetic Practitioner Mindset mentor.
Qual: BChD
Figure 1: 23-year-old patient before and four months after TMD treatment with Bocouture BoNT-A
Table 1: Overview of studies supporting BoNT-A for treating TMD1,2,30,33
Embrace the Future of Facial Rejuvenation
Emface and Exion
Become a provider
BTL leads the way toward a new era of facial rejuvenation. Combine BTL’s revolutionary EMFACE with its latest innovation to target all layers from muscle to skin Meet the demand for bespoke and minimallyinvasive treatments and deliver unparalleled patient outcomes
When you combine devices you achieve better outcomes ecause you can stimulate collagen and elastin (which each espond differently to different energy sources) in the areas that ill provide the patient with the best results. We have a number f systems from BTL at my clinic, and have been very impressed ith the new EXION platform and it is becoming very popular with ur patients too”. Dr Ariel Haus - Dermatologist
Maximising Patient Satisfaction with EXION and EMFACE
Embrace the shift to the regenerative with BTL Aesthetics’ treatment offering
In the aesthetics world, the word on everyone’s lips is ‘holistic’. It is certainly at the forefront of our minds at BTL Aesthetics, with an extensive device portfolio that’s offered for patients seeking comfortable, easy and effective solutions without downtime.
Specialty trends suggest that aesthetic devices are rapidly gaining popularity, becoming recognised as essential for overall skin rejuvenation. The global energy-based device market is projected to grow by 13.8% compound annual growth rate (CARG) by 2030, compared to the European injectable market’s projected 10.8% growth.1,2
BTL Aesthetics offers a plethora of technologies to enhance skin health and quality, meeting patients’ demands for natural-looking rejuvenation with minimum discomfort and no downtime. 3 Two innovative technologies in particular – the brand new EXION and the revolutionary EMFACE – have emerged as game-changers for facial rejuvenation, particularly when delivered as a combination protocol.
Technologies in focus
By combining EMFACE with BTL’s new EXION, practitioners can target all layers of facial rejuvenation from muscle to skin, maximising treatment possibilities and taking patient outcomes to the next level.
EXION Face
Combining synchronised monopolar RF with mechanical ultrasound energy for the very first time, this combination is clinically proven to result in a 224% increase in the skin’s own natural production of HA levels, as well as a significant production of elastin.* In the era of regenerative medicine, with EXION Face you are now able to upregulate the body’s natural capability to produce HA in a needle-free, pain-free and enjoyable way.* Outcomes that can be seen using this handpiece include:*
· 224% increase in hyaluronic acid
· 50% increase in elastin
· 41% skin texture improvement
EXION
Fractional RF
EXION Fractional RF takes traditional monopolar radiofrequency (RF) energy and combines it with innovative AI to achieve precise energy delivery. EXION’s built-in extended mode creates a thermal gradient below the needles. This reaches deeper than any other microneedling device, up to 8mm in depth, without full needle insertion.* Thanks to the AI technology, you only need a single pass, making the procedure extremely time efficient and comfortable. Results include:*
· 250% increase in collagen
· 41% reduction in acne scars
· 81% comfort rating
EMFACE
EMFACE is a groundbreaking non-surgical treatment designed to rejuvenate and revitalise the skin. 3,4 Through precise application of treatment pads to the forehead and cheeks, EMFACE is the first device to simultaneously apply synchronised radiofrequency (RF) and HIFES energies to improve facial muscle tone and density in just 20-minute sessions.5 Studies have shown:3,4
· 37% reduction in fine lines and wrinkles
· 50% increase in elastin
· 30% increase in collagen
· 23% more lift
The perfect combination
Whilst these technologies deliver outstanding results when used alone, applying a synergistic approach enhances outcomes even further. With EXION Face stimulating HA production, EXION Fractional RF working on texture concerns and EMFACE targeting muscle and connecting tissues, the door is opened for more bespoke patient journeys than ever before. This, in turn, can facilitate more revenue streams for your clinic, more loyal and repeated purchases and optimised long-term patient plans.
Both treatments have also proved to work well when paired with your bread and butter injectable treatments. EMFACE in particular acts as an effective foundation before injectables to create an improved baseline. This means smaller amounts of dermal filler or botulinum toxin are needed, resulting in more natural-looking results.
Staying ahead of the times
EXION and EMFACE present a prime opportunity for you to push your clinical offering to new heights, embracing the trend for natural, regenerative treatments which is sure to stick around.
Figure 1: Before and immediately after four treatments with EMFACE and EXION Face. Images courtesy of The Vue Medispa.
Discover the wonder of polynucleotides
An Italian excellence Since 1952
O f ficial distr ibutor in the UK
Using Polynucleotides for Eye Dermatitis
Dr Sonakshi Khorana and Dr David Eccleston discuss polynucleotide treatment for dry, itchy skin and eczema around the eyes
Periorbital dermatitis or dry skin around the eyes can be caused by a variety of factors.1 The most common cause is allergic contact dermatitis, to which various studies suggest between 31-72% of cases can be attributed.1-4 This can be triggered by leave-on cosmetic products (such as face cream and eye shadow) and eye drops, with the usual allergens being fragrances, preservatives and drugs of varying kinds.2
Multiple other sources have suggested that between 14-39.5% of cases are due to atopic dermatitis (eczema).1 Irritant contact dermatitis makes up 7-9%, in contrast to the body as a whole, in which irritant contact dermatitis accounts for 70-80% of all contact dermatitis causes.5 Among the most common reasons for contact dermatitis that affects the eyelids is the use of hair dye, especially those that contain p-phenylenediamine.6 Other less common causes may include periorbital rosacea, allergic conjunctivitis or psoriasis vulgaris.1
Women are more commonly affected than men, making up 73-80% of cases.1 This disparity has been attributed to the use of cosmetic products, which is more common among women.1 Calcineurin inhibitors are the first-line therapy for periorbital dermatitis, which blocks the protein that activates the cells involved in eczema.1 The patient involved in this case study was not having success with this, so was keen to explore other options. After learning about the potential benefits of polynucleotides for dermatitis and eczema, we suggested this as a new treatment approach.
Polynucleotides for dermatitis and eczema
Polynucleotides are a sequence of nucleotides, as in DNA or RNA, bound into a chain. When injected intradermally, they promote a trophic and stimulating action on existing fibroblasts (skin cells) that increases collagen synthesis, as well as the viability and number of fibroblasts.7 They also promote hydration and scavenging, which helps prevent unfavourable reactions.8
Because of this, logic suggests that polynucleotides should help renew skin that is affected by dermatitis, potentially leading to a reduction in the appearance of eczema, with clearer, smoother and more even skin.8,9 This is the possibility which we wished to investigate. In-depth studies are required to get a more extensive picture of polynucleotides’ role in these conditions.
Case study
A 63-year-old female patient came into the clinic. Her eyes were flaky and dry due to atopic dermatitis (eczema). She described them as being “really itchy.” There was also some lichenification, a secondary feature of many dermatoses, characterised by diffuse thickening of the epidermis and accentuation of skin lines.10
Her skin was relatively dry, and it was getting her down because she was unable to hide it, even when she put makeup on. Upon consultation, she revealed that she had been using products to help with the dryness, including hydrating skincare and pimecrolimus cream, an ointment used for eczema around the eyes.11 She said that
neither product had improved her condition. The patient had previously come into clinic to enquire about Profhilo because she had heard about the treatment, and that was when we initially spoke about polynucleotides for the eyes.8,12-14 Our rationale for suggesting polynucleotides was that they have some anti-inflammatory properties and help with skin hydration as well.14 We suggested we trial them as a treatment option, while managing the patient’s expectations by explaining that we could not guarantee they were going to work. This is a crucial step in the consultation process, as it ensures that the relationship of trust between the patient and practitioner is maintained, and any potential disappointment is avoided.
She was happy to go ahead with the suggested treatment because she had a combination of inflamed skin and very dry skin, and nothing else had worked to date. We did also discuss managing the condition medically. She had already used pimecrolimus (Elidel 1% cream) prescribed by her GP, and we suggested we could swap that over to Tacrolimus 0.1% ointment and increase the emollient use.15 However, that meant using a lot of greasy moisturisers in the area, which was not ideal and was something she wished to avoid.
We also spoke about treatments to improve wrinkles around the eyes such as botulinum toxin to address crow’s feet once everything had settled, because these lines had become more enhanced with how dry and flaky the skin was. She agreed that this was something she was interested in, but has not had toxin treatment yet. It can be performed a few days after polynucleotide treatment, and as long as the skin has settled, there are no contraindications.
RESHAPING THE AESTHETIC EXPERIENCE
REVISETM+ Soft gel for periorbital area
• High molecular weight HA
• 12 mg/mL HA
Malleable gel with optimal shape with low extrusion force
The tear trough area is in high demand amongst patients as a target for rejuvenation, yet is one of the most difficult to treat. At last, a product that matches efficacy with safety allowing practitioners to confidently treat this area.
Miss Jennifer Doyle Consultant oculoplastic surgeon
We would always wait two weeks after toxin treatment for results to take effect before administering polynucleotides in the same area.
In addition, we spoke about using retinol-based eye creams, but as those can cause dryness, that would be the next step once we got everything under control.16
Treatment
Our products of choice were Plinest (20mg per ml) and Plinest Eyes (7.5mg per ml) from Mastelli by DermaFocus. They work to normalise cellular function and make the fibroblasts work more effectively.7
Research involving six subjects shows that fibroblast viability significantly increases with Plinest polynucleotides compared to controls after 96 hours and one week, and more cells are observed in scratch test assays.7 Plinest was also found to enhance tissue repair better than hyaluronic acid (HA) alone, with histological evaluation demonstrating almost complete tissue repair with mature and well organised collagen fibres, as well as consequent uniform deposition of the extracellular matrix.7 HA resulted in incomplete tissue repair with collagen fibres only partly occupying the repaired area.7
The patient’s first treatment was on September 20, 2023 with Plinest at 20mg per ml.8 The second treatment was on October 13, 2023, and she had Plinest Eyes – 7.5mg per ml – on that occasion. The third treatment was on November 24, 2023, and the final treatment was on January 12, 2024. We used Plinest again on those occasions.
While we could have continued to use Plinest Eyes, the patient tolerated the higher dose in Plinest well after her first treatment, with really good improvement that she was pleased with, so we decided to revert back to this. It is important to be aware that some patients may experience more swelling with Plinest because of the higher concentration, which is why Plinest Eyes is an excellent alternative.8 The protocol is a minimum of three treatments based roughly three to four weeks apart, and then maintenance is every six months.8
A 30G needle with 2ml syringe was used in each session, as per the Plinest protocol, and small intradermal blebs or micro-bolus were injected just around the upper lid, lower lid and crow’s feet area.8 The treatment typically takes about half an hour. Patients are numbed for half an hour before using EMLA cream; it’s a delicate area, so we wanted her to be as comfortable as possible.
Considerations
Patient results
The patient had a significant reduction in inflammation, redness and flakiness. Normal hydration levels were restored, and there was improved elasticity. She said her skin felt much softer and less tight, and also reported the skin around her eye was less sore and itchy. Skincare no longer stung when she put it on, which was another concern she had noticed. She was really happy with the results. The patient will come back in for maintenance in six months when we will assess how well the treatment has lasted and top up as required.
Polynucleotides as a versatile treatment option
We have found polynucleotides to be an excellent addition to clinical practice as they can be used as a standalone treatment or in combination with others. Clinical research into the procedure suggests it works well to prime the skin, with evidence indicating that polynucleotides can make skin more receptive to laser, radiofrequency, fillers, chemical peels, microneedling and surgery.8 In particular, we have valued being able to offer patients an effective option for treating concerns around the eyes – an area which is generally regarded as challenging to treat.
In terms of potential side effects and complications, given that she has eczema and sensitive skin around the area, we were confident that she would not have any reactions because we know polynucleotides have a low risk of adverse events.8 As with an injectable procedure, temporary swelling, redness and tenderness around the injection site can occur.8 There is also a small chance of allergic reaction.8
While we are yet to treat more dermatitis patients with polynucleotides, it appears to be a feasible option moving forward. It would be interesting to read specific research on this treatment approach when more data becomes available.
Dr Sonakshi Khorana is a GP with a special interest in medical and cosmetic dermatology. She serves as a dermatology specialist for renowned skincare brands and holds memberships at the Royal College of GPs, British Medical Laser Association and Aesthetic Complications Expert (ACE) Group World.
Nonetheless, it is really important to warn patients about the risk of bruising, especially around the eyes. In our experience, using ice can be a nice adjunct to help control the bleeding and make the procedure a lot more comfortable. This is important because the patient will need to come back for four treatments in total, so they have got to be as comfortable as possible. In this case, the patient had a small amount of bruising, but she did not complain of any side effects.
Dr David Eccleston qualified in medicine from the University of Birmingham in 1987 and undertook postgraduate dermatology training at the Birmingham Skin Centre since 1994. He is a global trainer and key opinion leader for Evolus, DermaFocus and Cutera as well as running his own private GP practice.
Qual: MB, CHB, BCAM
Figure 1: 63-year-old patient before and three weeks after four treatments with Plinest Eye polynucleotides
10 & 11 October 2024 ExCeL, London
CCR delivers world-class, scientific agendas that will progress your skills and professional development.
Headline Sponsor
Top speakers taking to the Aesthetics Journal Arena stage
Receive guidance and training from medical aesthetic experts
Mr James Olding Specialist Registrar in Oral & Maxillofacial Surgery
Dr Anjali Mahto Consultant Dermatologist
Dr Christopher Rowland Payne Consultant Dermatologist
Dr Tapan Patel Aesthetic Practitioner
Dr Manav Bawa Aesthetic Practitioner
Anna Baker Nurse Prescriber
Dr Kate Goldie Aesthetic Practitioner
Live injectable training from the Galderma faculty
Dr Ana Mansouri Aesthetic Practitioner
Dr MJ RowlandWarmann Dentist
Jackie Partridge Nurse Prescriber
Dr Munir Somji Aesthetic Practitioner
Dr Kathryn TaylorBarnes Aesthetic Practitioner
Dr Zoya Awan Aesthetic Practitioner
Examining Elective Filler Dissolving
Nurse prescriber Tanya Albin offers advice on elective filler dissolving treatment and supporting patients through the change
Elective filler dissolving has risen steeply in recent years, with an increasing number of public figures openly discussing reversing their previous procedures 1 This would directly correlate with the trends we are seeing in clinic with more natural looks being frequently requested. But what significance can the dissolving process have on our patients?
Hyaluronidase, which is an enzyme that breaks down hyaluronic acid, has been administered in medical applications for more than 60 years, originally being used to increase the absorption of drugs into tissue and reduce tissue damage in cases of extravasation of a drug.2 Since its first use in aesthetics in 2007, its utilisation has been on the rise, and not just for emergency reversals.3
This article will explore the impact of both overfilling and dissolving on patients’ wellbeing, alongside clinical guidance on effective dissolving and post-treatment care.
When dissolving should be encouraged
Patients may not have considered dissolving poor dermal filler treatments and may present as ‘filler blind’, however, as clinicians we have a duty of care to ensure we are offering our patients the best possible outcomes rather than continuing to refill at the patient’s request. You may have to say ‘no’ to your patient if you believe that another treatment could be clinically damaging.
I have found that having a thorough initial consultation of at least 45 minutes to establish desired outcomes and the risks associated with potential overfilling should help educate patients about their decision-making. For example, when it comes to lip augmentation, I strongly recommend opting for shape over volume to maintain definition of the vermillion border. Over the years, I have learnt to become more direct about overfilling, as I believe it is my duty of care to avoid unnecessary treatment.
Ultimately, we can encourage patients to make an informed choice, but some may wish to refuse elective dissolving. Ethically, at this point, refusal of further treatments should be verbalised and clearly documented.
The mental impact
Many patients, however, do not need to be encouraged to dissolve their existing filler. Patients are looking for more natural approaches to aesthetic procedures and are embarking on filler dissolving journeys in the hope of pursuing more natural alternatives. They are actively seeking out dissolving of previously injected dermal fillers, especially after potentially becoming ‘overfilled’ and ‘pillowy’ as a result of package deals, misinformation and online trends.4
With this rise in elective hyaluronidase, it is important as practitioners that we are equipped not only with the tools and education to safely conduct the procedure, but also knowledge of how to consult our patients beforehand. Many patients will have had their filler for several years and will be accustomed to their appearance, so may be distressed and self-conscious when it is reversed. It is imperative that they are well educated as to what the procedure entails and the effects this change in appearance can temporarily have on mental, physical and emotional wellbeing.
A contributing behavioural factor to this has been referred to as ‘perception drift’.5 In settings where the overfilled aesthetic becomes prevalent, the distorted appearance transforms into the norm, potentially becoming an aesthetic ideal. With each successive treatment, the patient’s memory of their natural appearance can be obscured. As exposure to manipulated features increases, patients can end up with a distorted ideal, opting for treatments which take them further and further from their original features.
In my clinic, alongside their consultation, patients must complete a body dysmorphic disorder (BDD) questionnaire upon arrival, which helps to highlight any potential issues relating to anxieties surrounding appearance.6 Medical images of your patient should be taken and clearly stored in your patient notes for reference, primarily as a means of medicolegal
protection. Second, it documents the efficacy of a treatment, and images can be used as a reference for your patient who can forget how they looked prior.2,7
Pre-treatment considerations
It is imperative that patient safety considerations are discussed before and during elective dissolving. Local injections of hyaluronidase can cause side effects such as local pruritus, swelling and allergic reactions. The incidence of allergic reactions is reported to be 0.05% to 0.69%, and urticaria and angioedema have also been reported to occur at a low frequency.2 Allergy to hyaluronidase is reported as being from earlier bee/wasp venom sensitivity, or previous hyaluronidase treatment.8 In this instance, patients would be contraindicated to elective dissolving, and should be cautioned about any future dermal filler procedures.
Intradermal skin allergy testing (IDT) is prevalent in the practice of medical aesthetics, but is heavily debated in the literature in terms of the need and accuracy, so the decision to carry it out is dependent on the practitioner.9,10,14 Despite this, the Complications in Medical Aesthetics Collaborative (CMAC) does provide guidelines on how to carry out IDT, and the Aesthetics Complications Expert (ACE) Group World also recommends it.9,10 The test is often deployed as a method of ‘reassuring’ the practitioner that the patient will not develop anaphylaxis. Practitioners should be aware that most reactions to hyaluronidase are delayed type IV sensitivity reactions and may only present days after the test.9
It is my preference to perform IDT so that every possible step to highlight potential allergy has been made and is clearly documented. This is to reassure the patient and myself that I have tried to mitigate any risk. I carry out the test by injecting 0.02-0.05ml until a wheal (i.e. a bleb) is present, and marking around the bleb with a pen so I can visualise any possible reactions. It is also recommended by CMAC to inject a small control amount of normal saline approximately 2cm away and observe the patient for 20 minutes before taking any further action.9
It is worth noting that whatever the testing policy in your clinic, in emergencies such as vascular occlusion, the risks of delaying treatment outweigh the benefit of conducting such a test.10,11
Appropriate complications training is imperative before any clinician undertakes a dissolving procedure. They should ensure their emergency kit holds the clinical protocol for allergy management and anaphylaxis guidelines to ensure that in case of allergy, the patient can be safely and appropriately managed.
Emergency kits should include adrenaline 1:1000 (1mg/1ml), and follow the General Resuscitation Council Guidelines.12
Carrying out the dissolving
Following appropriate consultation, medical history, consent and possible testing, the patient can be prepared for elective dissolve. Most commercially available hyaluronidase brands consist of lyophilised powder, which can be diluted with both normal saline and bacteriostatic saline. The latter is preferred as this lends to a more comfortable injection.9 The most common hyaluronidase brand, Hyalase, comes as a dry powdered vial containing 1:500 units per ml. There are varying recommendations for how to reconstitute, and with which solution. A range of 1-10mls has been evidenced in clinical practice.8,9 In clinic, I find reconstitution in 2ml bacteriostatic saline has a desirable clinical outcome for elective dissolving.
It is important to consider that the higher the molecular weight, cross-linking and volume of hyaluronic acid in the product you are dissolving, the higher the required dose of hyaluronidase and the potential number of sessions.13 Doses should be titrated according to clinical effect.14 If the patient is unsure of what product was originally injected and at what volume, multiple appointments may be needed to complete the dissolving depending on response. A 2023 study into 18 varying dermal filler brands showed that all were dissolved with hyaluronidase within 32 minutes, thus evidence suggests most HA fillers will respond well to hyaluronidase.15
Prior to injection, the area should be inspected, palpated and clearly marked out. It should then be cleansed using a suitable skin solution, for example a hypochlorous solution like Clinisept+. Methods of delivery can vary, with larger treatment areas requiring delivery via cannula to enable larger disbursement and minimise needle entry points. For example, using a cannula to the mid-face and jawline may be preferable over the needling technique as it can be more comfortable in these large areas.10 For filler nodules or localised migration such as in the lip, it may be preferable to use more precise delivery via needle.10
In the event of a nodule, there may be resistance when injecting; however, it is important to try to penetrate the nodule to remove the filler successfully.8 All treatments with hyaluronidase, regardless of the method of delivery, should be massaged following placement to aid the mechanical breakdown of the filler and ensure the hyaluronidase is dispersed.8
A growing technique that should be considered for both administration of dermal fillers and dissolving is the use of
ultrasound. Ultrasound guided dissolving is particularly beneficial as you can target exactly where the dermal filler is in situ, ensuring more precise injections. However, safe performance of this method requires sufficient understanding of facial anatomy and how to interpret the ultrasound images. The use of topical applied hyaluronidase –Topilase – has gained popularity and can be beneficial for localised improvement of overfilling and Tyndall Effect in the tear trough region.16 This is a far less invasive choice suitable for practitioners to prescribe for minor corrections rather than complete dissolving.16 Patients can use the treatment at home a maximum of three times at three weekly intervals, depending on the amount of product which needs to be dissolved.16 It should be massaged vigorously into the skin for three to five minutes.16
Injectable hyaluronidase aftercare guidance should consist of immediate observation; asking the patient to wait in clinic for 30 minutes following treatment can be beneficial in terms of monitoring signs of reaction. Common reactions with hyaluronidase can be localised swelling, angioedema, bruising and less often anaphylaxis.17,18
Home care advice consists of analgesia if needed, keeping the area clean and using a cool compress for swelling and minor discomfort.15 Topical hyaluronidase does not require such stringent aftercare.16
Patients should be informed that whilst injectable hyaluronidase effects are immediate with a half-life of two minutes, peak effects can be seen around 24-48 hours, and they can continue to develop for up to two weeks after treatment.4 A review should be scheduled two weeks following the first treatment to ensure an appropriate response and to allow for further treatment if needed, or to begin the next stage of their treatment plan.15
Restorative treatments
In a recent study looking at post-dissolving skin, patients reported a negative effect on appearance after hyaluronidase treatment.18 This phenomenon is referred to in this study as ‘post-hyaluronidase syndrome’, which is defined as any of the following facial changes: hollowing of the facial tissues, loss of skin elasticity or discolouration of the skin.18,19 Indeed, following removal of fillers, the skin may show an appearance of looseness and loss of elasticity.19 A confounding factor is that natural age-related changes may have occurred while the filler has been in situ.19
Therefore, the importance of good skin health should be discussed, and I recommend that a medical-grade skincare regime be commenced before dissolving to
prep the skin and ensure the best possible results. Nevertheless, patients should be made aware of the possible need for careful refilling or other modalities that can help improve tissue quality, depending on the outcome of treatment. I find that options such as radiofrequency (RF) microneedling, polynucleotides or exosomes can be beneficial to restore skin health to its optimal state following the overfilling and dissolving process. These procedures can be commenced as early as two weeks after dissolving.
I favour an approach combining polynucleotides and RF microneedling. Polynucleotides work by stimulating fibroblasts, which encourages cell turnover, improves elasticity, boosts collagen production and hydrates skin with wound-healing polymers.16 They also calm inflammation and rebalance melanocyte activity to create an even skin tone.16 I find this works well to prep the skin before potential refilling. My product of choice is Plinest from Mastelli by DermaFocus. After the skin is primed with this, RF microneedling can be applied to increase collagen and elasticity. This works by providing a controlled, localised thermal effect on the dermis, triggering the body’s healing processes and inducing skin tightening.17 I prefer Morpheus8 from InMode, but of course, there are numerous other treatment combinations you could suggest to patients to rejuvenate their skin post-dissolving. It is essential that a plan is in place for further or alternative treatments before the dissolving is conducted, as this can help patients feel more in control of the process and meet their expectations clearly. Patients should feel heard and supported following the dissolving process.
Dissolving with caution
Practitioners need to be well equipped with managing patient expectations when offering elective dermal filler dissolving as demand for it continues to grow. We must offer clear education and support for our patients, not only from a medical procedural point of view, but also considering the impact dissolving can have on patients.
Tanya Albin has worked in the aesthetic field for 14 years, while also continuing to work in the NHS, background in acute care within A&E, theatres, ITU and prison nursing. She owns her own CQC-registered clinic in Canterbury, Kent.
Qual: BSC Adult Nursing, MSC Advanced Clinical Practice and BSC Non-Medical Prescribing
VIEW THE REFERENCES AT
Case Study: Multi-Modality Approach to Facial Ageing
Dr Priya Verma
presents her Highly Commended Aesthetics Awards full-face case study addressing facial ageing
Increasingly, we are approaching facial ageing concerns using a combination approach, with the understanding that ageing is occurring at multiple layers in the face.1 A comprehensive understanding of this layered arrangement of the face involving skin, subcutaneous fat, muscles, deep fat compartments, retaining ligaments and bone, should inform our approach to treatment.2
Treatments for facial ageing should consider the most effective way to bring about improvements in skin sagging and photodamage, restoration of fat pad volumes, correction of fat and bone atrophy and modulation of facial muscles.3,4 Combining aesthetic treatments, from injectables to energy-based devices, to target these different facial structures can lead to better results than just a single treatment modality alone.5,6 When patients present with clinical concerns that may be better addressed with a surgical approach, but are wholly against surgical methods, taking a non-surgical approach to treatment should involve comprehensive expectation management.
The following case study represents an example of multi-modality treatment in a patient who wanted strictly non-surgical treatment – something we see increasingly in practice.
Introducing the case study
My patient was a 53-year-old British female who was relatively treatment naïve, having only ever tried microneedling. She did not have any medical problems, other than being overweight. Her main concerns during the initial consultation included jowls causing blunting of the jawline, lip thinning and a gummy smile, all impacting her confidence. She was very open to receiving a full facial assessment and to be recommended holistic treatments to rejuvenate her entire face. She was ready to embark upon a skin transformation journey.
The patient was examined by eye, and it was noted that she had a Fitzpatrick skin type II, thick skin, even texture, sporadic solar lentigos and facial redness, excess adiposity in the nasolabial fat, jowls, submental and neck regions. She also had a retrognathic chin with loss of volume in the lips, coupled with overactive lip elevators causing excessive gingival show on smiling (Figure 1).
The patient was against surgical intervention at this stage in her life and preferred a less invasive option, thus we explored the non-surgical options together while having honest discussions about realistic treatment outcomes. I devised a multi-stage treatment plan, which would aim to address her primary concerns but also address skin quality which would further enhance her clinical outcome.
Two internal 1470 nm diode laser therapy sessions using Endolift were recommended, six to twelve months apart, for skin tightening and fat debulking in the nasolabial folds, lower face and neck, followed by injection lipolysis. Treatment with 2910 nm Erbium glass fractional fibre laser UltraClear was then suggested for resurfacing and improving skin tone. I advised neurotoxin into the lip elevators to relax the gummy smile, plus soft tissue fillers in the lips, jawline and chin to optimise balance in the lower face and give her more smile confidence. She understood results would take time and improvements would be progressive.
For every recommended treatment, my patient was informed of the mechanism of action, possible side effects and complications, downtime and aftercare during her detailed consultation. She was provided with written information and encouraged to take time to assimilate it prior to commencing treatment. We discussed the rare risk of motor nerve injury with Endolift in the lower face, occasionally leading to smile asymmetries, so she could schedule social engagements accordingly.7
Post-consultation, she was emailed the plan, and a cooling-off period was encouraged. After an 18-day consideration period, the patient decided to proceed.
Progressing with treatment
Since the priority was debulking and skin tightening in the lower face and neck, Endolift was the first step. This laser works by tunnelling an ultra-fine micro-optical fibre under the skin to generate heat which stimulates neocollagenesis, collagen remodelling and adipocyte cell disruption, resulting in firmer, tighter skin with reduction of unwanted fat.7
The skin was thoroughly disinfected, then anaesthetised for patient comfort using a 25ml mixture of 2% lidocaine and 0.9% saline injected under the skin. This method of subdermal infiltration is the accepted protocol for EndoliftX numbing, as it provides a sufficient dilution to numb a wider area than lidocaine alone.
The laser fibre was manoeuvred in a fan-like pattern across all segments of the face and neck, delivering both anterograde and retrograde pulsed laser energy into the subdermal and subcutaneous planes. A cross-hatching technique was employed, delivering thermal energy in a multi-directional manner, keeping speed of retraction slower to allow for greater heat generation and therefore lipolysis. A combination of fibre sizes was used, both 300 and 400 microns, varying the laser spot size and depth of laser energy penetration between areas. I find that the 300 micron fibre is great for light fat melting and skin tightening, while the 400 micron size has more thermal energy transmission to melt larger fat pockets. No special preparation was required prior to Endolift treatment.
One month afterwards, two sessions of injection using phosphatidylcholine lipolysis from SRS were used in the submental fat (0.1ml within each of the six injection points, per session) and the inferior jowls (0.1ml within each of the six injection points, per jowl, per session).
In the same session, two units of Botox per side were injected into the nasal alar, targeting the lip elevators (levator labii superioris alaeque nasi/levator labii superioris) to reduce the gingival show on smiling. Following this, 0.5ml of Juvéderm Volbella, a cross-linked hyaluronic acid filler, added subtle volume to the upper and lower lips, depositing linear threads of product, staying beneath the vermillion border to prevent risk of migration.
Six months later, a second Endolift session was performed together with the UltraClear laser within the same session (this is possible because the devices target different layers of the face). UltraClear works by exfoliating the epidermis through cold ablation, thereby improving photodamage and overall skin texture.8 Before the
procedure we had discussed skin preparation, i.e. avoiding sun exposure for four weeks prior.9 I applied 5% EMLA topically to the full face for 30 minutes prior to the treatment, and the patient experienced no pain whatsoever. Clear+ mode, a light resurfacing option with 40% coverage, one ring and depth of 50 microns, was used across the full face with feathering into the neck.
A month after this, her lower face definition was further enhanced using Juvéderm Volux, a high G prime filler designed for long-lasting structural support. I injected 2mls of Volux per side, fanning subcutaneously at the posterior jawline and mandibular angle, denoted by the anatomical locations JW1/JW2/JW3 as per the MD Codes.10 0.5ml of Volux was placed per side anteriorly in the jawline, code JW4, delivering linear threads subcutaneously. A further 1ml of Volux was used in the chin, code C2, using small subcutaneous micro-boluses, to project the pogonion of the chin. All filler treatment was delivered using either a 25G 38mm/50mm cannula, which I find, in my hands, delivers a better artistic result than a needle as it helps the product integrate better into the soft tissue.
Safety considerations
During this patient’s treatment journey with lasers and injectables, no side effects or complications were encountered. One of the possible complications from Endolift in the lower face and neck is heat-related irritation to the myelin sheath of the marginal mandibular branch of the facial nerve.7 This can cause a loss of inferolateral movement of the lower lip on the affected side from weakness of the depressor labii inferioris muscle.7 To avoid this risk, I meticulously mark out the surface anatomical landmarks for where the nerve becomes more superficial. I feel for the anterior border of the masseter to find the antegonial notch on the mandible, palpate the facial artery and mark 1cm above and below this as a no-go territory. I stay superficial with the laser to avoid deeper structures, and do not allow static firing of the laser energy.
With hyaluronic acid fillers, serious risks include vascular compromise, infection and nodule formation (inflammatory or non-inflammatory; early or delayed).11 These risks were mitigated by sound anatomical knowledge, avoiding vascular territories, thorough disinfection of the skin, aspirating and slow injecting, ending with post-treatment massage.11
After every treatment session, my patient was given both verbal and written aftercare instructions to optimise results. After Endolift, lymphatic drainage massage was demonstrated, which she was encouraged to do twice daily to facilitate clearance of melted fat through the lymphatics, through increasing blood flow.12 After the UltraClear laser, the patient was given a post-treatment pack to take home which contained a cleanser, petroleum jelly and moisturiser to lock in hydration, normal saline and gauze to cool the skin and Calecim Professional growth factor serum to facilitate wound healing. She was given my mobile number and instructed to send daily photos and symptom updates for the first 10 days so I could closely monitor her recovery and identify complications such as viral or bacterial infections early.
Post filler treatment, the patient was advised to massage the lips, chin and jawline twice daily for five days to allow even distribution and prevent nodules.11 She was advised to contact me any time in case of any signs of vascular compromise. I saw her again at one-, three- and six-months post-lasers; a two-week review was offered after Botox for any adjustments; and fillers reviewed at four weeks once fully settled.
The results
The patient reported her treatments as having been ‘life-changing’. Formal examination of her final result reveals significant volumetric reduction in the fat within the nasolabial fat compartment, jowls, submental and anterior neck regions (Figure 1). The body of the
upper lip has been subtly everted and volumised, with the oral commissures no longer being predominantly downturned but instead at a neutral position. The retrognathic nature of the chin has vastly improved with more anterior projection and elongation, thereby improving her appearance in profile. The jawline is more defined from the debulking, tightening and contouring effects. The overlying skin has benefited vastly from improved skin tone, with less vascularity and hyperpigmentation.
The patient looks healthier, younger and happier. I observed that with every passing visit to the clinic, she walked in with more confidence and her head held high, completing the goal of the ultimate holistic result.
The era of the holistic approach
When presented with clinical signs of ageing spanning multiple layers of the face, we must educate patients on the value of using a multi-modality approach, often built up across many months. Expectation management is of paramount importance when undertaking a complex non-surgical treatment plan, particularly when the most favourable approach would be surgery. We can safely and effectively combine injectables like soft tissue filler, injection lipolysis and neurotoxin with energy-based devices such as internal laser skin tightening and ablative laser resurfacing.
Dr Priya Verma is an aesthetic doctor at PHI Clinic in London, and a GP with a background in primary care research. Dr Verma is a key opinion leader and global faculty member for Eufoton, and is an international trainer for EndoliftX. Dr Verma is a passionate educator, training colleagues in laser skin tightening and speaking regularly at global conferences.
This case study was Highly Commended at The Aesthetics Awards 2024. Entry for the 2025 ceremony opens this month. Visit aestheticsawards.com to enter.
15 March 2025 Grosvenor House London
Figure 1: 53-year-old patient before and three months after full-face treatment. Images courtesy of Dr Priya Verma
SAY HI to
NUCEIVA® is indicated for the temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at maximum frown (glabellar lines), when the severity of the above facial lines has an important psychological impact in adults below 65 years of age.1
In a 150-day, multicentre, double-blind, controlled, single-dose Phase III study. Adult patients (n = 540) with moderate to severe glabellar lines at maximum frown as assessed by the investigator on the validated 4-point Glabellar Line Scale (0 = no lines, 1 = mild, 2 = moderate, 3 = severe), who also felt that their glabellar lines had an important psychological impact, were enrolled. Patients were randomized 5:5:1 to receive a single treatment (0.1 mL injected into each of 5 glabellar sites) of 20 U prabotulinumtoxinA (n = 245), 20 U onabotulinumtoxinA (n = 246), or placebo (n = 49). The primary efficacy endpoint was the proportion of responders (patients with a Glabellar Line Scale score of 0 or 1 at maximum frown by investigator assessment) on day 30. Responder rates for the primary efficacy endpoint were 87.2%, 82.8%, and 4.2% in the prabotulinumtoxinA, onabotulinumtoxinA, and placebo groups, respectively. The secondary endpoint was the proportion of responders (patients with a Glabellar Line Scale score of 0 or 1 at maximum frown by investigator assessment) on day 2 and day 150. In addition, another secondary endpoint was the proportion of responders (measured with a Subject Satisfaction Scale by subject assessment) on day 30.2 www.evolus-international.com
Prescribing information
NUCEIVA® (botulinum toxin type A) 50 Units powder for solution for injection. Before prescribing, please refer to the Summary of Product Characteristics (SmPC). Presentation: One vial contains 50 Units botulinum toxin type A produced by Clostridium botulinum. After reconstitution, each 0.1 ml of the solution contains 4 units. Indication: For the temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at maximum frown (glabellar lines), when the severity has an important psychological impact in adults < 65 years old. Administration: Intramuscular injection. Care should be taken to ensure not to inject into a blood vessel. Should only be administered by healthcare practitioners with appropriate equipment, qualifications and expertise in this treatment. Once reconstituted, Nuceiva should only be used to treat a single patient during a single session. Posology: The recommended dose after reconstitution with sodium chloride 9 mg/ml (0.9%) solution for injection is a total of 20 units divided into five injections of 4 units (0.1ml) each: 2 injections in each corrugator supercilli muscle and 1 injection in the procerus muscle. Botulinum toxin units are not interchangeable from one product to another. Doses recommended in units are different from other botulinum toxin preparations. Treatment interval should not be more frequent than every 3 months. In the absence of any undesirable effects secondary to the previous treatment session, a further treatment session with at least a three-month interval between the treatment sessions is possible. Efficacy and safety of repeat injections beyond 12 months has not been evaluated. Special populations: Not recommended in patients > 65 years old. Contraindications: Hypersensitivity to the active substance or to any of the excipients (contains human albumin). Generalised disorders of muscle activity (e.g. myasthenia gravis, Eaton Lambert Syndrome). Infection or inflammation at the proposed injection sites. Warnings & precautions: Injection into vulnerable anatomical structures such as nerves and blood vessels must be avoided. Caution should be exercised when Nuceiva is used in patients with bleeding disorders, if complications have resulted with previous botulinum toxin injections and when the targeted muscle shows weakness or atrophy. Risk of eyelid ptosis following treatment. Procedure-related events: Needle-related pain and/or anxiety have resulted in vasovagal responses, including transient symptomatic hypotension and syncope. Pre-existing neuromuscular disorders: Patients with unrecognised neuromuscular disorders may be at increased risk of clinically significant systemic effects, including severe dysphagia and respiratory compromise from typical doses of botulinum toxin type A. Hypersensitivity reactions: Anaphylactic reaction may occur after injection of botulinum toxin. Epinephrine (adrenaline) or any other anti-anaphylactic measures should
ACTS IN 2 DAYS2
At day 2, the percentages of responders in each of the Nuceiva®, onabotulinumtoxinA and placebo groups were 54.2% (130/240), 57.0% (139/244), and 12.2% (6/49), respectively. The test of superiority of Nuceiva® vs placebo was highly statistically significant: the absolute difference in the percentages of responders was 41.9% (p < 0.001).
LASTS UP TO 4 MONTHS1
Nuceiva® injections significantly reduced the severity of glabellar lines by 1 point or greater at maximum frown for up to 139 days, as measured by the investigator assessment of glabellar line severity at maximum frown.
HIGH PATIENT SATISFACTION
91.3%2
Proportion of patients with at least a 1-point improvement on the subject satisfaction scale (SSS) at day 30 (i.e., a score of 1 [satisfied] or 2 [very satisfied]). The percentages of responders in each of the Nuceiva®, onabotulinumtoxinA and placebo groups were 91.3% (219/240), 86.6% (213/246), and 6.3% (3/48), respectively. The test of superiority of Nuceiva® vs placebo was highly statistically significant: the absolute difference in the percentages of responders was 85.0% (p < 0.001).
therefore be available. Local and distant spread of toxin effect: Adverse reactions possibly related to the spread of toxin distant from the site of administration have been reported with other botulinum toxins. Patients may experience exaggerated muscle weakness. Swallowing and breathing difficulties are serious and can result in death. Use not recommended in patients with a history of dysphagia and aspiration. Pregnancy and lactation: Not recommended during pregnancy or lactation and in individuals of childbearing potential not using contraception. Undesirable effects: The most commonly reported are headache, eyelid ptosis, application site bruising, influenza like illness, injection site bruising, injection site pain and injection site swelling. Serious undesirable effects that may occur include eyelid ptosis, an immune response, distant spread of toxin, development or exacerbation of a neuromuscular disorder and hypersensitivity reactions. For full list of side effects, consult SmPC. Legal category: POM List price: 50 Units powder for solution for injection per vial: £75.50 MA number: PLGB 55681/0002 MA holder: Evolus Pharma B.V. Apollolaan 151. 1077 AR Amsterdam. NL. July 2023 | UK-NUC-2300239
Adverse events should be reported.
Reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search MHRA
Yellow Card in the Google Play or Apple App store. Adverse events should also be reported to Evolus International Ltd at medicalinformation@evolus.com or 08000541302.
REFERENCES
1. Nuceiva® SmPC, July 2023
2. Rzany B. et al. A multicenter, randomized, double-blind, placebo-controlled, single-dose, phase III, noninferiority study comparing prabotulinumtoxinA and onabotulinumtoxinA for the treatment of moderate to severe glabellar lines in adult patients. Aesthet Surg J. 2020;40(4):413-429
A summary of the latest clinical studies
Title: “Filler-Associated Acute Stroke Syndrome”: Classification, Predictive Modelling of Hyaluronidase Efficacy, and Updated Case Review on Neurological and Visual Complications
Abstract: This study synthesises information on central nervous system (CNS) complications post-filler injections, and evaluates the effectiveness of hyaluronidase (HYAL) treatment. A thorough search of multiple databases, including PubMed, EMBASE, Scopus, Web of Science, Google Scholar and Cochrane was performed. The analysis integrated findings from 20 reviews and systematic analyses, with 379 cases reported since 2018. Hyaluronic acid (HA) was the most commonly used filler, particularly in nasal region injections. The average age of patients was 38, with a notable increase in case reports in 2020. Initial presentation data revealed that 60.9% of patients experienced no light perception, while ptosis and ophthalmoplegia were present in 54.3 and 42.7% of cases, respectively. The statistical and machine learning analyses did not establish a significant linkage between the HYAL dosage and patient recovery; however, the injection site emerged as a critical determinant. The study concludes that HYAL treatment varies in effectiveness based on the injection site and the timing of administration. The non-Newtonian characteristics of HA fillers may also affect the incidence of complications. The findings advocate for tailored treatment strategies incorporating individual patient variables, alongside prompt and precise intervention.
Title: Comparison of the Effect of Intradermal Injection of Botulinum Toxin and Normal Saline in the Treatment of Facial Skin Pores
Authors: Pazyar N, et al
Published: Journal of Family Medicine and Primary Care, July 2024
Keywords: Botulinum Toxin, Facial Pores, Normal Saline
Abstract: Skin pores (SPs) are normal and benign skin structures that are mostly located on the face (nose, cheeks, etc.), but can cause aesthetic concerns or complaints. Known effective treatments of large SPs include botulinum toxin A (BTXA) and normal saline serum (NSS). Randomly, out of 25 subjects, some were injected with botulinum toxin at ten points, and each point was equivalent to 2.5 units of Masport (500 units vial of Masport diluted with 10 ml of NSS). Some other people were injected with 0.05 ml of NSS by intradermal injection at ten points. Based on optical coherence tomography results, it was determined that the diameter of facial pores decreased significantly. Dermoscopy showed a significant decrease in the average size of facial pores, and also, the pore score decreased significantly. In addition, the results showed that the size of skin pores and facial fat on both sides of the face did not decrease significantly from the patients’ point of view. Based on the results of the present study, it can be concluded that intradermal injection of botulinum toxin is an effective and safe method to control facial pores, which showed acceptable results after three months.
Title: Optimal Practices in the Delivery of Aesthetic Medical Care to Patients on Immunosuppressants and Immunomodulators: A Systematic Review of the Literature
Abstract: This review seeks to determine the physiologic responses of immunocompromised patients, with regards to outcomes and potential complications, following non-surgical aesthetic procedures. A comprehensive systematic review of the literature was performed to identify clinical studies of patients who had undergone non-surgical aesthetic procedures while immunosuppressed. 43 articles reporting on 1690 immunosuppressed patients who underwent filler injection were evaluated, of which the majority (99%) were HIV patients, while the remaining eight were medically immunosuppressed. The complication rate of filler in this population was of 28%, with subcutaneous nodules being the most frequently reported adverse event. The authors conclude that patients on immunomodulatory medications may be at increased risk of filler granuloma relative to the general population, while patients on immunosuppressants may be at increased risk of infectious complications. Rudimentary guidelines for optimal pre-procedural patient assessment, aseptic technique, injection technique and finally anti-bacterial and anti-viral prophylaxis are reviewed. Ongoing advancements in our understanding of the mechanisms underlying these inflammatory processes will undoubtedly optimise management in this patient population.
Title: Exploring the Potential of Omega-3 Fatty Acids in Acne
Patients: A Prospective Intervention Study
Authors: Guertler A, et al
Published: Journal of Cosmetic Dermatology, July 2024
Keywords: Acne, Diet, Omega-3
Abstract: Omega-3 fatty acids (ω-3 FA), eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), are essential nutrients known for their anti-inflammatory properties, which involve reducing pro-inflammatory cytokines, eicosanoids and insulin-like growth factor-1. This suggests their potential to alleviate acne severity, especially when deficits are present. Over 16 weeks, 60 patients without prescription medication adhered to a Mediterranean diet, incorporating oral algae-derived ω-3 FA supplementation. At four visits (V1-V4), blood EPA/DHA levels were tracked using the HS-omega 3 index, alongside clinical assessments and standardised questionnaires. At baseline, 98.3% of patients had an EPA/DHA deficit, with the mean HS-omega 3 index rising from 4.9% at V1 to 8.3% at V4 AC showed significantly higher indices than AP at V4. Objective improvements in both inflammatory and non-inflammatory lesions were observed. While self-reported appearance worsened in four patients, overall quality of life improved, particularly in AP. Dietary triggers were more clearly defined than beneficial foods. To conclude, many acne patients have a ω-3 FA deficit. The HS-omega 3 index can be increased by a Mediterranean diet and oral supplementation with algae-derived ω-3 FA. Acne severity improved significantly in patients with target ω-3 FA levels.
Strategically Targeting Your Company to a Specific Age Demographic
CEO of pharmaceutical company Evolus David Moatazedi discusses the rationale behind marketing your brand to millennials
David Moatazedi has served as the Evolus president, CEO and member of the board of directors since May 2018. During this time, the company launched botulinum toxin Nuceiva, and is due to release dermal filler range Estyme to the UK market in 2025.
As of 2024, the brand has been identified as the fastest growing company in the medical aesthetics sector for the third consecutive year. Moatazedi attributes this success to the company’s focus on having a specific target market: millennials.
He explains that the origination of Evolus centres around the concept of ‘evolve with us.’ From the outset, the product was designed with a focus on the millennial generation. “This is because this demographic views aesthetics differently than their parents, seeing it as a beauty product rather than a clinical medical treatment. By targeting this younger audience, we saw a significant opportunity to differentiate ourselves from traditional medical companies,” he notes.
Here, he tells the Aesthetics Journal how the company curated and executed a campaign targeted to the millennial audience and advises on how aesthetic companies can grow to achieve business success.
Why the millennial market?
“Millennials, defined as those born between 1981 and 1996, are now the largest generation in the workforce and a critical market segment for many industries, including aesthetics,” notes Moatazedi. Indeed, with Evolus being a US company, millennials are set to overtake baby boomers as America’s largest generation, making them a crucial demographic for businesses to target.1
Evolus therefore identified and utilised this gap in the market, with Moatazedi stating, “While older generations might approach aesthetic treatments with caution, younger individuals are more open to these procedures. They view it as a normalised treatment, not a scary medical procedure. Research from the American Society of Plastic Surgeons shows that millennials are actually twice as likely as their parents to undergo aesthetic treatments.2 This shift can be attributed to changing perceptions and the normalisation of cosmetic enhancements through things like social media and celebrity endorsements.” So, for any aesthetic company, Moatazedi believes that focusing on this younger generation is a huge way to drive your growth and differentiate yourself from the rest of the market.
How do you create a non-traditional medical company?
Shake up your brand experience
To appeal to this younger demographic, Evolus aimed to create a company that diverged from the traditional medical model. “We developed a digital platform powered by engineers outside the aesthetic sphere, ensuring our technology was cutting-edge and user-friendly. Our design team focused on maintaining a consistent brand experience, ensuring the same vision whether we were targeting an investor, trader, doctor or consumer,” explains
Moatazedi. He believes that this approach works better than employing different agencies and creatives to target different audiences, as it helps to maintain a strong and consistent brand message. One study by Lucidpress found that consistent branding can increase revenue by up to 23%.3 “Consistency in branding is crucial for creating a memorable and trustworthy image. For Evolus, this meant ensuring that every touchpoint, from marketing materials to customer service interactions, reflected the same aesthetic and message,” he says.
What are your top tips for targeting millennials?
For companies looking to target millennials, Moatazedi provides his three top tips:
1
2 3
Simplicity: Be selective about what you offer. Millennials value simplicity and clarity in products and services.
Consistency: Maintain a consistent look and feel across all platforms. This helps build brand recognition and trust.
Authenticity: Ensure that your brand reflects your personality and values. Authenticity resonates with millennials, who are adept at spotting insincerity.
He emphasises that this doesn’t mean that nothing can ever change or develop. “Take Apple for example – of course the products look different today than they did 10 years ago. But is the essence of them the same? Absolutely. You need to stay true to your brand, but adapt it to the time period that you’re in,” he notes.
Create an inclusive campaign
Unlike many companies that prioritise the product before branding, Evolus reversed this approach. He explains, “Our branding and marketing efforts are designed to resonate with the energy and ethos of the younger generation, emphasising empowerment and inclusivity. Our models are diverse in age, skin tone and expression, reflecting a broader definition of beauty that includes tattoos, piercings and unique styles.” He adds that Evolus aims to represent a wide range of people that are reflective of society today. “We ensure that
It’s not necessarily about how old someone is –it’s the vibrant younger spirit and essence that will always be reflected in our marketing
our models are representative of real life – often in our campaigns they’re moving around, being expressive or being playful,” he notes.
Align with their values
Moatazedi adds that understanding the millennial demographic also involves recognising their high standards for corporate responsibility and ethical practices. For example, millennials are significantly more concerned with environmental, social and governance (ESG) factors than previous generations. According to Nielsen, 73% of millennials are willing to pay more for sustainable products.4 “Evolus has made a conscious effort to align with these values by moving away from animal testing where possible and adopting more sustainable practices. This not only enhances our relevance, but also solidifies our authenticity in the eyes of our target audience,” he says.
Employing millennial individuals
For companies looking to target the millennial generation, Moatazedi recommends hiring younger employees with different looks or skills that can introduce new techniques and perspectives, without undermining the foundation you’ve already built. “This approach fosters inclusivity and keeps your practice dynamic and relevant – don’t be scared to introduce something new,” he says.
How do you balance multi-generational appeal?
Moatazedi notes that while focusing on a younger demographic, it’s essential not to alienate older patients. He explains that the youthfulness represented is more about the energy and the feel of the brand than it is the age of the people depicted. “It’s not necessarily about how old someone is – it’s the vibrant younger spirit and essence that will always be reflected in our marketing,” he notes.
He adds that the company ensures its campaigns are full of personality, designed to evoke a ‘fear of missing out’ (FOMO) among an audience. “This approach not only attracts millennials, but also appeals to older generations who are curious about how younger people maintain their youthful appearance and how they can do the same,” he says. So, by integrating modern marketing strategies and diversifying the skill sets within your practice, you can also cater to a broader audience without losing your existing clientele.
How do you choose representatives that align with your brand?
When selecting brand representatives or key opinion leaders (KOLs), Moatazedi
explains that it's essential to consider not only their fundamental qualifications but also their alignment with your target demographic, especially if you're aiming to reach millennials. “This generation values authenticity and relatability, so it's crucial to choose individuals who can genuinely embody and convey your brand's ethos. Millennials appreciate energy and dynamism, and your representatives should naturally exhibit these traits in both their professional and personal lives,” he says.
He explains that of course, the must-haves for being a KOL include being scientifically rounded, understanding data and products, and being able to speak transparently and openly. However, the cultural elements are also incredibly important, he says, noting he always asks the question: are they open to doing something different to the norm?
“In the Evolus offices, people can express themselves having whatever hair colour they want, dressing how they want, wearing what makeup they want – they show up to work how they do in their personal environment. They are allowed to have their personality! It’s the same with our KOLs. They don’t have to be a mould of a company that they’re representing, we want them to come out of their shells and be themselves. Encouraging that individuality is very important to me,” explains Moatazedi.
He adds that again, this alignment ensures that the brand message remains consistent and impactful. “It's important to step back and evaluate whether potential representatives can authentically promote the youthful spirit and innovative approach your brand aims to project. By doing so, you enhance your brand’s connection with millennials, fostering trust and engagement,” Moatazedi concludes.
Creating a consistent brand message
Targeting your company to a specific age range, particularly millennials, requires a thoughtful and strategic approach. By understanding their unique needs and preferences, businesses can create compelling and authentic brands that resonate with this influential demographic. Moatazedi summarises, “At Evolus, our success in this area demonstrates the potential rewards of focusing on younger consumers while maintaining appeal to older generations. Evolving with the times and embracing innovative marketing strategies can help your company stay ahead in a competitive landscape. As millennials continue to shape the market, companies that prioritise simplicity, consistency and authenticity will be well-positioned to thrive.”
Creating Trust In Your Team
Business coach Kevin Riley advises on how to foster a trusting and consistent team environment
Without experience in the aesthetics sector, it can be viewed as a daunting realm to enter as an employee. The media would have outsiders believe the specialty fosters a sense of toxicity and unrealistic standards, and this is often a misconception that may put talented individuals off entering into the sector for career opportunities altogether.
As a business growth specialist, I’ve worked with business owners from global firms and small to medium enterprises (SMEs) operating in the British aesthetics sector, all of whom battle to overcome negative perceptions of their sector whether they directly relate to their own business or not. What is true for all of them is that trust and truth can be harnessed to create a successful and harmonious team culture. One that welcomes in new talent and retains valuable people who create success for the business.
Common misconceptions
From conversations with clients and new entrants to the field, some people see the specialty as solely concerned with outward appearance, neglecting the importance of wellness, self-care and confidence building. Thankfully, those with a true passion for becoming an aesthetics professional find
this the easiest of misconceptions to break through. The perception that the specialty offers limited career paths or is overly focused on trends raises concerns about a lack of opportunities for salary progression and investment in innovative treatments. There is worry that employees might be forced to prioritise the services a business wants to promote over what is best for the patient.
So, what part does trust and truth play in battling misconceptions? Imagine anyone booking an appointment without having had a previous positive experience or having been recommended by someone who has. You cannot sustainably grow a business without repeat business or referrals. And who builds the reputation of your business?
Your team
Talent in your team matters because without it, aesthetics businesses will not have happy patients providing positive reviews. Consistently happy patients can only be achieved by receiving the best standards of service from rigorously trained, accredited professionals retained in those businesses.
Recruiting the best people
From the outset, a team has to have clarity around what their values are and how they align with them as a group and as individuals. Quite simply, if there is not an alignment, individuals will not be able to work in the team or the business, so define your culture and values and recruit people who fit into them.
Values-based assessment tools include interviews, group activities (meet the team, meet the people who draw on our support), written or computer-based activities, scenario-based discussions and work observations. In fact, if you can demonstrate your culture and values to the outside world through your social media and to other stakeholders in the business, you are likely to attract the right people.
Things that destroy trust and how to avoid them
A big common mistake that destroys trust within a team is when we are not consistent. If a team experiences a consistent message and personality from their leader, this creates a safe environment for them to carry out their roles in a consistent fashion. It sounds simple but people in leadership roles have things impacting their daily lives that can create inconsistent energy and responses. Imagine not being confident to approach your team leader with an issue because you’re not sure if they will snap at you because their temperament is unpredictable. It takes a mindset shift to be a leader who creates trust through consistency. In its most simplest form, this means choosing to respond to your
Tips to create a trusting environment
Once you have formed a team you trust, what are you doing as a leader to provide the environment for them to deliver consistency? Here are four top tips:
1
Highlighting the legitimacy of your services and products: By clearly communicating the evidence-based approaches and medical standards you adhere to – even as early on as during the onboarding process and then throughout via regular team training – you can increase trust by emphasising the legitimacy and quality of your services and products. Ensure that all products come from reputable companies and highlight certifications and endorsements. This transparency reassures patients and team members about the integrity and reliability of what you offer as an employer and a business.
2
Implementing clear career progression pathways: Outline the potential for career progression from the outset by establishing a well-defined pathway within your business. This facilitates a sense of purpose and motivation among team members, demonstrating your commitment to their long-term growth and success. Regularly discuss and review individual career goals, providing guidance and opportunities for advancement.
colleagues as opposed to reacting without a thought of how your communication will be received.1
Delivering truth as a leader is also something that requires skill. Anyone can deliver a truthful conversation of facts and assessment within a business environment, not everyone can do it without causing offence or destroying trust in the relationship. Look at former Apple and Google executive Kim Scott’s feedback style of ‘radical candor’ where you can be truthful and specific but also be kind and sincere.1 For instance, a manager might say, ‘Your presentation yesterday lacked clear data to support your points, which made it hard for the team to understand your conclusions. I know you're capable of delivering great work, so let's review the data together before your next presentation’. This balance of direct feedback and personal care helps create a culture of trust and continuous improvement.2 Micro-management is another way to damage trust.2 Once a team member is
3
Open and honest communication:
Maintain an open dialogue with your team about challenges you may face. Actively involving your employees by seeking their input and opinions is a great way to create trust within the business – use this as an opportunity to create an open forum through regular feedback and creative sessions. This transparency builds a supportive and cohesive team environment, but also leverages collective insights to navigate difficulties effectively.
4
Engaging with associations: Involvement with medical associations or complications groups can further solidify your business’ credibility. An affiliation with these groups allows you to stay informed about the latest standards in the field, best practices and innovations. It also demonstrates to your team and patients that you are dedicated to maintaining high standards. Actively display accreditations in areas with frequent footfall, like reception areas, to ensure the affiliation is clear for all to see.
By implementing these strategies, you can foster a trustworthy and consistent environment where your team feels valued, motivated and aligned with the high standards that define the success or failure of your business.
trained, not giving them the space to fulfil their tasks can build resentment or break down confidence in the relationship. Think about how, as a leader, you can empower your team to take accountability for their role and only bring in increased levels of support in areas that need development. People take accountability when they are given the confidence to make decisions or provide solutions without fear of repercussions if those decisions are not always perfect. Remember, you may not be the right person to provide support if needed, so who is the expert in the team you could call on?
Continuing a trusting dialogue with teams
Trust is essential to create a long-term harmonious culture. There is a misnomer that if you tell people how they are performing, it will ruin trust. The key here is to have a conversation in person where information cannot be misread or misinterpreted by feeding through a third party. Having a truthful conversation can
create more trust if you first confirm that you know the facts and are having the conversation to help the individual. Stop if the conversation was aimed at asserting your dominance or getting what you want. Choosing what to address and considering its value to the business is important to benefit both you and your team.
Keeping trust high when regulation is low
The standards of qualification and training needed to work in a reputable medical aesthetic clinic are not widely known to the general public. Increasing trust in a broadly unregulated field requires a top-down approach from business leaders. As new people enter your team, stress the importance of being proud of their skills, the effort given to achieving qualifications and being confident to call themselves the best. In return, you will give them the tools, such as training or allocating a budget to fund their studies, to maintain or advance their expertise for the time they remain in the team.
Give your team the tools to become brand ambassadors, making it easy to share your clinic’s standards with friends, colleagues and patients. Not all of us are natural marketers or wordsmiths, so give them the key messages and selling points that they can put into their natural voice, and reiterate these if and when necessary to keep your key messages at the forefront of their minds.
The impact of a trusting team
When you have a team with trust at the heart of its culture, your patients will be able to see it and feel it. They will see your team enjoys being at work; they will experience motivated, happy people who deliver an exceptional service.
As a group and as individuals, a trusted team makes better decisions for the business and can even be entrepreneurial. They feel comfortable to work together to address challenges effectively or bring new ideas to the business, increasing efficiency and profitability.
Kevin Riley is founder of Coaching 360, a group of business growth services companies based in Warwickshire. His coaching and advice has helped hundreds of companies survive the pandemic whilst others have grown to sell for millions. His passion for business growth has led to him becoming an in-demand keynote speaker in the creative industries.
Optimising Your Aesthetic Practice With AI
Digital consultant Rick O’Neill explores how clinic owners can responsibly utilise AI to help scale their aesthetic practice
As the world of medical aesthetics continues to evolve, staying ahead in digital marketing is crucial. When the internet came along around 20 years ago, it revolutionised marketing. For example, the Yellow Pages – once a place where every business advertised – finally stopped its print edition in 2019. Online marketing has now taken its place, allowing more businesses than ever to tightly target their audiences.
Even now, new platforms and techniques to promote businesses are constantly emerging –TikTok, for example. In my opinion, artificial intelligence (AI) is a game-changer for promising efficiency and innovation in content creation and administrative tasks.
Using AI to generate content has gained mass appeal, with the likes of OpenAI’s ChatGPT-4 and Co-Pilot now embedded in Microsoft Office 365. Available in free and paid versions, these tools can easily churn out blog posts, social media content and marketing copy with ease – it is genuinely incredible to witness. For aesthetic practitioners, this proves beneficial as they can focus their attention on their patients and avoid spending their precious evenings writing copy. But of course, it all comes with a caveat. Originality in content will always win out.
Using AI in your practice
AI is a time-saver, whether used to simplify repetitive tasks or to handle ancillary jobs. However, as we navigate this new (and slightly scary) post-AI world, it is essential to balance the advantages of AI with a touch of realism and authenticity. Search engines such as Google have begun to scrutinise AI-generated content, giving preference to the human touch and pushing organic content to the top of their search results.1 Patients themselves are also becoming more aware of AI-generated content with the emergence of fake
I anticipate that many of the tools you use every day will increasingly feature an AI component
reviews and a lack of original content. The door is now open to outright fakery – for example, with AI you could craft yourself 100 fake excellent reviews in minutes (please do NOT do this – it HAS been done; you WILL eventually be found out, and Google could penalise or delist companies which appear to be automated).2
Microsoft called their AI ‘Co-Pilot’ for a very good reason. AI can assist, but it should not replace the genuine personal connection which your current and potential patients seek.
Nevertheless, here are just a few ways you can put AI to work in your practice.
AI imagery
AI-generated imagery is becoming increasingly popular in various specialties, including medical aesthetics. Tools like DALL-E 2 and MidJourney allow you to create customised images for marketing materials, social media posts and even website design. However, it is crucial to use this technology responsibly. Always ensure that the images are representative of your actual practice and treatments. Misleading visuals can damage trust and credibility. Additionally, always disclose when an image is AI-generated to maintain transparency with your patients.
Figure 1 depicts a website that my company designed using AI imagery for a clinic in Saudi Arabia. The models used are all AI-generated and do not exist in reality…
Social media and article writing
Social media works best when you create a constant drumbeat of interesting content for your audience. At times you will simply want to post pictures of your practice or comments from happy customers, but the foundation of great content is blogs, articles and thought pieces which show a little more effort. AI can help with this in two ways.
Figure 1: A clinic advertisement including AIgenerated imagery. Image courtesy of LTF Digital.
Firstly, AI is exceptional in playing a role as your ideas sidekick, suggesting content themes based on trending topics. In a matter of minutes, you can use AI with prompts like ‘What 10 things are people considering dermal fillers thinking about?’ This will create a pipeline of great article ideas which will resonate with your customers.
Secondly, of course, it can be used to create drafts of the articles themselves. However, it is essential that you, as the expert and the person whose name will ultimately be on the article, then refine it to ensure its relevance, authenticity and tone are right for you. This synergy between the efficiency of AI and the human insight and personality you bring is the way to elevate your practice’s online presence effectively.
Multi-platform content
Are you juggling Instagram, Facebook, TikTok, LinkedIn and your own website? Write your content just once and then repurpose original content through AI for the ideal length and format for your different platforms. You can do this by entering your content into an AI platform, then simply giving the software instructions on what length, format and style you want it repurposed into. This will optimise effectiveness and maximise reach without sacrificing the authenticity that builds trust and loyalty.
Email marketing and paid advertising
AI-driven platforms can analyse your patients’ data to personalise your marketing efforts, meaning you can target your patients with precision. It is crucial to note that using AI platforms can pose a General Data Protection Regulation (GDPR) risk when it comes to people’s data and personal details. 3 Any contact details or sensitive/confidential information should not be entered into standard AI sites. But never fear, more secure options are coming, such as Amazon Web Service’s new AI Data platform.4
By automating the mundane, practitioners can focus on crafting messages that resonate more effectively. This could be used to look up the past treatments of each patient, for example, and use that insight to make personalised recommendations or include relevant content on that basis. While AI can assist in drafting and personalising email copy, it can also help with building and sending emails through AI-powered email marketing platforms like Mailchimp and HubSpot. These platforms use AI to optimise send times, subject lines and content layout to increase engagement and conversion rates.5
Over-reliance on AI can also result in generic content that lacks your unique voice
Administration automation
From scheduling appointments to dealing with routine enquiries, AI can streamline your operations. This allows your team to dedicate their time to what matters most –patient care. Here are some specific ways AI can aid in admin automation:
· Appointment scheduling: AI can manage appointment bookings through chatbots and automated systems, reducing the workload on your administrative staff.
· Patient follow-ups: Automated reminders for follow-up appointments and post-treatment care can be managed through AI, ensuring patients receive consistent and timely communication.
· Billing and invoicing: AI can handle billing processes, sending invoices and managing payments, thereby reducing errors and ensuring timely transactions.
· Data management: AI can organise and maintain patient records, making it easier to access and update information as needed.
Again, GDPR considerations need to be at the forefront of your mind while implementing any form of data automation.3 This move from administration to service is not just about efficiency; it can genuinely make a difference to your profitability. The key is to implement these solutions without ever losing the personal touch that defines exceptional service. For example, bookings can be highly automated, but do not cut off your phone line completely! AI can put much more information (services, aftercare and product information) at a patient’s fingertips, but again, do not become out of touch. People still want to speak to their practitioner when they need reassurance.
Potential drawbacks of AI
Whilst AI offers numerous benefits, it is important to consider potential drawbacks. Patients may become sceptical if they can identify AI-generated content, leading to a loss of trust. Authenticity and personal connection are crucial in the medical aesthetics field. Over-reliance on AI can also result in generic content that lacks the unique voice of your practice.
To use AI responsibly, ensure that all content is reviewed and personalised to reflect your expertise and brand identity. Disclose the use of AI when appropriate and maintain transparency with your audience.
The future of AI in aesthetics
So, what have we learnt? The good news is that it’s nothing you didn’t know already. AI offers amazing efficiency, but it lacks the nuance of human interaction. We often want a human we trust to step in and help us when we have specific queries. Keep being you – integrate AI-generated drafts with personal stories or insights from your practice to ensure content not only reaches the target audience, but also connects with them. AI presents a frontier of possibilities for aesthetic practices. It promises tools to revolutionise your marketing and operations, and trends suggest an ever-deeper integration of AI into practice management and patient engagement. I anticipate that many of the tools you use every day will increasingly feature an AI component, allowing you to put AI to work in simplifying complex and repetitive tasks.
As we embrace this digital future, however, we must never lose sight of the human element that lies at the heart of the specialty. By blending AI’s efficiency with authentic personal engagement, we can harness the best of both worlds, ensuring our practices not only thrive but resonate deeply with patients.
AI won’t replace you, but a human who has mastered AI might!
Rick O’Neill is a digital consultant for the medical aesthetics, cosmetic surgery, and pharmaceutical specialties. He is also the author of Black Belt Digital, a book dedicated to growing an aesthetic clinic or medical spa. With more than 20 years of experience in digital marketing, O’Neill is the founder and owner of the awardwinning digital agency LTF Digital, which is based at Silverstone Race Circuit.
The Aesthetics Awards 2025 entries are opening in August!
The ‘Oscars of Aesthetics’ is back and entries are opening very soon. You must be an Elite member of Aesthetics to enter - subscribe today to start your entry. Become
In The Life Of
A lot of the patients I see at my complications clinic have been medically gaslit by their injectors who either tell them there’s nothing wrong, or they are making it up. It is a taxing part of my job, and it requires me to be on top of my game so I can bring about meaningful resolution for these compromised and damaged patients.
Complications management is proper medicine – it requires diagnostic skills, managing the patient in front of you and solving the sort of medical puzzles that we would usually do in other branches of medicine. It needs a multidisciplinary team and that is what I like about it. It is also hugely rewarding and a privilege to have the skillset to help.
Alongside this, I treat a whole scope of medical aesthetics, having been in the specialty for 14 years. I do a lot of regenerative treatments; biostimulators, polynucleotides, microneedling, lasers and peels feature very heavily in my treatment plans.
In The Life of Dr MJ Rowland-Warmann
Dentist and aesthetic practitioner
Dr MJ Rowland-Warmann shares a typical day pursuing her passion of treating and helping patients
A typical working day…
Most days I wake up between 5 and 5:30am and feed my army of cats – we have five! I then make breakfast and usually do yoga just to get myself in the mood for the day, as well get my body moving. My mornings are my productive time. I have a nice study that looks out onto the forest, and I like to get a couple of hours of work done before I go into Smileworks, my clinic in Liverpool. It takes me about half an hour to commute in, so I have a bit of time in the car where I get to think about things other than work, or prepare myself for the work day.
My day typically begins between 8:30 and 9:15am, dependent on whether I have an emergency patient to see in my complications clinic. When I arrive, I catch up with my practice manager and personal assistant, and debrief with my video creator regarding my online courses.
Our training centre, that hosts for Smileworks HUB and industry partners, offers courses on toxin, fillers and facial ultrasound. I used to only see a few complications a year, until COVID-19. Now, the number of complications I see has taken a dramatic uptake and I run it every week. I also have an ‘emergency sessions’ in my diary so if I have vascular adverse events that come in, they can be seen on a same-day basis or the following day.
Currently, my next available appointment for a non-emergency complication is almost eight weeks away which means I am often quite busy, but that’s not a terrible thing. I’m one of those people who has my schedule rigorously planned to a military standard, and I’m always going 100 miles an hour. And I like it!
It sounds bad, but I sometimes don’t have lunch, or I tend to keep my lunch light – a small sandwich or a salad – because I don’t like eating in the middle of the day, it’s just not my thing! But I’m a big coffee drinker, so I usually have that as a substitute.
When I get home, which varies from 5:30 to 8pm, I say hello to my cats and have a well-deserved sit down. In the summer months, I enjoy taking care of my plants and tending to my garden. I like to read before bed – I always have a book on the go as I’m not a great television watcher. That is really my wind-down time. The last book I read was Toni Morrison’s Beloved – it’s a moderately difficult read but it’s an extremely interesting book.
My hobbies are things that occupy my mind to such an extent that I cannot multitask, such as reading and flying planes. I find it useful to have these outlets where I can completely switch off from work. I take time off every four to six weeks to spend a week flying in Florida. It is one of those things where I must 100% focus on keeping myself alive so I can’t check emails and I can’t answer calls. And in any case, I am out of range and out of reception!
Other work commitments…
As a key opinion leader for Galderma, I love speaking about products that I am passionate about. I had the opportunity on behalf of Galderma to speak at ACE 2024 about their product portfolio and ultrasound, which features heavily in my treatment plans and my complications management life.
I speak at their training events, sharing knowledge about Sculptra and Restylane and I’m thrilled to announce I will be speaking for Galderma at CCR 2024 at the Aesthetics Journal Arena on October 11.
Most memorable day in aesthetics…
I do not think there has been one single, memorable day. There are many cases and interactions that are all equally memorable. It is a collection of memories that are all positive and have meant I have had immense pleasure in my job. It is the privilege of helping patients that really stands out to me.
What’s the best advice you’ve ever received?
It’s just a job. At the end of the day when you’re on your deathbed, you’re never going to think, ‘I wish I worked more.’
What’s your favourite film?
Event Horizon. When I tell people that they look at me as if I’ve got three heads but it’s my favourite.
Your chosen career if you weren’t a doctor?
I’d be a pilot – I might still do that in time.
Dr MJ Rowland-Warmann
Filler’s Place in Medical Aesthetics
Dr Tristan Mehta shares his thoughts on why dermal fillers still firmly belong in the world of aesthetics alongside other emerging treatments
It is undeniable that the treatment portfolio available to medical aesthetic practitioners has expanded dramatically in the past few years. With more and more options at our fingertips, some have said that dermal fillers (particularly hyaluronic acid fillers) are taking a back seat and may be eclipsed by other trending treatments like biostimulators and polynucleotides.
The British Association of Aesthetic Plastic Surgeons 2023 Audit revealed that the number of filler injections administered to female patients by members reduced from 3,100 in 2022 to 2,227 in 2023, while toxin injections reduced by only 200.1
However, I argue that this does not mean that filler procedures are a dying art. Dermal fillers are a core aspect of medical aesthetic practice, and when delivered by a highly-qualified medical professional, are an indispensable part of most holistic treatment offerings.
The origin of scepticism
There has always been some negative press around fillers. Members of the public and celebrities are quick to be named ‘botched’ if their filler looks a certain way. The products are often blamed for people looking ‘fake’, with terms such as ‘pillow face’ and ‘duck lips’ becoming widespread in discussions on the topic.
Post COVID-19, I saw a boom in patients requesting injectable treatments, especially fillers. Many of these patients were treated with a full-face approach as they became more conscious of their facial appearance, using fillers for every indication. I think this resulted in some people being over-treated with fillers, leading to unnatural results in some cases. After people became aware of this, there was some kickback towards fillers, as they were regarded as the culprit for such undesirable results. I feel that some people are still wary of the treatment to this day, even though most practitioners have become a lot more aware since then that, often, less does mean more when it comes to aesthetic injectables. At the same time, the media loves the opportunity for a new headline, so some of the newer treatments may have been getting more coverage than fillers, which are already well-established as a treatment option, pushing them to the periphery.
Working in synergy
Nevertheless, I feel that nothing will be able to replace the benefits of hyaluronic acid dermal filler. Filler is no longer being used to address every concern patients are presenting with as more treatment options gain popularity, but this change is more of a redistribution of procedures across different modalities, rather than necessarily a decline in fillers themselves.
Some practitioners and patients may be tempted to replace fillers with alternative treatments like polynucleotides, biostimulators or device treatments as they believe they have a lower associated complications risk. However, although these treatments can be extremely effective in terms of skin rejuvenation, I would say that when practitioners reach a certain level of expertise with fillers, it becomes clear that nothing can replace the deep volumising effects they provide.
Training to become an expert
I think we will see fillers becoming a more expert treatment in the coming years – which is what they always should have been. When we administer fillers, we are effectively injecting implants deep into tissues which carries some risk. I firmly believe fillers should only be carried out by people who really understand and are appropriately qualified in anatomy, physiology, rheology and other related subjects. This is about proper training and education. It’s not about learning how to inject over a weekend; the real goal is becoming a master in aesthetic practice.
One of my key philosophies is that you should to train become a specialist, not just a technician. Technicians will follow the manual, adhere to trends and be influenced by what is happening in the market. Specialists, however, understand this medical field from first principles. They can apply their true expertise to the patient’s subjective concern, developing an appropriate holistic treatment plan. In ageing patients, I find that this almost always includes dermal fillers.
An unparalleled option
I think dermal fillers will remain central in medical aesthetics, but the years have taught us that they need to be respected. They need to be delivered by medical practitioners with a high level of understanding and education of what products should be placed where. I think we will see a re-emergence of dermal fillers and a new-found respect for them. By adhering to stringent standards, as I have outlined here, we will be able to deliver vastly improved and far more natural results as we combine them with the rest of the modalities available within medical aesthetics.
Dr Tristan Mehta is founder and CEO of Harley Academy. He has more than 10 years’ clinical experience in medical aesthetics education. His time is split between clinical education, private practice at STORY Clinic London and managing Harley Academy. Qual: MBBS. BMedSci, PgDip (Aes Med)
Fillers are still the backbone of my clinical practice. I use them when I need to create volume such as deep in the temple or the mid-face, or to add structure and definition in the jawline. I would then use biostimulators more superficially to promote skin rejuvenation and a tighter skin envelope. I would also consider regenerative treatments like polynucleotides to further improve skin condition, such as under the eyes. Devices can have an amplified effect on skin results when combined with stimulatory injectables.
I do think combination treatments are really coming into play right now, and using treatments in synergy can drastically improve the level of results patients can expect. Without a doubt, this treatment approach includes dermal fillers where appropriate. They just cannot be replaced.
Dr Mehta will be speaking on medical aesthetic training at the Getting Started in Aesthetics Agenda at the In Practice Theatre on Friday October 11 at CCR 2024. Register free on p.34.
Transcending traditional lasers, harnessing the synergy of the unique powerful trio: CO2 Laser
A SCULPTING MAESTRO FOR DRAMATIC RESURFACING 1570nm Laser
BOOSTS COLLAGEN FROM WITHIN FOR LASTING REJUVENATION
