NOVEMBER 2024: Upper and Mid-Face

THE UPPER AND MID-FACE ISSUE November 2024 | VOLUME 11 - ISSUE 12

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CPD: Optimising Botulinum Toxin Results Dr Nestor Demosthenous reviews facial botulinum toxin pharmacodynamics

Special Feature: Lifting The Cheeks With Dermal Filler Approaches Selecting Injectables for Treatment of the Upper and Mid-Face

ALSO IN THIS ISSUE

Dr Karla Murta explores avoiding upper and mid-face complications Dr Andrew Cooney and aesthetic nurse Olivia Day discuss annual appraisals

one product, many possibilities Sculptra stimulates collagen type I and improves skin quality for firmer, glowing skin for up to 2 years.1-3

Patient was treated with three sessions of Sculptra at six weekly intervals by Michelle Mclean, Aesthetically You.

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Individual results may vary.

All rights reserved. Permission sought to use patient’s images.

References: 1. Bohnert K, et al. Plast Reconstr Surg. 2019;45(5):718–724; 2. Fabi S, et al. Poster presented at the International Master Course on Aging Science (IMCAS) World Congress.

26–28 January 2023. Paris, France; 3. Goldberg D et al. Dermatol Surg. 2013;39(6):915-922.

Adverse events should be reported.

For the UK, Reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for Yellow Card in the Google Play or Apple App Store.

For Ireland, Suspected adverse events can be reported via HPRA Pharmacovigilance, Website: www.hpra.ie;Adverse events should also be reported to Galderma (UK) Ltd, Email: Medinfo.uk@galderma.com Tel: +44 (0) 300 3035674 UKI-SCU-2400058 September 2024

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Contents • November 2024 08 News

The latest product and specialty news

19 News Special: New Safety Guidelines

Aesthetics reports on JCCP guidelines after non-surgical BBL death

CLINICAL PRACTICE 21 Special Feature: Lifting the Cheeks with Dermal Filler

Three practitioners highlight their approach to using hyaluronic acid in the mid-face

25 The Rise of Undetectable Dermal Fillers

Natali Kelly shares how Revanesse is the perfect partner for natural-looking artistry

26 The Future of Medical Aesthetics Presented at CCR 2024 CCR returned bigger and better than ever for its 2024 edition

News Special: New Non-Surgical BBL Safety Guidelines Page 19

30 The Biggest Aesthetics Innovations of 2024

Discover the latest innovations that were unveiled at CCR

37 CPD: Optimising Facial Botulinum Toxin Results

Dr Nestor Demosthenous explores botulinum toxin pharmacodynamics

41 Selecting Injectables for the Upper and Mid-Face Dr Carol Mastropierro discusses the best injectables for optimal treatment

45 Avoiding Upper and Mid-Face Complications

Dr Karla Murta explores complications and techniques to mitigate risks

49 Case Study: Treating Periorbital Veins with Laser

Practitioners discuss the use of vascular laser to treat veins around the eyes

52 Treating the Male Periorbital Area Dr Kam Lally outlines treating the periorbital area using dermal fillers

54 Management of Nodular Complications

Dr Laila Hassan investigates toxin-induced nodular complications

56 Case Study: Treating Rosacea Using a Novel Laser Device Charlotte Guest discusses treating rosacea with Asclepion Laser

57 Abstracts

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

IN PRACTICE 58 Understanding Your Revalidation

Dr Andrew Cooney and Olivia Day discuss how to approach your annual appraisal

60 Debunking the Myths of CQC Registration

Niamh Curley and Michelle Cook simplify CQC registration

62 Keeping Up With The Latest Aesthetics Trends

The UK’s top clinic groups share insights into what patients are thinking

64 In The Life Of

Aesthetic practitioners discuss a typical day using Allergan Spark

65 In Profile: Dr Pamela Benito

Dr Pamela Benito shares how childhood dermatitis inspired her aesthetics career

66 The Last Word

Dr Kamran Amjed encourages practitioners to screen patients medically as well as cosmetically

NEXT MONTH: REGENERATIVE MEDICINE • Polynucleotides for the Intimate Area • PRP for Hair Loss • Post-Hyaluronidase Syndrome

Special Feature: Lifting the Cheeks with Dermal Filler Page 21

Clinical Contributors Dr Nestor Demosthenous obtained his medical degree and BSc Hons Neuro from the University of Edinburgh in 2006, and his MSc in Aesthetic Medicine with distinction from QMUL in 2019.

He is a an Allergan Medical Institute Faculty member, and is actively involved in clinical research.

Dr Carol Mastropierro is an aesthetic doctor and owner of WRINKLESS in Stevenage, Hertfordshire. As a clinical trainer in injectables and cosmetic dermatology for Harley Academy, she is dedicated to enhancing learning and setting high standards, while delivering exceptionally natural results.

Dr Karla Orsine Murta Dias is an aesthetic practitioner and clinical trainer at Harley Academy. She is the medical director at Dr Karla Clinic, in Marylebone, London. She also works as an ophthalmologist at Moorfields Eye Hospital NHS Foundation Trust.

Dr Murta is dedicated to advancing the field through research, education and patient care.

Dr Massimiliano Cariati is a consultant oncoplastic breast surgeon and aesthetic doctor, with an award-winning research background. He has a specialised interest in facial and body rejuvenation, and in the use of novel surgical and non-surgical technology and devices.

Dr Tatiana Lapa is an aesthetic practitioner and founder of Drs Tatiana and Rishi Advanced Aesthetics. She is an international key opinion leader for dermal fillers, as well as for energy-based devices.

Dr Rishi Mandavia is an ENT Surgeon with a specialist interest in facial plastic surgery. He is the managing director of Drs Tatiana + Rishi Advanced Aesthetics Clinic in London.

Dr Kam Lally graduated in Medicine from the University of Oxford and went on to complete an academic post with an honorary lectureship at the University of Leicester. He is a GP, medical director of Aestheticology Clinics UK, and global key opinion leader for Teoxane. He is also the Royal College of General Practitioners (RCGP) national aesthetic medicine lead.

Dr Laila Hassan is an aesthetic physician with 12 years of experience as a laser therapist and anti-ageing expert. She is the founder and CEO of Zee Aesthetic Clinic in Pakistan and serves as the director of education and development for the American Board of Laser Surgery (ABLS) in Pakistan.

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Editor’s letter Regulation in medical aesthetics has been a huge focus this past month, and rightly so. After a Parliamentary debate last month, the Scottish Government has confirmed that regulation of the aesthetics sector will be implemented by April 2026. We are yet to hear from the UK Government following their Shannon Kilgariff consultation on the licensing of non-surgical Editor & Event Manager cosmetic procedures in England which was @shannonkilgariff held at the end of last year, but their response is expected to come any time now. As always, here at the Aesthetics Journal we will be following this closely and reporting the latest online and in the Journal. Naturally, the tragic death of a patient following a non-surgical Brazilian Butt Lift with dermal filler sparked extensive discussions on regulation during the Clinical Cosmetic Regenerative (CCR) Congress. New safety guidelines were highlighted in response to the incident, stressing that BBL procedures – whether involving fat transfers or dermal fillers – should only be performed by GMC-registered medical professionals within CQC-regulated settings. You can read our full report and understand the guidelines on p.19.

November’s issue of the Aesthetics Journal places a keen focus on enhancing the mid and upper face, two areas critical to rejuvenation.

This month’s CPD article takes a deep dive into mastering toxin injections, offering tips and insights that will help you refine your technique and deliver even better outcomes for your patients.

We also bring you a special feature on cheek augmentation with HA filler, exploring how to achieve a natural lift and contour that many patients seek. Well, we are now and truly in events season!

Throughout our news you’ll see our reports following some of the specialty’s recent events, which our team have attended. October saw another phenomenal CCR Congress, and on p.26 we reflect on the incredible success of the event. Our post-show report highlights the cutting-edge treatments, live demonstrations, and expert sessions that made this year’s congress unforgettable. There are plenty of events coming up in the aesthetics specialty, so please keep an eye out for our team and do say hello!

As always, we’d love to hear your thoughts on this month’s content.

Share your highlights on social media using #AestheticsJournal and tag us @AestheticsJournalUK. Don’t hesitate to reach out with any feedback or ideas for future collaborations via editorial@aestheticsjournal.com.

Clinical Advisory Board

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Leadership

Ms Nora Nugent leads BAAPS as new president

Talk #Aesthetics

The British Association of Aesthetic Plastic Surgeons (BAAPS) has appointed consultant plastic surgeon Ms Nora Nugent as its new president.

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#CCR2024 Julie Scott @nursejuliescott I presented at CCR on imposter syndrome and polynucleotides with DermaFocus, as well as participating in Meet the Mentor. Great week!

Ms Nugent has experience in both aesthetic and reconstructive surgery, serving as a consultant plastic surgeon since 2012. Previously, she held the role of vice president of BAAPS and is the current president of the European Society of Aesthetic Plastic Surgeons (ESAPS). Her areas of expertise include facial aesthetics, breast surgery and body contouring.

#Awards Dr Steven Liew @liewlift OMG I won the TAM Congress 2024 Academy Award! Massive imposter syndrome right now!

In her new role, Ms Nugent aims to build on BAAPS’s efforts in patient safety and education, emphasising international collaborations to enhance training standards.

She commented, “It is a pleasure and an honour to take over the presidency of BAAPS. As well as continuing our work on patient safety, I will also be focusing on the health benefits of aesthetics, BAAPS support development and continuing our international collaborations.”

Advertising

ASA rules against misleading sunbed advert

#BAMAN Harrogate Aesthetics @harrogateaesthetics What a brilliant day at BAMAN conference – full of networking, education and nurturing our community!

The Advertising Standards Authority (ASA) has ruled against a tanning salon which was advertising false information on the health benefits of tanning beds.

#Gratitude Dr Marc Pacifico @marcpacifico A big thank you to everyone who took part in the BAAPS conference this year – what a great success!

#Conference Dr John Quinn @quinnmedicineman Second Saturday speaking at a conference! Thank you Cutera for asking me to speak at CUCF!

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In May 2024, the salon in Plymouth published an advertisement entitled ‘Benefits of Tanning’, which listed ‘prepares skin for UV exposure prior to holidays’ and ‘maintains healthy vitamin D levels’ as reasons to opt for treatment. The ad also stated that tanning can help prevent ‘SAD, PMS and general depression’, alongside ‘skin disorders such as psoriasis and eczema’ and ‘osteoporosis’.

Two claimants challenged whether the advert contained misleading information about the health conditions listed, and if the ad was irresponsible because it linked claims for health benefits with the use of sunbeds.

The company stated that they were unaware the claims in question were problematic, and had been using them for years, believing them to be accurate. They provided links to websites which they said substantiated their claims, one being an at-home sunbed seller which said sunbeds could boost vitamin D levels. Another was a psoriasis charity website which stated some forms of UV therapy can aid psoriasis, but actually advised against the use of sunbeds.

The ASA ruled that marketers should not discourage essential treatment for health conditions for which medical supervision should be sought. It also said that the company did not have sufficient evidence to substantiate its claims, hence the advert must not appear in its current form, and all future ads cannot misleadingly or irresponsibly claim or imply that health benefits could be obtained from sunbeds.

Aesthetics | November 2024

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Conference

Allergan Aesthetics announced as Headline Sponsor for ACE 2025 Allergan Aesthetics, an AbbVie company will be taking over the main plenary at ACE 2025.

The company will be offering two days of exciting content to delegates that will include a series of live demonstrations delivered by its esteemed AMI Faculty, in addition to a deep dive into its other value-added services, such as Business Consulting, Spark and Medical Affairs, of which all aim to support aesthetic practitioners at every stage of their injector journey.

Djamshid Ghavami, general manager UK&I, said, “Our purpose is to empower confidence, and ACE gives us the opportunity to do just that, by offering all injectors from beginner to advanced the opportunity to upskill their injection technique and build their confidence in their own skills, whilst also learn about our latest technologies and products on the market.”

Regulation

Scottish Government confirms aesthetic regulation by Spring 2026

Vital Statistics Based on Google Search data across 70 countries, collagen filler leads cosmetic searches in 38 of 70 countries, representing 54% of searches (Healthnews, 2024)

Psychiatric illnesses are the leading cause of NHS staff absences, accounting for 25.6% of time off in December 2023 (Claims, 2024)

Out of 500 consumers across the UK, 76% believe aesthetic treatments are more accepted now than five years ago (Allergan, 2024)

In the UK, the number of men seeking cosmetic surgery surged by 118% from 2021 to 2023, including hair transplants, liposuction and rhinoplasty

After a Parliamentary debate, the Scottish Government has confirmed that regulation of the aesthetics sector will be implemented by April 2026.

In the session, the Government also committed to completing a consultation for new aesthetic regulation and publishing a report on the findings by this Christmas. The report will cover the issue of non-medics providing treatments without regulation, and the proposition of a minimum age to receive aesthetic procedures in Scotland.

Stuart McMillan, Member of Scottish Parliament for Greenock and Inverclyde, motioned the debate, and afterwards commented, “I was pleased to secure this Member’s Debate as with the growing popularity of medical aesthetic procedures comes a growing need to properly regulate their provision. This was first raised with me in 2018, so while it’s been a long time coming, it’s welcome that the Scottish Government is recognising this. The public consultation which is due to be published before the end of this year is a very important step in the right direction, ensuring that any regulation is as effective as possible, with a focus on fairness and patient safety.”

(Michael Saul, 2024)

In 2023, individuals aged between 20-39 accounted for about 30% of all noninvasive procedures (ISAPS, 2024)

Hamish Dobbie, managing director at DRVICTORIA Skin Clinic in Edinburgh and attendee of the debate, continued, “It was heartening to see the commitment from Jenni Minto [the Scottish Minister for Public Health] that her Government would implement new legislation in the parliamentary session to correct the issue of lay people providing aesthetic treatments without regulation. I felt the bipartisan support displayed in Parliament’s Chamber and the recognition of the need for urgent action were particularly promising.”

More details of the upcoming Scottish consultation are expected soon.

According to the BCAM annual clinical survey conducted from 2023 to 2024, 30% of BCAM members report receiving treatment reported from children under 18 years old (BCAM, 2024)

Aesthetics | November 2024

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Events diary 14 -15 March 2025 ACE 2025 th

th

Anthea Turner at CCR 2024 Television presenter Anthea Turner, known for various television shows, including Blue Peter, GMTV and The Perfect Housewife, spoke at CCR 2024 on behalf of Lynton Lasers. In an interview with the Aesthetics Journal, Turner shared her thoughts on the significance of speaking at events like CCR, emphasising how engagements foster networking and collaboration within the aesthetics field. Turner’s presence at the conference underscored the evolving relationship between celebrity influence and the aesthetics field, sparking vital conversations about best practices and specialty standards.

Aesthetic practitioners call for regulatory changes After the tragic death of Alice Webb following complications of a ‘liquid BBL’ performed by a non-medic, Bonnie-Louise Cooper shared her own experience of life-threatening complications following her non-surgical Brazilian Butt Lift (BBL) in November 2023. She appeared on This Morning to discuss her story. She was joined by Ashton Collins, director of the national cosmetic registry Save Face, and aesthetic practitioner Dr Manav Bawa, both of whom advocate for a ban on these treatments. The segment highlighted ongoing concerns about the safety of non-surgical BBL procedures and the need for increased regulation in the aesthetics specialty.

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RAMCE 2024 conference agenda revealed The agenda for the Regenerative Aesthetic Medicine Conference and Exhibition (RAMCE) 2024 has been unveiled.

29th March 2025 Welsh Aesthetic Conference

IN T H E M E D I A

Aesthetics

Regenerative Medicine

15th March 2025 The Aesthetics Awards 2025

What’s trending in the consumer press

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The conference, organised by aesthetic distributor DermaFocus, will take place on November 9 at Pullman London St Pancras, and provide updates on clinical research, investigations and case studies on regenerative medicine.

The company shares that talks will include molecular biologist Dr Nichola Conlon speaking on supplements, aesthetic practitioner Dr Olivia McCabe-Robinson on the merits of exosomes, aesthetic practitioner Dr Sarah Jenkins on polynucleotides for intimate health and nurse prescriber Frances Turner Traill on polynucleotide complications, plus much more.

DermaFocus executive director Milad Bemana said, “RAMCE 2024 is set to be even bigger and better than last year. As well as learning about the latest advancements in polynucleotides and exosomes, you’ll discover how to combine treatments with other modalities for optimal results, hear from expert speakers on their unique case studies and experiences, and meet innovative companies ready to support you on your regenerative aesthetics journey.”

Mental Wellbeing

New medical aesthetic mental health training established New mental health training scheme Your Mindful Mentor has launched in the UK. Michelle Overton, accredited counsellor and the company’s founder, explains that it’s offering a new course entitled ‘Understanding Body Dysmorphic Disorder in Aesthetic Medicine’. The training is designed to educate practitioners on the best way to approach potential BDD patients through online sessions, a resource library and webinars, she says.

The CPD-accredited training has been endorsed by the BDD, because as Foundation.

The charity’s head of operations Kitty Wallace commented, “Our charity is committed to raising awareness and understanding of BDD, as clinicians, we know that you are highly likely to have interactions with vulnerable members of our community. We would like to thank you for your interest in BDD, and your active intention to best support your patients by increasing your understanding on the subject. We are delighted that Overton has developed this comprehensive CPD training on the subject.”

Devices

Merz Aesthetics unveils ultrasound technology Medical aesthetic and cosmetic treatment company Merz Aesthetics has announced the launch of Ultherapy PRIME. Ultherapy PRIME is an ultrasound technology designed to enhance non-surgical skin lifting treatments. It features real-time imaging, allowing practitioners to visualise skin and tissue layers, thereby targeting areas with higher collagen and elastin content. This capability aims to improve treatment precision, according to the company.

Merz Aesthetics shares that the system also offers a 35% larger screen and increased processing power, which could streamline workflows for aesthetic professionals.

Bob Rhatigan, CEO of Merz Aesthetics, commented, “The launch of Ultherapy PRIME demonstrates our commitment to persist in innovation. As the leader in non-invasive lifting, we’re excited to bring Ultherapy PRIME to our customers as the next generation, premier platform.”

Aesthetics | November 2024

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Conference

Opportunity opens for ACE 2025 business speakers The call for papers to speak on business-related topics at the Aesthetics Conference & Exhibition (ACE) 2025 is open now.

ACE is accepting applications for In Practice Theatre speakers, covering a huge range of potential topics including marketing, finance, insurance, business planning, social media, employee wellbeing, mental health, regulation and so much more.

Shannon Kilgariff, editor and event manager at Aesthetics, commented, “With the In Practice Theatre content being a roaring success at CCR 2024, we cannot wait to put on yet another excellent agenda for ACE 2025. Our visitors often tell us that CCR and ACE’s business talks are hugely useful for business growth and specialty insights, so if you feel you have a unique perspective on the field and want to share that learning with your peers, we want to know!”

To submit your abstract to speak at ACE 2025, fill out the form at aestheticsconference.com before November 29, 2024.

Research

Allergan Aesthetics releases report on patient individuality Pharmaceutical company Allergan Aesthetics has worked with specialty leaders and the public to put together the ‘Decoding the Future of Aesthetic Individuality’ report.

The company shares that the report dives into how factors ranging from biology and culture, to technology and social media, can impact people’s sense of individuality. The report states that the idea of individuality is deeply rooted in an evolutionary impulse to preserve our own species, but in times of struggle, individuals can lean towards conformity to solidify their place in certain social groups.

The company says in the report that aesthetic practitioners have an opportunity to encourage individuality in their patients and aid them in a journey of self-expression through personalised treatments. For practitioners, this means being a constant touchpoint for patients along their aesthetic journey, helping them feel supported in their right to aesthetic individuality.

Allergan Aesthetics interviewed a range of aesthetic leaders to gather their thoughts: Dr Jonquille Chantrey, Dr Mona Gohara, Dr Luiz Gustavo, Dr Kiyoko Kato, Dr Marco Antonio Correa Varella and more. The findings were presented on September 25 at Allergan Aesthetics’ ‘Decoding the Future of Beauty’ event.

Carrie Strom, global president of Allergan Aesthetics, shared, “Being inclusive of all people is one of our core principles. We believe in aesthetics for everyone. With that comes a relentless pursuit of new possibilities in medical aesthetics, driving innovation to new levels to tackle unmet needs for all individuals, and providing leading education to support practitioners in delivering this.”

Aesthetics | November 2024

BAMAN UPDATES CONFERENCE RECAP BAMAN’s annual Autumn Aesthetic Conference, held on September 26 and 27 in Birmingham, marked a significant milestone in the evolution of our association. We were thrilled to welcome 320 medical aesthetic nurses across the two days, and the feedback has been overwhelmingly positive.

One of the standout moments from this year’s conference was the first-ever attendance of the Nursing and Midwifery Council (NMC).

For years, BAMAN has advocated for the recognition of medical aesthetic nursing as a significant specialty, and the NMC’s presence at our event was a validation of that work. During the conference, Anna Trotter, assistant director for education and standards at the NMC, made a groundbreaking announcement regarding the long-anticipated changes to ‘remote prescribing’ in medical aesthetics.

The NMC has also invited BAMAN to collaborate on its 2025 review of its Code of Conduct, and to help facilitate discussions with our members on revalidation.

SPRING SYMPOSIUM 2025 Following our annual autumn conference, we are already gearing up for our fourth Spring Symposium! This is a star event in the BAMAN calendar, offering our most advanced members an invaluable opportunity to connect, learn and stay at the forefront of developments in medical aesthetics.

Tickets are on sale now on the BAMAN website at www.baman.org.uk or via the QR code below.

UPCOMING BAMAN EVENTS As we move through the autumn conference season, BAMAN will be represented at key events across the UK. We were happy to see many of you at CCR in October, and will attend the Aesthetic Nursing Conference and FACExpo this November.

We are also excited to be part of a special Dermatology Conference for aesthetic nurses in partnership with the British Dermatological Nursing Group (BDNG). This event, scheduled for November 23, 2024, will focus on critical dermatology issues faced by aesthetic practitioners.

Registration details are available on the BAMAN website and attendees will also receive one year’s free membership with the BDNG. This column is written and supported by BAMAN

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Professor Ofir Artzi Expert Insights Professor Ofir Artzi is a world-renowned dermatologist and founder of the annual SCARS Conference.

Here, Aesthetics finds out his top tips for executing a range of scar treatments, gathered during the recent Alma Academy 2024 in Pattaya, Thailand…

1. Why is treating scars so important?

Scars can destroy someone’s personal, social and professional life. They can be a permanent reminder of war injuries, horrific accidents, surgeries gone wrong and much more. Patients deserve to have their lives improved through scar treatment, not just saved.

2. How do you approach scar consultations?

I like to look at scars like they’re a picture or a landscape. I look at the colours, the textures, the elevations and depressions. For example, dark or blue-looking scar components can be traumatic tattoos, while the red parts are related to blood vessels. A red scar can be treated with vascular laser, and pigmented traumatic scars with picosecond laser. This approach helps me figure out how to navigate treating all scar components.

3. Why can different lasers be needed to address a scar?

Different lasers have different effects on the skin.

For example, non-ablative lasers stimulate elastin, improving the colour and texture of scars, while ablative lasers like CO2 boost collagen, making scars softer. Both elements are needed to truly treat a scar. This is why multi-platform devices like the Alma Hybrid laser represent advancement in scar remodelling, harnessing the power of both ablative and non-ablative wavelengths.

4. What is the best way to ascertain the ideal treatment protocol for a certain laser?

Consensus studies are definitely the gold standard here. Collaborative meetings and conferences are also a great place to discuss treatment plans and complex cases.

5. What does the future of scar treatment hold?

More and more people are realising that the earlier scars are treated, the better. Several studies have shown that lasers can up-regulate and optimise the level of special proteins such as HSP70 in the skin. While present, they will normalise wound healing and thus can reduce scarring. These studies and my experience suggest that starting laser on post-operative scars a maximum of four weeks post-surgery is optimal.

6. What is your biggest takeaway when it comes to treating scars?

I always say that behind every scar, there is a story that changes the life course of a human being. When you treat a scar, you treat a soul.

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Aesthetic Trends

Aesthetics Trends Report debuts at CCR 2024 The Aesthetics Trends & Product Launches Report 2024 was released at the recent Clinical Cosmetic Regenerative (CCR) Congress.

Alongside dozens of the newest products from the past year, the report features four of the top trends in aesthetics, shared by founder of RARE Consulting Ben Pask. He dives into medical aesthetics’ RSM specialisation, the future beyond injectables, concerns around cosmetic tourism and the growth of medical longevity.

Shannon Kilgariff, editor and event manager at Aesthetics, said, “This year has been particularly exciting, with breakthrough advancements in regenerative medicine, skincare and wellness supplements. We’re thrilled to present this annual report, offering a deep dive into the trends and products that will shape the future of patient care.”

You can read the report for free now at ccrlondon.com.

Symposium

Aesthetic Dialogue 2024 to take place at Prague Castle Aesthetic Dialogue 2024 will be held at the historic Prague Castle in the Czech Republic from November 8-9.

This symposium will gather leading experts in medical aesthetics, including anatomist Professor Sebastian Cotofana and aesthetic practitioners Dr Lee Walker, Dr Tapan Patel, Dr Roshan Ravindran, Mr Jeff Downie, Dr Monika Kavkova, Dr Jani van Loghem and Dr Kristina Davidovic. They will discuss crucial topics such as fillers, toxins, energy-based devices and exosomes.

The event will feature live demonstrations, cadaveric anatomy dissections and interactive panel discussions. With attendees from more than 30 countries, the symposium aims to facilitate collaboration and knowledge sharing among professionals in the field.

Dr Monika Kavkova, Aesthetic Dialogue founder and scientific committee director, commented, “The symposium is designed as a real dialogue between anatomists and clinical specialists. The concept is the only one of its kind in the world, where we offer the audience insight into the field from different perspectives.”

Device

Sofwave introduces full-body muscle stimulation Aesthetic device company Sofwave has launched its Pure Impact electric muscle stimulation technology.

The company explains that Pure Impact can be combined with the original Sofwave device to target skin laxity, muscle tone and firmness on the body. This works using wireless electrodes to deliver electrical pulses to the body, causing muscle contractions and stimulating nerve fibres to create toning effects, according to Sofwave.

Aesthetic practitioner Dr Munir Somji commented, “This revolutionary approach uses the explosive power of plyometrics to maximise muscle force development in minimal time. With the capability to utilise up to 16 synchronised electrodes, it delivers unparalleled muscle strengthening and toning results faster and more efficiently than ever before.”

Aesthetics | November 2024

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Skin Regeneration

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Business Security

Plasma device PlaDuo debuts in the UK New aesthetic device PlaDuo has launched in the UK. The company shares that the device utilises plasma technology to stimulate skin regeneration, tighten tissue and promote healing. The treatment combines nitrogen and argon gases, with the former being useful for skin tightening, wrinkles, pigmentation and melasma, and the latter shrinking sebaceous glands to reduce sebum production and acne visibility.

According to Acre Pharmacy, distributor of PlaDuo, the treatment can be combined with other modalities like microneedling to provide aesthetic and skin benefits.

Louise Johnson, head of devices and skincare at Acre Pharmacy, said, “We are absolutely thrilled to bring PlaDuo to the market because it offers a truly revolutionary approach to skin care, combining the power of both nitrogen and argon plasma to treat a wide range of skin issues. PlaDuo empowers individuals to achieve healthier, radiant skin. It’s exciting to offer a versatile, cutting-edge solution that blends aesthetic and medical benefits in one device, giving users the results they want with minimal downtime.”

Recruitment

New CEO joins Sinclair UK Aesthetic manufacturer Sinclair has welcomed new CEO Amber Edwards to its UK team.

Sinclair shares that Edwards has been working in sales and marketing across the pharmaceutical, aesthetics and device sectors in the UK and US for more than 25 years, so brings with her a wealth of experience.

Edwards shares, “I am thrilled to join Sinclair and to work alongside such a talented team to continue delivering innovative solutions for healthcare professionals and consumers in this rapidly growing category. With a scientifically differentiated portfolio, encompassing a broad range of products for skin rejuvenation and body contouring and a clear pathway for additional registrations in the US, Sinclair is well-positioned to become a global leader in medical aesthetics.”

This month’s newest clinic openings A round-up of the latest aesthetic clinics opening across the UK Aesthetic practitioner Dr Catharine Denning has opened the doors to her rebranded clinic Marylebone Skin in Heathfield. The treatments on offer include injectables, skin scanning, Sciton BBL HEROIC, longevity medicine, hormone replacement and more. The clinic also

Firebird data protection service launches Data protection service Firebird has been unveiled in the UK to provide support to aesthetic clinics.

The consultancy firm explains it has launched a dedicated service for aesthetic clinics and practitioners in the case of cyber attacks, personal data breaches, subject access requests, complaints and more. The company can provide data protection training, Data Protection Officer (DPO) services, emergency support and a general advice hotline.

Amber Badley, Firebird’s CEO and director of privacy management, commented, “Over the past seven years, Firebird has built a reputation for excellence and reliability in data protection. By providing dedicated services exclusive to the aesthetics sector, clinics can focus on their core services, confident that their data protection needs are in our expert hands.”

Skincare

The Skin Diary releases night cream Skincare service The Skin Diary has unveiled its new Night Repair Therapy cream.

The company shares that the product has been formulated by consultant dermatologists at the University of Manchester, with tests showing that the cream demonstrated repair of sun damaged dermal elastic tissue equivalent to that seen with retinoic acid.

Some of the cream’s key ingredients include bilberry extract which repairs skin damage through its antioxidant qualities, microdispersed aquose lycopene which is designed to improve the appearance of pigmentation and retinyl palmitate which can trigger cellular regeneration with long-term use.

Consultant dermatologist and founder of The Skin Diary Dr Clare Kiely commented, “Highly-acclaimed consultant dermatologists Professor Chris Griffiths OBE and Dr Tamara Griffiths have developed the Skin Diary Night Repair Therapy. Designed to regenerate and rebuild collagen and elastin in prematurely aged skin, the formula has been proven to the highest level of scientific evidence – double-blind, placebo-controlled clinical studies in human skin.”

features an educational suite for both patients and practitioners.

Nurse prescriber Joolia Gilvey has opened The Clinic at 10 St Martin at Palace Plain, Norwich. She shares that the clinic will be providing a range of injectable, skin and device treatments across four treatment rooms. The clinic is the first in Norwich to be offering the NeoGen treatment – the practice’s star treatment according to Gilvey.

Aesthetic practitioner Dr Javed Hussain has opened the third branch of his Neo-Derm clinic in Finchley, London. Dr Hussain says that the clinic will offer a range of treatments, including anti-wrinkle injections, fillers, RRS HA Long Lasting Skin Builder, chemical peels and the Lutronic Lase MD Ultra sub-ablative laser therapies for all skin types.

If you’re opening a new UK clinic soon, let us know at editorial@aestheticsjournal.com

Aesthetics | November 2024

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Charity

Transform Healthcare launches Electiva Foundation

14 & 15 March 2025 Business Design Centre, London

Event Spotlight: Allergan Aesthetics Headline ACE 2025 Djamshid Ghavami, Allergan Aesthetics, GM UK&I outlines what we can expect from Allergan Aesthetics at ACE Why did Allergan want to be Headline Sponsor at ACE 2025?

We were delighted to be offered the opportunity to become Headline Sponsor at ACE. ACE is a fantastic event, offering something for everyone, no matter where you are on your injector journey. Our purpose is to empower confidence, and ACE gives us the opportunity to do just that, by offering all injectors, from beginner to advanced, the opportunity to upskill their injection technique and build their confidence in their own skills, whilst also learn about the latest technologies and products on the market.

What can people expect from you at the event?

On our stand and during our live demonstration sessions we will showcase our global portfolio of brands including the Juvéderm® facial filler range, HArmonyCa™ and the body contouring solution Coolsculpting®.

In addition to our products, we are dedicated to offering value-added services that help build our customers’ businesses and drive the highest levels of clinical excellence and patient safety.

Our live demonstration sessions delivered by our market-leading Allergan Medical Institute will be interluded with demonstrations from the other value-added services we provide our clinical partners, which are designed to support aesthetic practitioners throughout their careers.

Our Business Consulting team, which is a paid-for service, will share how they accelerate our customers’ business growth to maximise their clinics’ potential.

Whilst Spark, by Allergan Aesthetics will demonstrate how they support the next generation of aesthetic professionals to build their skills and confidence through the provision of education, webinars, clinical and business support and access to world class resources. The Medical Affairs team will be present at the event to engage with healthcare professionals relating to scientific information and clinical data on the AA portfolio.

What are you most excited about for ACE? We are excited to be taking over the main plenary and offering two days of exciting content to delegates, which we believe will truly inspire injectors and advance their own skills in aesthetics.

Turn to p.34 to register now.

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UK medical aesthetic provider Transform Healthcare has launched the Electiva Foundation, a non-profit focused on delivering critical medical care in conflict-affected regions.

The CEO of Transform Healthcare Dr Sayani Sainudeen, and Mr Tony Veverka, CEO of Y1 Capital, have already facilitated the delivery of healthcare supplies to Gaza, Palestine. In Bangladesh, Electiva partners with the ABAM Foundation to provide clean drinking water, food relief and medical support for flood-affected communities.

Mr Mubashir Cheema, consultant plastic surgeon who is coordinating efforts in Gaza, commented, “The Electiva Foundation’s work is vital in regions where medical infrastructure is severely compromised. Their assistance allows us to provide life-saving care and supplies.”

Training

New Irish mentorship programme launches Aesthetic practitioners Dr Bonny Armstrong and Dr Jeremy Isaac have kickstarted the new Next Generation Aesthetic Mentorship Programme in Ireland.

The practitioners explain that the curriculum is split into four modules across four months, covering anatomy, facial ageing and the physiology of the mid-face, lower face and perioral regions. The sessions will include hands-on learning and assessment, with each delegate working with one live model per module.

They explain, “We are incredibly excited to bring to Ireland one of the first aesthetic mentorship programmes. It’s a proud achievement for us to establish a programme that not only provides hands-on training, but also guides and empowers practitioners to excel in their careers. We believe this mentorship will play a crucial role in shaping the future of aesthetics in Ireland.”

The upcoming Next Generation Mentorship dates in Belfast are for 2025: January 26, February 23, March 23 and April 27.

Conference

BAS releases details for 2025 conference The British Association of Sclerotherapists (BAS) has announced its 2025 Sclerotherapy Conference, scheduled for May 20 2025, at the Eton College Rowing Club, Windsor.

Attendees can expect CPD-accredited presentations from specialty experts, live demonstrations of varicose and thread vein treatments and opportunities to update their Basic Life Support (BLS) certification.

With approximately 50% of the population affected by thread or varicose veins and limited treatment options available through the NHS, this conference aims to serves as a crucial platform for practitioners to enhance their skills and share best practices.

Nurse practitioner and microsclerotherapy trainer Gaynor Hughes, commented, “This lively conference will have, for the first time, facial vein treatment using short wave diathermy in the live sclerotherapy demonstration sessions. Delegates will leave with practical ideas and advice easily implemented in their own clinics.”

Aesthetics | November 2024

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Conference Preview

IMCAS World Congress set to return to Paris

Insider News

In the new year, IMCAS will deliver invigorating lectures from internationally renowned experts, a wealth of cutting-edge advancements in techniques, approaches and procedures, as well as the latest products and devices to hit the market.

The 2025 scientific programme is overflowing with new topics like new data on exosome safety, biohacking, collagen regeneration with injectables and more! Alongside the fresh science, the classic IMCAS Signature modules will be returning, such as the renowned Anatomy on Cadaver course in which participants can watch live procedures with side-by-side cadaver dissections to see the anatomy in play.

The Live Augmented Surgery Course (reserved for board certified surgeons) is another surgical education and training opportunity that explores the fundamentals of underlying anatomy with updated tools and techniques, IMCAS explains.

The Global Market Summit is also returning – an IMCAS Signature event uniting all corners of the medical world, from physicians and leaders in the medical field, to entrepreneurs, start-ups and investors. The conference shares that its aim is to provide a plethora of networking and connection opportunities for its international attendees.

IMCAS Congress is to meet in Paris on January 30 to February 1 for its 2025 edition.

Taking centre stage at the Palais des Congrès in Paris, IMCAS has preparations well under way to deliver another edition of the world-leading congress to 18,000 members of the medical aesthetic community. The congress will provide learning on dermatology, plastic surgery and ageing science.

Collaboration

Roseway Labs and Cosmetic Courses partner to enhance training Aesthetics visited Roseway Labs, a compounding pharmacy, to find out more about its partnership with training provider Cosmetic Courses that aims to provide enhanced support for aesthetic practitioners in hormone imbalance management.

While being shown around the facilities, Aesthetics journalists learned that this partnership is designed to address key needs in the aesthetic field, including access to insurance, comprehensive training in menopause and expert compounding services, the companies explain.

Miriam Martinez Callejas, superintendent pharmacist and co-founder of Roseway Labs, explained how the pharmacy distinguishes itself from others by taking a holistic approach. “We collaborate with prescribers and focus on meeting patients’ individual needs, offering treatments that range from licensed medication to personalised, compounded solutions. At Roseway Labs, we believe that education and collaboration are key in transforming

As one participant notes, “Where else can you meet so much of the specialty in one single location?” With more than 350 exhibiting companies onsite, participants can benefit not only from the congress’s educational offerings, but also a variety of business prospects.

Considering attending IMCAS World Congress on January 30 to February 1, 2025? Visit the official IMCAS website at www.imcas.com to learn more. healthcare for women. Our partnership with Cosmetic Courses is supporting practitioners in both the aesthetics and medical fields to better support and improve the quality of life for women navigating menopause,” she states.

According to Roseway Labs, it maintains a robust quality management system that ensures safety and traceability throughout the compounding process. Each prescription undergoes a thorough review by a pharmacist, followed by meticulous formulation and final checks before dispatch. “Every step, from prescription approval to formulation and final dispatch, is meticulously recorded,” says Callejas, underscoring the pharmacy’s dedication to patient safety. The pharmacy specialises in women’s health, men’s health, dermatology, thyroid medication, low-dose naltrexone, longevity and wellness, nutritional support and treatments for hair loss. To further enhance its offerings, Roseway Labs has partnered with Cosmetic Courses to provide essential training for healthcare prescribers in menopause. This collaboration ensures practitioners receive comprehensive guidance on best practices and insurance coverage, allowing them to manage complex patient needs effectively.

Jim Savin, managing director at Cosmetic Courses, emphasised the importance of such collaborations for the specialty. Saban shared, “Our partnership with Roseway Labs is about ensuring that practitioners have a solid foundation. We provide comprehensive training, aligned with NICE guidelines, on managing hormone therapy and other aesthetic treatments.” Saban further noted, “Our collaboration extends beyond basic education – we move into more complex cases, helping practitioners manage challenging patient scenarios and medication requirements.”

According to the company, the collaboration aims to provide healthcare professionals – including nurses, doctors, dentists and pharmacists – access to specialised training and compounding services. As well as the tools necessary to provide safe, personalised treatments in field of medical aesthetics.

Aesthetics | November 2024

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Conference Report Alma Academy Thailand

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Exploring the Future of Devices at Alma Academy Thailand 2024 Aesthetics reports on the latest innovations unveiled at Alma’s seventh annual Academy in Pattaya, Thailand On September 26-29, aesthetic manufacturer Alma flew a group of UK practitioners and press to the idyllic seaside location of Pattaya in Thailand for the Alma Academy 2024.

The conference saw 340 practitioners from 33 countries gather to hear the latest on synergistic and advanced usages of Alma devices for a plethora of indications. This year’s event was also an opportunity to mark Alma’s 25th anniversary.

Lior Dayan, CEO of Alma Lasers, said, “Over the past 25 years, we’ve partnered with numerous clinics to advance the field of aesthetic treatments, consistently delivering clinically proven, high-value solutions that ensure exceptional patient experiences. Together with our partners, we will continue this legacy, driving innovation and excellence to shape the future of the aesthetic specialty and empower even more individuals worldwide.”

In an exclusive press roundtable, Dayan further discussed the company’s focuses and priorities for the future. The idea of personalised combinations took centre stage as patients are increasingly seeking a holistic approach. He emphasised that regenerative methods are set to play a big role here, with treatments such as biostimulators, exosomes, bioremodellers, stem cells and more having the potential to not only enhance results, but aid in skin prep and healing. “We want to deliver maximum kick, with minimum impact,” he said.

Two days of advanced learning Alma Academy welcomed 17 speakers from across the world to the stage to 16

share their expertise on areas including skin rejuvenation, pigmentation, acne, facial contouring and more. Treating scars appeared to be an area of particular focus at this Academy, with cases and treatment approaches to a range of different scars showcased by practitioners including Professor Ofir Artzi, Dr Krishan Mohan Kapoor, Dr Shraddha Desai and Dr Cemal Kavasogullari from the UK. The multiple case studies shared over the two days were a particular highlight, often eliciting impressed gasps from the crowd as they appeared on screen. Practitioners were also given the opportunity to showcase their own studies in the Fast & Furious session, in which six practitioners took to the stage for two minutes each to impress with their cases. The ultimate winner was Dr Lec Krenar Dobroshi from Kosovo, who presented a patient whose periorbital area had been rejuvenated with Alma devices.

The conference was clearly a prime opportunity to discuss innovative treatment approaches, such as using the Soprano device to achieve facial contouring – an idea which was presented by South Korean practitioners. Attendees could also use device-focused break out sessions to gain specific insights on Alma’s hero products: Harmony XL PRO, Opus, Hybrid and PrimeX. After speaking on stage across both days, Dr Kavasogullari reflected, “What stood out most to me at the Alma Academy was the collective willingness to share expertise and elevate the field of aesthetics together. In my presentations, I aimed to emphasise not only the physical transformation, but also the profound psychological impact that these treatments can have on our patients. It was Aesthetics | November 2024

an honour to be able to share these stories with a worldwide audience and contribute to the broader dialogue on the evolving role of aesthetics in comprehensive healthcare.”

Networking in style Alma is always guaranteed to bring the party, and the 2024 Academy was no exception.

The event represented an exceptional opportunity to connect with practitioners from across the globe, not only during the conference, but at the after parties too.

The first night brought an all-white, full moon beach party, complete with champagne, seafood barbecue, sashimi station, Alma branded coconuts, foot massages, photo opportunities and so much more. The night ended with a DJ set and dancing, impressive Thai fire show and firework display on the beach to mark the occasion with a bang.

The event was rounded off with a formal dinner at the beautiful Nong Nooch Tropical Garden, with signature cocktails, a sit down meal, traditional Thai dance show, dancefloor and more. As Lior Dayan remarked, working with Alma means being part of an exclusive and welcoming club and the Academy most certainly demonstrated this.

Alma’s development in the UK Alma Academy 2024 fell at a time when the UK division of the company is shifting and growing, recently partnering with Revanesse to exclusively distribute its dermal filler products in the UK. This reflects the CEO’s assertion that working in combination with other procedures is set to be Alma’s future, creating even more well-rounded and long-lasting treatment plans.

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Conference Report

BCAM Annual Conference 2024 held in London On September 21, the British College of Aesthetic Medicine (BCAM) held its annual conference for more than 300 delegates at Church House, Westminster.

Across a day of talks, BCAM shone the spotlight on a range of topics, including face and body, clinic management, complications and wellness.

Some highlights of the content included in-depth panels with all the speakers taking questions around case studies and best practice.

The wellness content stream highlighted a key area of growth in the aesthetics specialty, providing education on hormones from Dr Sohere Roked, collagen supplementation with nutritional therapist Eva Escofet and hyperbaric oxygen therapy with former NHS consultant Dr Nur Ozyilmaz.

The event was also an opportunity for recent examinees of the MBCAM examination to receive their certificates on stage.

The next BCAM Conference will be held on October 11, 2025.

Community Connection

BAMAN annual conference returns to Birmingham The British Association of Medical Aesthetic Nurses (BAMAN) held its annual conference at the Eastside Rooms in Birmingham on September 26 and 27.

This was the official launch of the association’s brand new name, having been previously known as the British Association of Cosmetic Nurses (BACN).

Across the two days, 320 attendees were presented with a variety of educational talks. Highlights from the first day included a session on body dysmorphic disorder by Áine Larkin, Mel Recchia discussing transformative techniques using collagen stimulation on the hands, and BAMAN chair Sharon Bennett explaining how to slim the face using neuromodulation.

The learning continued on day two, with Rachel Goddard discussing the association’s achievements over the last year, and what the road ahead looks like.

Nicky Robinson also spoke on how to consult with confidence, and Dr Bibi Maryam Ghalaie presented a non-surgical approach to treating cleft lips.

The next BAMAN Autumn Conference will take place on 18-19 September 2025.

Education

Cutera hosts annual CUCF event Cutera UK hosted its fifth annual Cutera University Clinical Forum (CUCF) on September 28 at Sopwell House, St Albans.

Moderated by aesthetic practitioner and medical director of PHI Clinic Dr Tapan Patel, the forum featured expert-led sessions, interactive discussions and treatment-specific workshops. This year’s faculty included Dr Tatiana Lapa, Dr Anjali Mahto, Dr Anna Hemming, Mr Kambiz Golchin, Dr Nima Mahmoodi, Dr Rishi Mandavia and Dr John Quinn. Internationally renowned dermatologist and laser specialist Dr Ashish Bhatia also presented, sharing insights from his case studies. The event concluded with a 1920s-themed black-tie dinner and awards ceremony, hosted by television presenter Anna Richardson, known for her work on Channel 4’s Naked Attraction.

Sam Keene, Cutera UK&I regional manager, said, “This year we were so pleased to be able to bring the Cutera network together again, to encourage collaboration through education and supply our providers with valuable insights and tools to support both their practices and patient outcomes.”

Aesthetics | November 2024

News in Brief Obagi Medical launches new Hydrate Light gel cream Global skincare company Obagi Medical has released the new Obagi Hydrate Light gel cream, designed to provide 24-hour hydration. Obagi Medical shares that the formula combines hydrators and humectants to enhance the skin’s moisture without clogging pores. A 14-day study conducted involving women aged 18-60 with various skin types reported positive results, with 96% liking the product’s consistency and 92% finding it effective for hydration.

Evolus recruits new international senior vice president Pharmaceutical company Evolus International has appointed Umberto La Magna as its new senior vice president. The company shares that La Magna has more than 30 years of expertise in the medical device and pharmaceutical industries, including the last 22 years specialising in medical aesthetics.

La Magna said, “At Evolus, we describe ourselves as a performance beauty company, taking learnings from the beauty sector and applying these within medical aesthetics. The beauty sector is great at capturing trends, and the healthcare sector is great at developing treatments that perform. By bringing performance beauty to life, I believe we can enhance our customer experience and evolve the future of beauty.”

Déesse PRO appoints Dr Patrick Treacy as new ambassador Déesse PRO has selected aesthetic practitioner Dr Patrick Treacy as the ambassador for its new LED platform EOS-X. This Class II device features an advanced hardshell delivery system with single, dual and triple wavelength capabilities, including the innovative application of 1070 nm technology, according to the company. “EOS-X delivers clinically-proven results by penetrating deeper into subcutaneous tissue, promoting a biostimulatory effect on ageing tissues,” Dr Treacy stated.

IRÄYE releases reusable silicone eye patches Lymphatic skincare company IRÄYE has released its new Reusable Silicone Eye Patches, designed to complement the effects of its Eye Revive Cream. The patches are designed to create an occlusive barrier, aiming to enhance the penetration of active ingredients for a visibly firm and brightened eye area, says the company. The Eye Revive Cream uses a formula designed to target the lymphatic system to reduce puffiness, minimise dark circles and improve the appearance of fine lines and crow’s feet, according to the company.

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News Special BBL Regulation

BBL Death Necessitates Implementation of New Safety Guidelines

Elaine Sassoon, a member of the BAAPS Council who played a key role in the development of the report, said, “The cosmetic sector faces a lack of regulation for unlicensed medical practitioners, putting people’s health at serious risk, particularly with buttock fillers for non-surgical BBL. While specialist surgeons follow safety guidelines, untrained individuals can inject unsafe, bulk-purchased products in unregulated settings.

We have a duty of care to ensure the safety of our population.”

Aesthetics reports on new safety guidelines introduced after a death related to non-surgical BBL procedure

Ms Nora Nugent, consultant plastic surgeon and president of the BAAPS, explained that the organisation has been campaigning for increased safety in aesthetics, and pushing for actionable measures against unqualified practitioners performing invasive procedures for a long time. BAAPS hope that the report will help local authorities identify unsafe and unacceptably risky practice.

Alice Webb, 33-year-old mum of five, died on September 24 at Gloucestershire Royal Hospital following a non-surgical Brazilian Butt Lift (BBL) procedure performed by a non-medic.

According to Gloucestershire police, an inquest into Webb’s death was opened and adjourned at Gloucestershire Coroner’s Court on October 3. The cause of death requires further investigation and a post-mortem examination is ongoing. In response, the Joint Council for Cosmetic Practitioners (JCCP), alongside the Chartered Institute of Environmental Health (CIEH) and the British Beauty Council (BBC), have issued new guidelines aimed at helping local authorities shut down clinics and prosecute practitioners.1 This report is supported by the British College of Aesthetic Medicine (BCAM), the British Association of Aesthetic Plastic Surgeons (BAAPS) and the British Association of Medical Aesthetic Nurses (BAMAN). These guidelines seek to address rising concerns about patient safety and the need for regulation within the sector.

What are the guidelines?

The report offers a curated guide by a panel of health protection and healthcare professional practitioner representatives, aimed at supporting local authorities and regulatory officers. It provides expert advice for identifying businesses and handling complaints regarding non-surgical or ‘liquid’ BBLs, as well as breast or genital augmentation using dermal fillers or other synthetic materials.1 The guidelines emphasise that BBL procedures, including fat transfers and liquid fillers, must be performed exclusively

by GMC-registered medical professionals in CQC-regulated environments. The need for increased training and certification for these practitioners performing non-surgical BBL procedures is also highlighted.1 To further ensure safety and compliance, the report addresses several key areas: risks and mitigations, competence, training and qualifications, BAAPS guidance for BBL, the Environmental Health Officer’s (EHO) compliance checklist, regulations around medicines and medical devices, consent protocols and auditing practices.

These comprehensive elements offer a framework for maintaining high standards and consistency in practice.

As the guidelines are implemented, it is essential to monitor their impact on patient behaviour regarding non-surgical BBLs. While the guidelines don’t enforce stricter regulations directly, they emphasise professional responsibility and patient safety by empowering regulatory bodies and authorities to hold practitioners accountable.

In 2022, BAAPS introduced updated guidelines recommending a safer approach called superficial gluteal lipofilling (SGL).7 Unlike the traditional method of injecting fat into deeper tissues, SGL involves injecting fat just beneath the skin, minimising the risk of complications. Additionally, BAAPS advises that surgeons use ultrasound guidance during SGL procedures to ensure precise cannula placement, reducing the likelihood of injury – a practice also inscribed by the JCCP.

The role of social media In recent years, social media platforms have played a significant role in popularising non-surgical cosmetic procedures.2 This visibility, influenced by the availability and affordability of treatments offered by high street providers and aesthetic clinics, can create a perception of non-surgical BBLs as routine and safe, despite the associated risks. 3 Dr Catherine Fairris, aesthetic practitioner and president of BCAM, highlights how the rise of liquid BBLs has been particularly influenced by these platforms. “The demand for non-surgical alternatives has surged, with many believing that liquid BBLs are a safer, less invasive option,” she explains. “However, this perception can be misleading, as the risks are still substantial.”

Enforcing accountability Local authorities now have the right, under the Health and Safety at Work Act 1974, to issue a prohibition notice to businesses and practitioners that pose a risk, are performing or likely to perform these procedures.1,8 Dr Fairris emphasises the importance of these measures, sharing, “Without strict oversight and accountability measures, we risk seeing the same patterns of unsafe practices continue.”

The JCCP has clarified that the ‘Level 7’ cosmetic qualification is not intended for high-risk body augmentation procedures like BBLs. The Council emphasises that continual professional development (CPD) alone is insufficient for verifying competence, particularly when these procedures are performed by unregulated individuals.

For procedures like BBLs, the JCCP insists that only GMC-registered doctors with additional postgraduate training, such as Royal College accreditation, are qualified. The guidelines aim to enforce stricter standards to enhance patient safety in aesthetic treatments.1 However without government-backed regulations, the impact of these measures remains uncertain. Dr Fairris comments, “We are advocating for the necessity of formal regulations that hold practitioners accountable for their practices and protect patients.”

Ensuring safety The implementation of these guidelines marks a significant step towards improving safety and accountability in the aesthetics field.

However, the effectiveness of these measures in deterring patients from high-risk procedures like non-surgical BBLs remains to be seen. As the sector navigates the complexities of social media influence, patient education and enforcement of regulations, the specialty’s key associations emphasise that ongoing efforts are needed to ensure that safety remains the top priority.

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Aesthetics | November 2024

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Lifting the Cheeks with Dermal Filler Three practitioners highlight their approach to using hyaluronic acid in the mid-face Sagging cheeks are one of the most common aesthetic concerns. In fact, a 2022 survey that investigated facial aesthetic priorities among 14,584 aesthetically conscious adults and 1,315 aesthetic physicians across the globe found that a lack of volume/definition in the cheekbones was in the top five facial concerns for both men and women.1 The same survey found that the most popular terms to describe female beauty included ‘smooth’, ‘natural’, ‘clean’, ‘soft’, ‘bright’, ‘symmetrical’, ‘proportionate’ and ‘beautiful’. For men, terminology also included ‘handsome’, ‘defined’, ‘masculine’ and ‘strong’.1 So, how can we best treat mid-face volume loss and help patients reach these goals? The practitioners interviewed in this article highlight how anatomical knowledge and good product selection will go a long way. Here, they share their best tips for success.

Ageing of the mid-face Facial ageing is a multifaceted process that involves changes to the bone, soft tissue and skin. As bones recede and remodel, fat pads and muscles are realigned. This causes an inferomedial displacement of the overlying skin envelope, contributing to hollows in the cheeks and flattened angles of the face.2 Additionally, skin quality declines as collagen breakdown increases, while collagen synthesis decreases. Elastin is lost through natural degradation, while water is lost as the hygroscopic glycosaminoglycans degrade. External factors such as exposure to UV light, pollution and poor diet also have an impact.

Other factors contributing to ageing include progressive reduction in cell number and function, including in melanocytic and Langerhans cells, and a decrease in hormones that has an impact on skin physiology.2 Independent nurse prescriber Alexandra Mills explains that these changes can result in numerous concerns. “Patients can experience a hollow or sunken appearance as a result of fat pads diminishing; reduced collagen and elastin cause the skin to lose its firmness and sag, resulting in droopy cheeks. The natural lift and fullness of the cheeks can lessen, affecting the overall facial contour and definition; cheeks become more prone to wrinkles and fine lines due to repeated facial expressions and reduced skin elasticity; and nasolabial folds can become more pronounced due to loss of cheek volume,” she explains.

Dentist and aesthetic practitioner Dr MJ Rowland-Warmann adds that patients usually start to notice mid-face changes in their late twenties. “They’ll say things like they look tired, or their face looks a bit flat,” she notes, highlighting how they’re the ideal demographic for subtle volume replacement.

Dr Rowland-Warmann continues, “We also see older patients present with more advanced volume loss under the eyes and throughout the entirety of the mid-face. Their skin will look saggier and more deflated, with many commenting that they think they look sad.”

Aesthetics | November 2024

Special Feature Cheek Augmentation

Hyaluronic acid: a go-to tool For patients presenting with mid-face ageing concerns, the practitioners agree that hyaluronic acid (HA) dermal filler is the ideal treatment. Dental surgeon and aesthetic practitioner Dr Nina Bal says, “If a patient is young and has no or minimal laxity, only a flatness in the cheek area, I normally go straight to recommending HA.” For older patients who have more sagging and skin laxity, Dr Bal will combine HA injections with a skin tightening treatment using either laser or radiofrequency and high intensity focused ultrasound (HIFU).

“HA is excellent for volume restoration in hollow and sunken cheeks, giving them a more youthful appearance, while also improving hydration and elasticity,” says Mills, explaining, “HA attracts and retains moisture, which helps smooth wrinkles and fine lines.”

“Cannula approaches minimise the number of entry sites and the amount of trauma” Dr MJ RowlandWarmann

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Special Feature Cheek Augmentation Dr Rowland-Warmann adds, “HA is a very useful tool for all ages. It can replace deep volume loss and support overlying tissues. For someone who needs a bit more rejuvenation, I tend to combine it with a biostimulator such as Sculptra to achieve a more comprehensive improvement.”

Selecting a brand With more than 160 dermal fillers available in the UK, knowing what to invest in can be challenging.3 “It’s important to do your research into both the product itself and the company behind the brand,” Mills emphasises, adding, “Look at their clinical studies and find out what support the company offers beyond training.”

For Dr Bal, her product of choice is Revanesse, due to its combination of high viscosity HA filler and being quite flexible.

“It gives definition without being too sharp and obvious on the cheekbones,” she explains, continuing, “If someone does want that more defined look, Revanesse Shape is a good option.” Dr Bal highlights that the integration is excellent, and the filler has been formulated to minimise the body’s natural inflammatory responses, so patients don’t experience much pain or swelling.4 Dr Rowland-Warmann favours Restylane.

She explains that the fillers within the range are based on two technologies – OBT and NASHA. OBT gels are softer and more flexible,5 whereas NASHA gels are firmer and used to create projection and definition.6 Dr Rowland-Warmann explains, “I’ll do a pinch test to assess tissue thickness; if I’ve got someone with thin tissue, I’ll use an OBT product to add volume in the mid-face or gently enhance contours. Someone with thicker tissue will respond better with NASHA.” Mills shares that, “The HA dermal filler I prefer to use is the Saypha portfolio of fillers. Saypha dermal fillers are composed of a unique max core technology, which is associated with rheological properties that optimise their G prime with viscoelasticity.”

For the cheeks, she chooses Saypha

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Volume and Saypha Volume Plus. She explains that the depth and indication of use is defined by the concentration of HA used between 23-25mg/ ml, while the low extrusion force, reduced swelling and ergonomically designed glass syringe all add to the safety profile and improved outcome achievable.7

Before

aestheticsjournal.com After

Pre-treatment knowledge All practitioners agree that a detailed consultation and thorough medical history are imperative. Typical Figure 1: Before and four weeks after 2ml of Revanesse Outline contraindications to HA dermal injected to the cheeks (1ml each side), 1ml of Revanesse Ultra+ in the lips and 2ml of Revanesse Shape in the chin. Images fillers include active infection courtesy of Dr Nina Bal near the site of injection, allergy or hypersensitivity to to the mandibular angle (the mid-cheek the ingredients within the filler, as well as safety line), and descending vertically from certain medications such as blood thinners the middle of the zygomatic arch (the lateral and immunosuppressants, pregnancy and safety line).10 8,9 breastfeeding. Dr Bal also highlights the importance of recognising body dysmorphia Injection techniques in patients and knowing how to manage this Mills emphasises that the cheek is a critical ethically and effectively, or refuse treatment area to master when treating the face. “I where necessary.10 use both a retrograde bolus injection and/ The practitioners go on to emphasise how or a cross-hatch technique to gain optimal essential facial anatomy knowledge is. results safely,” she explains, continuing, “Understanding the anatomy pertaining to “The injection depth chosen will depend the vessels that pass through the cheeks is on whether the clinical case scenario so important,” says Dr Rowland-Warmann. involves epi-periosteal, subcutaneous and/ The facial artery provides the main blood or deep dermal injections in the deep medial supply to the face, arising from the external and lateral cheek fat pads. Volumisation carotid artery and entering the face from the and projection are used in different case submaxillary region. Research has found its scenarios and are paramount to judge course is highly variable amongst patients, symmetry and proportion.” Mills notes that so care must be taken to stay above the she aims to use small volumes to bring about 11 mid-cheek groove to minimise risks of injury. natural and safe cheek augmentation as part Practitioners should also have awareness of her treatment philosophy. “At the heart of of the infraorbital artery, superficial any treatment, I always try to balance patient temporal artery, transverse facial artery, expectations with what is possible, ensuring zygomaticofacial artery and facial vein. a safe environment,” she says.

All have pathways in the middle third of Dr Bal prefers to use a cannula. She explains, the face, so working within safety lines is “I use a 22G cannula, which reduces the recommended.10 These are identified in one chance of me hitting a blood vessel.” This study as running from the medial canthus is supported by research which suggests that sharp needle technique shows a higher complication risk with intra-arterial injection.12 “If I do use a needle, then I make sure I go underneath the SMAS on the periosteum level,” adds Dr Bal.

“If a patient is young and has no or minimal laxity, only a flatness in the cheek area, I normally go straight to recommending HA” Dr Nina Bal

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She explains, “Normally, I will trace a midline from the lateral canthus to the tragus. In the middle of that, I go in with my 21G needle, so I can slide a 22G cannula inside. Then I trace another line from the lateral canthus and the oral commissure, and the alar of the nose and the tragus. So, from the intersection of those two lines, I get the apex of the cheeks.

I then fly the cannula on the periosteum up until that intersection and place 0.2ml of Revanesse Outline to create a nice apple of

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the cheek. I then do a retrograde injection of the cheek with a cannula in that area to define the cheekbone.”

stay away from extreme cold or heat temperatures for about a week, hydrate regularly to help skin heal and rejuvenate, avoid alcohol and blood thinners for at least 24 hours, and sleep elevated for the first few nights to minimise swelling.13

Dr Rowland-Warmann follows the A.A.R.T approach, which stands for assessment, anatomy, range, treatment, created

by Galderma. “While it systemises the outcomes, it also retains the unique features of the individual patient,” she says. Dr Rowland-Warmann goes on to explain, “You assess the patient by looking at the face as whole, evaluating the facial symmetry, the facial thirds, the projection and how the area of concern fits in the face overall.”

Additionally, the treated area may be red or tender for a few days, and some patients may experience temporary lumps or bumps at the injection site, she says.13

Potential complications

She highlights that like Dr Bal, she prefers cannula treatment. “Cannula approaches minimise the number of entry sites and the amount of trauma,” she says. In terms of treatment approaches, Dr Rowland-Warmann explains that it very much depends on what she wants to achieve and where she wants to volumise.

“In an older patient, I may start with 1ml per side, whereas in a younger patient it would be more like 0.5ml per side,” she explains, noting that she is very conservative in the amount of product she uses and emphasises that you can always add more at a later date.

Expected side effects “Swelling and bruising are the most common side effects associated with HA injection,”13 says Dr Bal, highlighting that she will also prepare patients for temporary asymmetry of cheeks. “Sometimes, in my experience, one can bleed or bruise and the other won’t, so they take time to settle,” she explains.

To minimise the risk of swelling and bruising, Mills explains that practitioners should advise patients to avoid strenuous exercise or any activities that could cause facial sweating for at least 24 hours, Before

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Mills explains that although rare, any injection poses a small risk of infection.13 Dr Rowland-Warmann emphasises that, to minimise risk, makeup should be avoided for 24-48 hours and patients should be advised to keep their skin as clean as possible. “Remember, as HA filler is an injectable implant, it cannot be cleaned once it’s infected. The only remedy is to give antibiotics or dissolved,”13 she says.

The biggest risk associated with HA filler injections is vascular occlusion. “Left untreated or undiagnosed, this can lead to skin necrosis,” says Dr Bal. To minimise the chance of an occlusion occurring, she massages the filler once she’s finished injecting, and always check for capillary refill, making sure it’s not delayed by more than three seconds.13 Mills emphasises the importance of knowing your anatomy and physiology very well to avoid arteries, as well as being thoroughly educated on HA filler so you know where to place it.

Dr Rowland-Warmann adds that using ultrasound to map the patient’s anatomy beforehand can reduce risk, while injecting slowly and with small quantities helps too.

“Know what to look out for if something doesn’t seem right and have protocols and referral pathways in place to get the help the patient needs. If you use reputable

Special Feature Cheek Augmentation products, the companies behind them will usually have a very good vigilance team that can assist, while organisations like the Complications in Medical Aesthetic Collaborative (CMAC) or Aesthetic Complications Expert (ACE) Group World can also help. It’s useful to have everything in place before you reach for the syringe,” she says.

Dr Rowland-Warmann adds that no practitioner should be ashamed to admit they need help. She runs a complications clinic, taking referrals from all over Europe, and is never judgmental of medical professionals looking for support.

“Sometimes you just have to throw your hands up and say, listen, I’m out of my depth, please help me. Doing it means that the patient gets seen and fixed quickly, which is so important. They go back to their original practitioner with no loss of trust, because they have taken swift action,” she explains.

Expected results “HA injection to enhance the cheeks is the procedure that I find has the most impact for overall facial rejuvenation,” says Dr Bal. She explains, “Patients instantly see a lift and more definition, with results lasting up to 18 months.”4 As well as increased volume, definition and lift, Mills highlights that patients can also expect to see smoother skin as HA can smooth the fine lines and wrinkles on the cheeks, and enhance facial symmetry, balancing features and proportions.

Dr Rowland-Warmann adds that ‘subtle’ is the keyword. “HA treatment shouldn’t make you look 20 if you’re 40 because that will look weird! It should restore patients’ youthful contours and make them look refreshed,” she says.

Delivering optimal results

After

To elevate your aesthetic outcomes, Dr Rowland-Warmann advises, “Don’t buy the cheapest product! Many will be of dubious quality and, in my experience, are more likely to lead to complications.

Always go with the companies that invest in research and development, have products with a strong track record of efficacy and safety, provide training and offer ongoing support.”

Dr Bal adds, “My advice is don’t let the treatment be led by what the patient demands. Always do your own assessment and be confident in your knowledge and experience. That way, you’re far more likely to get a satisfied patient!”

VIEW THE REFERENCES AT

Figure 2: Before and four weeks after treatment with 1ml of Saypha Volume and 2ml of Saypha Volume Plus injected to the cheeks. Images courtesy of Alex Mills

Aesthetics | November 2024

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Advertorial Alma x Revanesse

40s who seek preventative ageing and beautification treatments.

Given their public profiles, often filming for TV or media campaigns, discretion and undetectability is paramount. They trust my approach of ‘less is more’, and believe in the long-term commitment it can take to do miniscule, detailed work. It is very rare that I will inject more than 2-3mls at one time.

What dermal filler do you choose for the ‘undetectable’ approach?

It's crucial to select a dermal filler you can trust to deliver consistent results without unwanted post-procedure inflammation. I choose the Revanesse® HA dermal filler range due to its low inflammatory properties, which not only align with my subtle technique, but also make it one of the most comfortable options for my patients.2 Interestingly, Revanesse® was the first dermal filler I chose to be injected into my own face and lips. I personally visited the Canadian lab to witness the artisanal manufacturing process firsthand, and was impressed by the extensive measures taken to reduce reactive agents.

The Rise of Undetectable Dermal Fillers

Revanesse® particles are designed to be spherical, allowing for a smooth injection and enhancing biocompatibility.2 The filler is also pre-hydrated to prevent excess water absorption, minimising swelling after treatment.2 This means patients can resume their normal activities without their treatment being detectable.

Reducing the risk of reactions down the line, Revanesse® uses minimal foreign bodies.3 Having a high molecular weight hyaluronic acid requires minimal cross-linking agent (BDDE).3 Plus, a special purification process also removes more toxins from the formulation.1

Nurse prescriber Natali Kelly shares how Revanesse® is the perfect partner for her natural-looking artistry While reports have said dermal filler treatments are reducing by 33% year on year,1 those in the know believe in the rise of ‘undetectable dermal fillers’. A key factor in achieving this is practitioner techniques, but also choosing the appropriate dermal filler. Natali Kelly, a renowned nurse with 20 years of experience, explains why the undetectable approach is more successful than ever. Plus, how Revanesse® HA dermal filler is the perfect partner for her artistry, delivering natural-looking results.

What are undetectable dermal filler treatments?

I've always believed that dermal fillers should be completely undetectable. Over the past 15 years, I've developed techniques that not only ensure my patients can return to work or home without anyone noticing, but also result in long-term, natural-looking results. Even after a decade of treatments, my patients maintain a youthful appearance without any visible signs of migration, and no corrective work required. My approach is to respect the anatomy of the face and treat conservatively, ensuring that results are both subtle and natural.

Why is Revanesse® your ultimate choice in your clinic?

In my opinion, using Revanesse® with my techniques allows for minimal downtime, less swelling and a long-term reduction in the risk of post-inflammatory complications, ensuring undetectable results and patient satisfaction.

Revanesse® offers a range of products tailored to different patient needs, allowing for personalised treatments and natural-looking results.4,5 With this in mind, the range is rapidly growing into a very popular choice among practitioners worldwide, currently used in more than 80 countries.

Harley Academy provides excellent training in Revanesse®, to ensure more practitioners uncover the secret of undetectable filler artistry.

Natali Kelly is an aesthetic nurse prescriber with more than 18 years of experience combining her surgical background with non-surgical aesthetics and cosmetic dermatology. Kelly qualified from King’s College London, and is now an awardwinning injector, specialising in contouring for both face and body using injectables and energybased devices.

Why is this approach so popular in your practice?

Firstly, I am a minimalist by nature, which is evident in my artistry and how I design my clinic and patient’s faces. I've seen first-hand how many patients are apprehensive about dermal fillers due to concerns about downtime, unnatural results and invasive procedures. This led me to develop injection techniques that are minimally invasive so I could build trust, ensuring safety and satisfaction.

This advertorial was written and supplied by Alma x Revanesse

I like to educate my patients and empower them to maintain individual beauty, enhancing their features and profile balancing.

My clientele often includes high-profile individuals in their 20s to Aesthetics | November 2024

For more information, contact your local Revanesse® Sales Business Manager

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CCR Post-Show Report

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The Future of Medical Aesthetics Presented at CCR 2024 The 11th edition of CCR returned bigger and better than ever

The UK’s largest medical aesthetics conference, Clinical Cosmetic Regenerative (CCR) Congress, returned on October 10 and 11, with an impressive turnout of 3,985 attendees. Over the past 11 years, CCR has been dedicated to sharing knowledge, connecting all areas of the medical aesthetics specialty, and promoting high standards in best practices – and this year certainly lived up to the hype.

Over the two days, CCR welcomed 150 exhibitors and 140+ speakers to Excel in London, making it the biggest and busiest CCR to date!

Shannon Kilgariff, editor and event manager of the Aesthetics portfolio, commented, “It was amazing to see so many aesthetic professionals and companies congregate for an incredible CCR 2024. This year we saw the quality of scientific, clinical and business education, as well as the exhibition and participating companies, reach new heights. A heartfelt thank you to all our speakers for their exceptional insights, research and live demonstrations throughout the event. I also want to extend my gratitude to our sponsors, exhibitors, partners and Aesthetics Clinical Advisory Board for their continued support in making CCR a success year on year. I can’t wait to see everyone again at our next event, ACE, in March!”

A special thanks is also extended to our registration sponsor SkinCeuticals, and our partners for this year’s event, including our skin prep partner Hypo21, clinical 26

waste partner Initial Medical, consumables partner Medfx, complications partner ACE Group World and treatment chair partner Ellisons.

Educational highlights from Headline Sponsor Galderma Pharmaceutical company Galderma returned as Headline Sponsor for the fourth year in a row, delivering unmissable new insights and live demonstrations.

As the aesthetics specialty evolves, the demand for minimally-invasive procedures continues to rise, driven by patients’ desire for natural-looking enhancements for facial harmonisation and balanced profiles. The Day 1 Galderma symposium, led by Dr Munir Somji, Jackie Partridge and Dr Yusra Al-Mukhtar, uncovered the latest trends and expectations of patients and how Restylane optimises treatment outcomes, while addressing the needs of individual patients.

On Day 2, Dr Kathryn Taylor-Barnes, Dr MJ Rowland-Warmann and Dr Ana Mansouri discussed the A.A.R.T (Assessment, Anatomy, Range and Treatment) approach during patient consultations and leveraging its regenerative pathway. A live demonstration was performed using Sculptra.

Galderma also hosted the CCR Networking Lounge across the two days, providing delegates with refreshments in between talks and the space to create vital new connections.

Aesthetics | November 2024

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Jackie Tuzee, head of marketing for Galderma, commented, “Galderma were proud to be Headline Sponsors of CCR 2024. We always enjoy the buzz of CCR and engaging with top specialty experts and diverse groups of HCPs, sharing insights around the latest trends in aesthetics and showcasing how the Galderma injectables portfolio, including Restylane and Sculptra, can help practitioners deliver a natural look to meet patient needs and expectations. We were also able to showcase our Alastin skincare range and how it can improve outcomes for patients pre- and post-procedure.

We look forward to CCR 2025!”

Injectable insights at the Aesthetics Journal Arena

Dr Anjali Mahto led the dermatology discussions, looking at the importance of optimising skin health in order to enhance injectable treatment outcomes. Following this, Mr Dalvi Humzah and Mr Lorenzo Garagnani outlined an anatomical approach to hand rejuvenation, and Dr Kate Goldie rounded off the afternoon chairing sessions focused on regenerative medicine. These included exosomes, polynucleotides, the link between regenerative treatments and wellness, skincare and much more. The final session saw Dr Goldie perform a live demonstration combining regeneration with structural optimisation.

Discovering new concepts at the Innovation Stage The Innovation Stage provided attendees with in-depth guidance for developing their clinic offerings through 30-minute workshops and live demonstrations. In these sessions, attendees discovered the latest products, protocols and techniques from the most innovative device and skincare suppliers in the specialty.

Highlights across Day 1 included a talk by Dr Tapan Patel for Cutera on how to integrate AviClear into your practice, Nurse Jamie launching the new Alma and Revanesse partnership, and treating pigmentation using topical skincare with Miss Jennifer Doyle on behalf of Alastin.

Other key opinion leaders took to the stage to represent Asclepion Laser Technologies, BeautyForm, BTL Aesthetics, Crown Aesthetics, Deleo, Dermalux, EvoCyte, Hansbiomed, Hydrafacial, Medical Aesthetic Group, NeoGen and Sciton.

CCR Post-Show Report

Treatment demonstrations at the Symposium Stage Top brands showcased their latest techniques through live treatment demonstrations at the Symposium Stage, featuring leading KOLs. Dr Patrick Treacy, global head of engagement and relations at Harpar Grace Katie Hughes-Dawkins and aesthetician Rebecca McMahon discussed the clinical benefits of Déesse PRO LED therapy, celebrity TV personality Anthea Turner outlined her journey with Lynton Laser treatments, and Dr Andrew Christie-Schwarz looked into exosomes and immuno-tolerisation with DermapenWorld.

Across the two days, Symposium stage sponsor, DermaFocus, hosted lunchtime takeovers with Dr Bibi Ghalaie, Dr David Eccleston, Dr Yusra Al-Mukhtar, Dr Anoob Pakkar-Hull, Dr George Christopoulos, Dr Raquel Amado and Dr Xavier Goodarzian.

Bringing the Aesthetics Journal to life, this Arena was the go-to place for the latest scientific research and innovative techniques. A toxin takeover chaired by our Clinical Advisory Board lead Sharon Bennett looked at off-label uses and an explanation of the different toxins on the UK market. Representing the new aesthetics branch of the Royal Society of Medicine, Dr Christopher Rowland Payne chaired sessions exploring injectable considerations for various areas of the face. The day concluded with a live demonstration for full-face rejuvenation.

Day 2 continued the education, with Dr Munir Somji outlining the science and data of exosomes for Cure Medical, Dr Elisabeth Dancey discussing the latest innovations in the delivery of cosmetic injectables in collaboration with Medical Aesthetic Group, and Dr Vincent Wong presenting his ‘EyeTite Refresh’ approach with InMode.

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The final symposium saw the introduction of the 2ml Challenge. Chaired by Dr Raul Cetto and Sharon Bennett, this brand-new concept allowed delegates to discover the power of precision through an engaging live demonstration where three top injectors (Dr Munir Somji, Dr Javed Hussain and Dr Nina Bal) pushed the boundaries of artistry using only 2ml of hyaluronic acid dermal filler. Filler brands used included Restylane, Revanesse and RSS HA. Bennett and Dr Cetto assessed the outcomes in real time, providing in-depth critiques and before-and-after comparisons.

More aesthetics leaders took to the stage to showcase their experiences using the newest treatments and techniques from ALLSKIN MED, Fotona UK, Hawksley & Sons (T-Lab), IRÄYE, LPG and Sofwave.

Business advice at the In Practice Theatre As well as clinical education, at CCR, attendees had the opportunity to set themselves apart from their competitors and expand their business knowledge at the In Practice Theatre, supported by theatre sponsor SkinCeuticals.

The first day kicked off with sessions on how to expand your clinical practice, chaired by Mr Adrian Richards.

The MHRA also presented a session on the illegal trade in weight loss medicines. The afternoon looked at the future of aesthetics, with Ben Pask’s talk on the latest statistics garnering a huge crowd with the distribution of the Aesthetics Trends Report. The day finished with the Gloves Off by Aesthetics Panel, featuring Áine Larkin, Dr Elizabeth Hawkes, Dr Souphi Samizadeh and Miss Jonquille Chantrey covering ethics, regulation and private v.s public practice.

The second day started with an agenda to our Getting Started in Aesthetics Partner Harley Academy, designed to help aesthetic professionals kick start and stand out in their aesthetics career. The women in business panel also returned, sponsored by Dermaze, featuring Francesca Ogiermann-White, Alison Taylor, Dr Bonny Armstrong, Dr Maryam Zamani and Dr Olha Vorodyukhina.

Other companies that supported the business development needs of clinics at the In Practice Theatre included Patient Perfect, The Skin Diary and Zenoti.

Aesthetics | November 2024

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CCR Post-Show Report

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The return of the Medical Longevity Summit This year saw the second edition of the Medical Longevity Summit, a two-day agenda focused on how to promote a healthier and longer healthspan for patients. Curated alongside Dr Mayoni Gooneratne and supported by Headline Sponsor Roseway Labs, the Summit focused on enhancing aesthetic outcomes by utilising functional, integrative, regenerative, lifestyle and wellness treatment approaches.

Sessions across the two days included the role of gut testing, why BHRT is the way forward in hormone health, optimising cellular health, medicinal mushrooms for healthspan and why everyone is suddenly obsessed with the vagus nerve.

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Sponsor Roseway Labs, said, “We were delighted to be headline sponsors of the Medical Longevity Summit at CCR, marking our second year exhibiting at this influential event. CCR 2024 provided an exceptional platform to connect with leading healthcare professionals in the specialty, showcasing the latest advancements in longevity and antiageing treatments. Being part of CCR has been invaluable for strengthening our presence and engaging with an innovative aesthetic community dedicated to enhancing health and wellness.”

Alongside the insightful content, 19 companies exhibited and engaged in conversations with attendees over the two-day period.

Other sponsors at the Summit included Human Health Affiliates, Knowing Labs, NAD+ AT HOME, Oxford Healthspan, Totally Derma and Yotsuba Japan.

Tara Saghafi, head of commercial for MLS Headline

On the success of the Medical Longevity Summit, Dr Gooneratne commented, “This year’s summit was bigger and better than before, and so well attended. I think it shows that this is the next evolution for aesthetic professionals, and the questions people were asking were really exciting because I could tell a lot of them were seriously considering adding these services to their clinics.

I can’t wait for next year where we will have even more features, speakers and exhibitors!”

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The latest innovations in medical aesthetics

Recognising excellence through CCR’s award winners The CCR Stand Awards returned for 2024, celebrating the best stands at the event and the hard work put in by all companies involved.

We’re delighted to announce our winners below: ● Best Stand SkinCeuticals ● Best Marketing Campaign Healthxchange ● Most Sustainable Company The Skin Diary ● Best Visitor Experience Belle & Aerolase

CCR brought delegates the latest products, services and solutions through the easily accessible Innovations Trail. The trail provided a simple and direct way to discover the latest and most influential products on the UK market. Read more about them on p.30.

The Korea Zone, in partnership with the International Beauty Industry Trade Association (IBITA), also returned for CCR 2024. South Korea has long been recognised as a trailblazer in the medical aesthetics specialty, consistently leading the charge with innovations that often reach global markets years later. With Korean companies now expanding into new territories across the UK, the zone offered practitioners and distributors an exciting opportunity to discover the newest advancements in medical aesthetics and stay ahead of the competition.

Bringing together the community As well as educational learning, CCR helped delegates to expand their professional community through a variety of networking opportunities.

Day 1 ended with the annual networking drinks, sponsored by DermapenWorld.

Community members gathered to share insights from the day, reconnect with peers and enjoy complimentary drinks together while celebrating DermapenWorld’s first anniversary on the UK market. Our charity partner the Body Dysmorphic Disorder Foundation also gave a speech and collected donations throughout the event.

Kelly Tobin, country director at DermapenWorld, said, “Sponsoring the CCR networking event was a great opportunity to say thank you to everyone that has supported DermapenWorld UK as we celebrate our first anniversary since launching at CCR 2023! It was a fantastic networking event and we appreciated you raising a glass to our incredible specialty and its continued success.”

Day 2 started with a breakfast hosted by the British College of Aesthetic Medicine and Crown Aesthetics, uniting medical doctors/dentists and enabling them to foster new connections.

Across both days, delegates had the chance to meet top practitioners in the specialty at the brand-new Meet the Mentor initiative. The event was created to connect aspiring professionals with experienced experts in the field, allowing them time to sit down and engage in a ‘speed dating’ format to ask about their insights, solutions and advice.

Speakers for CCR and Aesthetics Members and VIPs got the opportunity to unwind and catch up in our Speaker Lounge, sponsored by ValuraNova. The Alma mascot Alman also connected delegates by conducting interviews with top practitioners and bringing the party around the show.

As a new feature for 2024, delegates also got the unique chance to engage with companies personally during Stand Seminars. Throughout the two days, exhibitors hosted talks on their stands to create a personable and intimate environment for attendees to be educated about the latest products, devices and solutions, as well as ask any questions.

Your next aesthetics event Now that CCR 2024 has concluded, it’s time to start looking forward to your next event in medical aesthetics. The Aesthetics Conference and Exhibition (ACE) 2025 will be taking place on March 14-15 at the Business Design Centre in London. We’re delighted that our Headline Sponsor has just been announced as Allergan Aesthetics – read more on p.9. Scan the QR code to register your interest and keep updated with all the latest information.

And that’s not all! The Aesthetics Awards will be back with a bang after the second day of the conference, returning to the dazzling Grosvenor Hotel.

Finalists for the event will be announced in our January issue, but tickets are on sale now! Make sure to purchase your tickets before December 31 to receive the early bird rate.

Save the date

25 & 26 September 2025 ExCeL, London

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We can’t wait to see you all again soon!

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Innovation Spotlight CCR Innovation Trail 2024

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The Biggest Aesthetic Innovations of 2024 Discover the products breaking boundaries in the aesthetics specialty this year, from skincare to wellness treatments Brightening Serum

Light Therapy

A-LUMINATE from Alastin

Blue Derma from K-Laser

The new serum aims to minimise the recurrence of surface pigmentation, help correct the appearance of hyperpigmentation and reduce the appearance of uneven skin tone with PATH-3 technology, tranexamic acid and niacinamide. It is designed to support the results of in-clinic treatments such as chemical peels, lasers and skin brightening treatments.

Utilising cutting-edge blue light technology, Blue Derma effectively targets and treats a wide range of dermatological conditions, including acne, wound healing, psoriasis and skin rejuvenation. This non-invasive, painless treatment accelerates tissue repair and reduces inflammation, offering transformative results for patients seeking effective skin care solutions. A published human skin study indicated increased fibrillin and collagen equivalent to retinoic acid.

Ceramides, fatty acids and humectants optimise active ingredient absorption and skin barrier function.

Multi-Platform Device

Exosomes

Dynamix from Lynton Lasers

E50 HAIR Exosomes from Cosmeditech

The new Dynamix device comprises radiofrequency (RF), intense pulsed light (IPL) and lasers. It will allow practitioners to integrate a range of Lynton treatments in their clinics, including ReBright (IPL), ReModel (RF), Remove Q (Q-Switched Nd:YAG), ResurFACE (Erbium YAG laser) and more.

Exosomes

Exomine from Hawksley & Sons Exomine provides a completely autologous method to harvest platelet-derived exosomes, facilitating the release of billions of vesicles by causing stress to the platelets within PRP. Exomine is often combined with tissue grafting to facilitate healing, enhance regional tissue quality, achieve tissue radiance, increase elastin and collagen to reduce wrinkles, and address hair loss.

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Aesthetics | November 2024

E50 HAIR Exosomes were developed to treat hair loss and induce hair growth.

They work by kickstarting follicles’ natural growth and repair processes.

The exosomes, which are small vesicles containing peptides, growth factors and DNA, are delivered deep into the dermis where they reinvigorate damaged and ageing cells.

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Innovation Spotlight CCR Innovation Trail 2024

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Exosome and Polynucleotide Serum

V-Tech Serum from Promoitalia V-Tech combines the power of high molecular weight polynucleotides (2%) with synthetic exosomes, enriched with biomimetic peptides (20mg) and plant stem cells. It is designed to stimulate skin rejuvenation from the first application, offering benefits such as skin regeneration, antioxidant protection, deep moisturisation and restoration of the skin barrier.

Bio-Restitutive Soft Filler

Karisma rH Collagen from Aesthderm Karisma rH Collagen is a bio-restitutive soft filler that induces natural restoration of pre-ageing conditions, by promoting the production of type I collagen in human fibroblasts. Only two treatments are required, and patient satisfaction has been very high. The combination of hyaluronic acid, rH collagen and carbomethylocellulose 0 makes this product stand out in the market.

Supplement

Primeadine Original Powder from Oxford Healthspan According to Oxford Healthspan, this is the only plant-derived spermidine powder on the market, aiming to trigger cell renewal, reduce inflammation and rejuvenate stem cells and mitochondria.

The product includes a special type of prebiotic fibre called FOS that selectively feeds the friendly, spermidine-producing bacteria in the gut microbiome.

Radiofrequency Microneedling

RF Combo Jector from Beautyeurope The RF Combo Jector from Beautyeurope can combine product delivery and radiofrequency, with adjustable RF levels and variable needle mesotherapy length extending from 0.2-5mm. This capability provides a dual stimulation effect on the skin, with results in a shorter recovery time for patients.

Skin Booster

Even more new and innovative products will be showcased at ACE 2025 on March 14-15 2025, and through the Best New Innovative Product category at The Aesthetics Awards 2025.

Keep your eye on Aesthetics to bring you all the latest in the specialty!

Sisthaema Hevo-T from Maxel Clinic Wholesale Sisthaema Hevo-T is a cutting-edge skin booster designed to rejuvenate and hydrate the skin deeply. Formulated with cross-linked hyaluronic acid and trehalose, it delivers long-lasting hydration and enhances skin elasticity. This product is ideal for patients over 40, addressing signs of ageing such as fine lines, wrinkles and loss of volume.

Aesthetics | November 2024

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CPD Botulinum Toxin

Optimising Facial Botulinum Toxin Results Dr Nestor Demosthenous discusses the pharmacodynamics of botulinum toxin and the differences between the available preparations In the 1980s, ophthalmologist Dr Jean Carruthers and dermatologist Dr Alastair Carruthers discovered that one of their patients treated with botulinum neurotoxin (BoNT) for blepharospasm had a marked reduction in their glabellar lines.1 At the time, it was only being used to treat hemifacial spasm, strabismus and benign essential blepharospasm. They began treating the glabellar complex of staff and patients. In 1992, they published their seminal paper on the efficacy of onabotulinumtoxinA (Botox) for improving the appearance of glabellar frown lines.2 It can be argued that the use of BoNT in this way gave birth to medical aesthetics, with the product being extensively researched over the years. A PubMed search, at the time of writing, identifies 3,433 peer-reviewed articles with toxin still being the number one performed non-surgical aesthetic treatment globally. 3 This article will explain the pharmacodynamics of BoNT, and the differences (and similarities) between some of the commercially available

preparations. As there has been increasing discussion in ‘antibody resistance’, I have also included my understanding of this and presented the limited evidence here.

Pharmacology All commercially available botulinum neurotoxin type A (BoNT/A1) proteins are manufactured by fermentation of clostridium botulinum and subsequent purification of the protein from bacterial lysates. BoNT/A1 is a relatively large protein of 150 kDa, consisting of an N-terminal light chain of 50 kDa and a C-terminal heavy chain of 100 kDa, covalently linked by a disulfide bond.4 The two C-terminal subdomains of the heavy chain are involved in binding to and uptaking into the nerve terminal, whereas the N-terminal subdomain is responsible for the translocation of the light chain into the cytosol. The light chain cleaves SNAP-25, a molecule essential for fusing pre-synaptic vesicles of neurotransmitters with the plasma membrane at the nerve terminal.4 Legend Light Chain Heavy Chain BoNTA

VAMP/ Synaplobrevin

TRPA1

SV2

TRPA1

Normal

Presynaptic

1 Synaptic vesicle nears the membrane

2 Vesicle docks at the membrane via the SNARE complex

Syntaxin

3a Vesicle fuses with membrane

SNAP-25

3b Neurochemicals (e.g. CGRP, SP) released into synapse

PSG

4 Receptors inserted into membrane intracellular extracellular

OnabotulinumtoxinA Mechanism of action

1 Neurotoxin binds to PSG and SV2

3 Neurotoxin light chain translocates into cytosol

intracellular

2 Neurotoxin taken into the cell via endocytosis

4 Neurotoxin cleaves SNAP-25 (a SNARE protein)

extracellular

Figure 1: The mechanism of action of botulinum toxin5

Aesthetics | November 2024

The neurotransmitter does not cross the neuromuscular junction, and therefore no signal is transmitted to the muscle fibre, thus communication between nerves and muscles is broken (Figure 1). The favourable pharmacological properties include high selectivity, very high potency, and most importantly, reversibility of the neurotoxic effect.5

Comparison of commercially available toxin preparations AbobotulinumtoxinA (Azzalure), incobotulinumtoxinA (Bocouture), onabotulinumtoxinA (Botox) and prabotulinumtoxinA (Nuceiva) are four commercially available formulations of botulinum toxin type A in the UK. They are all approved by the Medicines and Healthcare products Regulatory Agency (MHRA) for temporary improvement in the appearance of moderate to severe glabellar lines.6 Two other toxins currently available in the UK are letibotulinumtoxinA-wlbg and abobotulinumtoxinA, but this article will focus on the first four due to the broader range of research around them.

OnabotulinumtoxinA is also approved for the use of lateral canthal lines as well as forehead rhytids.7 AbobotulinumtoxinA and incobotulinumtoxinA are also approved to treat lateral canthal lines, but many off-label cosmetic indications do exist.8,9 BoNT is a natural, single-chain polypeptide that can be assembled into a larger multi-protein complex.10 OnabotulinumtoxinA, abobotulinumtoxinA and prabotulinumtoxinA contain varying amounts of complexing proteins, but incobotulinumtoxinA does not.10 OnabotulinumtoxinA and prabotulinumtoxinA are associated with complexing proteins of a molecular weight of 900 kDa.10 AbobotulinumtoxinA is also associated with various complexing proteins, with molecular weights ranging from 500-900 kDa.10 In contrast, incobotulinumtoxinA is free from complexing proteins and has a molecular weight of 150 kDa.10 The role of complexing proteins is not clear. There is some evidence that after reconstitution, many complexing proteins 37

CPD Botulinum Toxin

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end up dissociating from BoNT as it transitions to its free state.11 In their native state, the complexing proteins have several functions, many of which are protective.11 It was initially believed that the proteins could assist with adherence to the target muscle, and that the complex’s overall larger size would limit diffusion.

However, there has been no difference seen in diffusion between the free and complexed forms.11 Another theory suggests that complexing proteins may enhance BoNT’s stability. However, studies have not proven this to be true, as the free form has demonstrated long-term stability in various storage conditions.1,12,13 The exact dosing ratio between the formulations remains controversial and often depends on physician preference and clinical application. A commonly utilised ratio between onabotulinumtoxinA, abobotulinumtoxinA, incobotulinumtoxinA and prabotulinumtoxinA is approximately 1:2.5:1:1.13 The dose of BoNT-A products can vary during treatment, based on muscle characteristics (e.g. type, strength and size of the muscle treated) and product characteristics (e.g. dosing, dilution and formulation).1 In general, stronger and larger muscles require higher doses to achieve the desired clinical effects compared to weaker and smaller muscles, including those that have atrophied over time from regular repeat treatments.13

Duration of clinical action

Aesthetics

Regular repeat treatments over time for aesthetic indications can cause weakness of the treated muscle, eventually leading to muscle atrophy.15 It therefore stands to reason that further treatments may require a smaller dose to produce the desired effect. Furthermore, these clinical effects may also appear to have a longer duration since the muscle has become weakened.15 With greater dosing of BoNT-A per treatment area, the clinical effects might last longer until a certain point.15 The degree of diffusion may vary between the formulations of BoNT-A, but these differences are believed to be subtle. Diffusion capacity is also dependent upon the dilution of the reconstituted BoNT.15 Prior to reconstitution, onabotulinumtoxinA, abobotulinumtoxinA and prabotulinumtoxinA must be kept refrigerated, whilst incobotulinumtoxinA may be stored at room temperature for up to 36 months, according to manufacturers’ guidance.

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The safety of BoNT-A has been well established over the years, and the various formulations appear to have similar safety profiles.16 PrabotulinumtoxinA is the newest on the market, so despite extensive studies and five years’ worth of safety data, a longer-term safety profile is still being established.25-28

BoNT treatment failure In recent years, there have been reports of failure of BoNT treatments.17 There are several potential reasons for treatment failure which can be divided into immunogenic and non-immunogenic causes.

In some patients, the subsequent re-treatments with exact dosing and techniques produce lessened results.1 Therefore, increased doses are then often used, and patients may stop responding altogether.1 Researchers Bellows and Jankovic defined the primary non-response as a situation in which patients treated with BoNT did not improve from the first or all the subsequent treatments.18 The secondary non-response is defined as a situation when the patient had responded to at least one BoNT treatment, but had lost that response with subsequent treatments.18

Causes of toxin failure can include over shaking, inadequate dosing, wrong injection depth or failure to map out the target muscles

The duration of clinical action appears to be clinically similar between the various formulations of botulinum toxin type A, but understanding variation is complex.13 Different factors such as muscle characteristics (e.g. type, strength and size of muscle treated), patient characteristics (e.g. local metabolism) and product characteristics (e.g. dosing, dilution and formulation) impact its effect.14 The current consensus is that all available BoNT-A produc ts have a clinical duration of about three to six months for their aesthetic effects.14 While limited evidence may demonstrate slight differences between these products, comparative trials have generally shown them to be similar.14

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Aesthetics

The formation of neutralising antibodies (nABs) is believed to be the main reason for reduced efficacy in some patients.19 This is controversial, however, as it is not completely supported in the literature.

Non-immunogenic resistance Not all patients with BoNT nABs are resistant, and not all resistant patients have nAB.20 This suggests that immunogenicity is not the only reason for the BoNT treatment failure. Other factors can include disease progression, underdosing, inappropriate muscle injection, expiration of placebo effect and changes in the pattern of muscle hyperactivity.21

The reconstitution technique may affect the efficacy of BoNT treatment. The crystals of BoNT may be damaged by aggressive handling (shaking, aspiration, or injection of the solution with high pressure when using a small gauge needle).22 Dressler et al. demonstrated a 42% loss of potency of BoNT in a mouse hemi-diaphragm following aggressive reconstitution with a small gauge needle.22 The solution was injected and aspirated multiple times and a vial shaken for 30 seconds. This was compared to gentle reconstitution with a large gauge needle, a single aspiration injection and two gentle shakes.22 Immunogenic resistance The prevalence of nABs is found to be higher in older BoNT-A formulations than in newer ones.23 Moreover, the overall incidence of nABs after BoNT-A treatment is minimal and reported to be 1% to 2.1% across different studies.18,23 Across the clinical indications, nABs prevalence was significantly higher in dystonia, spasticity and urologic conditions, and nil to insignificant in hyperhidrosis and aesthetic indications.21

Aesthetics | November 2024

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CPD Botulinum Toxin

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Immunogenicity refers to the ability of a substance (antigen) to stimulate an immune response leading to (neutralising) antibody formation.23 NABs inhibit BoNT-A uptake (binding of the heavy chain) and therefore effect.1 NABs may be related to the complexing proteins found in the various formulations.23 For a long time, cases of therapeutic failure were reported in patients who had received onabotulinumtoxinA and abobotulinumtoxinA treatments, while there were no reports in those who had received incobotulinumtoxinA.1 As you will recall, incobotulinumtoxinA does not contain complexing proteins.

Antibodies were later found to affect a patient treated with this toxin.1 The primary response means that a person already has nABs to BoNT-A before the treatment starts and does not respond partially or fully which is rare.21 Secondary non-response means the patient responds very well to BoNT-A treatment initially, but subsequently starts to produce nABs, and, over time, may become less responsive to the treatment (partial secondary non-responder).21 Frequencies published range between 0%-3.5% over all indications.18,21 In ‘clinical indications’, the problem of nABs is most likely due to the higher doses of BoNT-A applied.21 Factors that can contribute to the formation of nABs include shorter intervals of treatment, higher dosage, amounts of antigenic proteins, serotypes and storage of formulations.23 The formation of antibodies is a continuous process, starting with a low antibody titer of little to no clinical consequence. This is then followed by a higher titer, which can lead to a partial non-response. Finally, a complete non-response follows in cases where a higher titer is formed as all neurotoxin is captured by antibodies.22 The formation of nABs can usually be observed when the injected dose does not show that same effect at the beginning of the therapy and does not result in a similar duration.24 Consequently, a higher dose is injected to achieve the same effect and duration (‘dose creep’).24 A higher dose can compensate for low or intermediate antibody levels, as has been show in neurological indications. This, however, would initiate a vicious cycle because a higher amount of antigen (neurotoxin) would further increase the antibody formation so that an even higher dose is required, which further drives antibody development.22

are not as readily available as BoNT-A, and do not carry the same licensing as the type A preparations we are discussing.

Antibodies can be tested for and measured to determine if therapeutic failure is antibody mediated, but this is not practical in a standard aesthetic clinic.

Weighing up the options We have looked at the pharmacology of readily available botulinum toxin preparations here in the UK. While there are some differences, namely in preparation, molecule size and reconstitution guidelines, there are many similarities in the mechanism of action at the nerve terminal. Their end result and duration of effect seems comparable. It is important that the reader appreciates reasons for failure of treatment, and not assume it is due to immunogenicity. Some non-immunogenic causes can include reconstitution techniques (over shaking), inadequate dosing, wrong injection depth or even failure to map out the target muscles.

Test your knowledge!

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

Questions 1. Who were the first

Dosing of toxin for aesthetic treatments is generally low compared with the therapeutic indications.18 Newer treatment indications, novel applications for aesthetic purposes and greater overall doses, as well as a younger patient population receiving treatments, may prove to be an immunogenic problem later on.

Initial symptoms of toxin resistance include decreased clinical efficacy or shortened longevity.18 Decreased efficacy could often be detected by generalised or focal remaining muscle activity after treatment.18 More residual muscle activity at a certain time could be considered as shortened longevity.18 The broad frontalis muscle reflects these decreases in efficacy more sensitively than the smaller glabellar or orbicularis oculi muscles.18 If treatment failure is encountered in practice, then a different type of BoNT product can be trialled.18 Another option would be to switch to a type B formulation, which again binds to nerve terminals and prevents acetylcholine release. However, these

a. Heather Johnson and Bill Johnson

to use botulinum toxin to treat static rhytids (wrinkles)?

b. Jean and Alistair Carruthers

2. BoNT/A1 is a relatively large protein consisting of an N-terminal light chain and a heavy chain.

Its sizes are...

a. 50kDa and 100kDa

c. Mark Dressler and Patricia Dressler d. James Watson and Francis Crick

b. 100kDa and 150kDa c. 150kDa and 900kDa d. 200kDa and 600kDa a. OnabotulinumtoxinA (Botox)

3. Which one does not need to be refrigerated?

b. AbobotulinumtoxinA (Azzalure) c. PrabotulinumtoxinA (Nuceiva) d. IncobotulinumtoxinA (Bocouture)

4. Which is not

Considerations with toxin dosage

Possible answers

considered to play in a role in treatment failure?

5. What is the overall

a. Aggressive reconstitution b. Dose c. Vial size d. Inappropriate muscle injection a. 5-6%

incidence of neutralising b. 1-2.1% antibodies after BoNT-A c. 7.9-9% treatment thought to be? d. 20-23% Answers: B, A, D, C, B

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Dr Nestor Demosthenous obtained his medical degree and BSc Hons Neuro from the University of Edinburgh in 2006, and his MSc in Aesthetic Medicine with distinction from QMUL in 2019. He is a an Allergan Medical Institute Faculty member, and is actively involved in clinical research.

Qual: MBChB, BSc Hons Neuro, MSc

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Injectables Selecting Products

volume, soften shadows and enhance facial contours. They are not to be confused with biostimulatory fillers, which include products containing calcium hydroxyapatite (such as HArmonyCa and Radiesse), poly-L-lactic acid (like Sculptra) or polycaprolactone (like Ellansé).9 Biostimulatory fillers are non-reversible and work by inducing an inflammatory response that leads to collagen deposition and skin tightening, gradually creating volume over time.2,3,9

Selecting Injectables for the Upper and Mid-Face Dr Carol Mastropierro discusses the best injectables for optimal treatment of the upper and mid-face In facial aesthetics, the selection of injectable products plays a pivotal role in achieving optimal outcomes for patients seeking non-surgical rejuvenation.1 This article aims to provide a comprehensive guide to navigating the complexities of injectables for the upper and mid-face, exploring the nuances of the ageing process and focusing on key considerations in treatment sequencing and essential principles for patient safety. A particular focus will be placed on the varying rheology of dermal fillers, as they are a versatile treatment modality in this area. By examining these critical factors, practitioners can enhance their proficiency in selecting and administering injectables, ensuring both efficacy and patient satisfaction.2,3

Understanding the ageing process As we age, the face undergoes fundamental structural changes, leading to an inversion of the ‘triangle of youth’.1,2 In youth, the widest part of the face is at the cheeks, tapering to a narrow chin, forming a downward-pointing triangle. As ageing progresses, this triangle inverts due to volume redistribution and structural changes, resulting in a broader jawline with jowls and less prominent cheekbones.4 In the upper face, ageing manifests as expression lines and wrinkles, hollowing of the temples and loss of zygoma definition. These changes are often due to the redistribution and loss of facial fat, as well as degradation of collagen and elastin in the skin.2,3 Hollowing of the temples occurs as the temporal fat pads diminish, leading to a gaunt appearance, often paired with prominent frontotemporal ridges and frontal hollowing.6,7 The mid-face also experiences significant changes. The once-pronounced cheek apex flattens, contributing to a less youthful contour.6 Additionally, the nasolabial fat pads enlarge, deepening the nasolabial folds.6 This is compounded by bone resorption in the piriform area, accentuating piriform shadowing. Bone resorption around the maxilla and mandible further contributes to facial sagging and volume loss.6

Product possibilities The UK market offers several options to address facial ageing, targeting different layers and employing various mechanisms of action. Botulinum toxin A, a well-established treatment, works by inhibiting the release of acetylcholine at the neuromuscular junction, effectively relaxing the muscles responsible for expression lines and wrinkles.1,5,8 Hyaluronic acid (HA) fillers are volumisers that instantly restore

As the aesthetics sector increasingly embraces regenerative medicine, polynucleotides (such as Plinest and PhilArt) have emerged as significant agents in skin regeneration.12 Polynucleotides are characterised by high fluidity and low viscosity, which allows them to diffuse easily within the skin layers, promoting even hydration and improving overall skin texture.19 These products are not designed for volumisation, but rather for enhancing skin quality, meaning they can be injected all over the upper and mid-face.12,19 The bioremodelling effect from the hybrid high and low molecular weight HA in the new Profhilo Structura can also be effective, addressing the resorption of the lateral cheek fat compartment – a key contributor to mid-face sagging.1,6,13 The rest of this article will explore where in the upper and mid-face these products can be used for optimal patient results.

Rheological principles of dermal fillers Rheology determines how well fillers maintain their shape, integrate with surrounding tissues and achieve the desired aesthetic outcomes. Key parameters such as viscosity, cohesivity and elasticity, along with G prime (G'), dictate how the product flows, adheres and integrates within facial structures. G' represents the elastic modulus of the filler, reflecting its stiffness and resistance to deformation. A higher G' indicates a firmer gel that provides robust structural support, while a lower G' denotes a more flexible and fluid consistency.1,4,5 Forehead: Low viscosity and flexibility Due to the highly mobile nature and thin skin of the forehead and glabellar, injectables with moderate viscosity and a lower G' should be preferred to ensure smooth integration without interfering with natural movement.14,24 Low G' HA fillers like Neauvia Flux or Juvéderm Volbella are my choice in the deep fat layer, injected via a 22G cannula to create a youthful convexity to the forehead and soften frontal bossing, as cannulas can enhance safety in areas of dense vascularity.28 Needles should not be used here, as this area carries one of the highest risks for filler-induced blindness due to the anastomoses between the glabellar region and the ophthalmic artery.31,32 While biostimulatory fillers are not indicated here as they could interfere with animation,28 other options for upper face lines include botulinum toxins to reduce dynamic and soften static wrinkles.8,29,30 Temples: Rheology catered to each layer The temples require strategic consideration due to their complex anatomy and multiple depths.15 For supraperiosteal injections, high G' fillers with high viscosity and moderate cohesivity like Juvéderm Voluma or Revanesse Shape are preferred for their robust lifting capacity, and ability to provide structural support while allowing integration with the temporalis muscle.15,24 The interfascial layer can be approached with a 22G cannula and a medium to high G' filler like Revanesse Contour or Teosyal RHA 4, which can be used here to fill hollows without causing surface irregularities.24 The subcutaneous approach with a 22G cannula can be performed with a medium G’ HA, such as Revanesse Ultra, or addressed with a biostimulator with a low to medium viscosity like Sculptra or Ellansé, as they stimulate collagen production over time for long-lasting volumisation and contouring.24,25

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Lateral cheek: High viscosity and elasticity High G' fillers like Neauvia Intense or Teoxane Ultra Deep are suitable for supraperiosteal injections, providing the necessary structural support and volumisation. These fillers can help optically elevate the mid-face, reduce jowling and contour the cheekbones.

Using 27G needles supraperiosteally and 22G or 25G cannulas in layer four are reliable techniques to approach this area.5,14 Medial cheek: Flexibility and cohesivity The medial cheek, which includes the suborbicularis oculi fat (SOOF) and deep medial cheek fat, requires more flexible fillers with moderate viscosity and cohesivity.5,14 Products like Teosyal RHA 3 or Revanesse Ultra offer the necessary balance between structure and integration, avoiding a bulky appearance on animation while providing volume restoration.5,14 Caution should be taken when using biostimulators medial to the line of ligament, where the facial tissues are mobile.28 Sculptra, however, can be considered because of its high fluidity, making it suitable for dynamic areas like the mid-face.24 Preauricular area: High cohesivity and longevity The preauricular area, representing the lower two thirds of the lateral temporal cheek fat, is often overlooked, but plays a crucial role in creating a harmonious facial contour.3,4 A filler with high cohesivity and moderate to high G', to provide the necessary definition and durability, can be spread across layer two via cannula.5,14 Neauvia Stimulate or Ellansé can provide this, ensuring that the filler stays in place and delivers a long-lasting effect.25 HArmonyCa, which combines HA with calcium hydroxide (CaOH), also offers excellent results by providing immediate volumisation and long-term structural support.26 Profhilo Structura, with its high elasticity and low viscosity, integrates into the tissue to improve laxity and restore the adipose tissue in the lateral cheek.13,27

Optimal treatment sequencing Achieving harmonious facial rejuvenation requires a strategic approach whereby practitioners can leverage the unique benefits of each product, rather than viewing these products as mutually exclusive.3,4 Generally, treatment sequencing should proceed from top to bottom, lateral to medial, and deep to superficial.2,5 This ensures that structural support is established before addressing surface issues, leading to natural, durable results.2,5 Depending on the practitioner’s expertise and specific patient concerns, it may be advisable to start with botulinum toxin in the upper face, given its favourable safety profile and high patient satisfaction.8,29,30 I prefer to start with toxin rather than other treatments because the results are almost immediate, with little downtime, making them an attractive starting point in a patient journey. Some practitioners choose to administer toxin in the same session as other injectable treatments; as there are no official guidelines on this, individual discretion is advised. Similarly, enhancing the lateral cheek with a high G’ filler is often seen as an initial step in mid-face rejuvenation, and one which receives high satisfaction from my patients.1,4 Volumisation of the medial cheek can also effectively support the under eyes and create a smooth transition between the cheek and nasolabial fold.1,4 The medial cheek and SOOF can be slightly trickier to address as they require being confident using a cannula in, beneath the SMAS.1,4 A 25 or 22G cannula is preferred as this minimises the risk of vascular and nerve complications.21 Deep placement is crucial to ensure natural facial animation and avoid an uneven surface.20 Biostimulatory products can be particularly beneficial for the temples and immobile parts of the mid-face. While they are more complex to use and carry a higher risk of complications, mastering them delivers satisfactory results and significantly reduces the amount of HA filler

Injectables Clinical Practice News Selecting Products

needed in future treatments.9,25 Since collagen deposition from biostimulators takes an average of three months, HA fillers can be considered roughly 12 weeks after using a biostimulatory product if further volume enhancement is needed.9,10 However, some specific products might have longer and/or more specific timeframes around when they can be used alongside other treatment modalities, so adherence to manufacturers’ guidelines is imperative.

Polynucleotides work exceptionally well for the outermost lines and wrinkles, which are often difficult to target with other injectable options. A course of three-four treatments is typically required three to six weeks apart, with skin quality improvements becoming fully apparent over the course of six months.12,19 Since polynucleotides are injected into layer one (the skin), they can be safely administered alongside other injectables, allowing for an integrated approach complementing the volumising effects of other treatments while enhancing overall skin quality.12,19 While I find that combination treatments typically deliver the best results, it is important for practitioners to start with the treatments they are most comfortable with and plan multiple sessions to manage and isolate potential complications.1,2,4 Treatment planning should always focus on the patient's primary concern, and if the suggested treatment differs from their request, extensive patient education is necessary to align the patient's expectations with realistic outcomes.

Familiarising yourself with the various options available by attending educational events can help navigate selecting treatments that provide the best possible outcomes.4,5,7

Safety considerations As medical professionals, patient safety is always at the forefront of our practice. It is essential to identify potential contraindications, such as medical conditions (especially autoimmune diseases) and allergies, through a thorough initial consultation. The risk of infection after all injectable procedures can be minimised by maintaining an aseptic, non-touch technique and providing appropriate aftercare advice.11 Patients should avoid touching or applying makeup to the treated area for at least 24 hours to prevent contamination and reduce irritation.22 Refraining from strenuous activities, hot environments like saunas, and exercise will help minimise bruising and swelling.22 Lastly, patients should be instructed to monitor the treated area for any unusual feelings and/ or colour changes, and report any concerns promptly.

Serious complications, such as vascular events and nodules, are rare but must be anticipated.16,17,18 Practitioners are encouraged to establish a safety network around them, keep a fully stocked emergency kit and not hesitate to seek assistance if complications arise. Continuous education and collaboration within the medical aesthetics community are key to ensuring patient safety and effective treatment outcomes.

Providing optimal results Achieving good aesthetic results requires understanding the ageing process and the range of injectables available. Injectors can better their practice by considering the rheology of fillers, strategically sequencing treatments and prioritising patient safety. Combination treatments offer comprehensive rejuvenation, and practitioners are encouraged to continuously expand their knowledge and refine their techniques to effectively tailor treatments to individual anatomy.

Dr Carol Mastropierro is an aesthetic doctor and owner of WRINKLESS in Stevenage, Hertfordshire.

As a clinical trainer in injectables and cosmetic dermatology for Harley Academy, she is dedicated to enhancing learning and setting high standards, while delivering exceptionally natural results.

Qual: MBBCh, Pg Dip, MD

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Aesthetics | November 2024

43

KL EF

50 microgram/g

cream trifarotene

0

=

AKLIEF

50 microgram/g

cream trifarotene Cutaneous use

Redefined by trifarotene

AKLIEF

50 microgram/g cream trifarotene

1-4

Cutaneous use

here,

Cream 75g

GALDERMA

GALDERMA

WOd

AKLIEF® (trifarotene) An antibiotic free treatment option Aklief is a topical retinoid indicated for the cutaneous treatment of moderate acne vulgaris of the face and/or trunk in patients from 12 years of age and older when many comedones, papules and pustules are present5 Aklief is contraindicated during pregnancy or for women planning a pregnancy

Aklief 50 microgram/g cream - Prescribing Information (United Kingdom)

Please refer to SmPC before prescribing. Presentation: Aklief is presented in a multidose container with airless pump containing 75g of cream. One gram of cream contains 50 micrograms of trifarotene. Indications: Aklief is indicated for the cutaneous treatment of Acne Vulgaris of the face and/or the trunk in patients from 12 years of age and older, when many comedones, papules and pustules are present. Dosage and Method of administration: Dosage: Apply a thin layer of Aklief cream to the affected areas of the face and/or trunk once a day, in the evening, on clean and dry skin. It is recommended that the physician assesses the continued improvement of the patient after three months of treatment. Special populations: Paediatric population and Elderly patients. The safety and efficacy of Aklief in children below 12 years old and in geriatric patients aged 65 years and above have not been established.

Renal and hepatic impairment. Aklief has not been studied in patients with renal and hepatic impairment. Method of administration: For cutaneous use only. Before using the pump for the first time, prime it by pressing down several times until a small amount of medicine is dispensed (up to 10 times maximum). The pump is now ready to use.

Apply a thin layer of Aklief cream once a day, to the following affected areas, in the evening, on clean and dry skin: • forehead, nose, chin and right and left cheeks – one pump actuation should be enough. • upper trunk (i.e. reachable upper back, shoulders and chest) – two pump actuations should be enough • one additional pump actuation may be used for middle and lower back if acne is present. Patients should be instructed to avoid contact with the eyes, eyelids, lips and mucous membranes and to wash their hands after applying the medicinal product. Contraindications: • Pregnancy • Women planning a pregnancy • Hypersensitivity to the active substance or to any of the excipients.

Precautions and Warnings: To mitigate the risk of erythema, scaling, dryness, and stinging/burning, patients should be instructed to use a moisturizer from the initiation of treatment (while allowing sufficient time before and after the application of Aklief cream to allow the skin to dry), and, if appropriate, reduce the frequency of application of Aklief cream, or suspend use temporarily. If severe reactions persist the treatment may be discontinued. The product should not be applied to cuts, abrasions, eczematous or sunburned skin. As with other retinoids, use of “waxing” as a depilatory method should be avoided on skin treated with Aklief. If a reaction suggesting sensitivity to any component of the formula occurs, use should be discontinued. Caution should be exercised if cosmetics or acne medications with desquamative, irritant or drying effects are concomitantly used with the medicinal product, as they may produce additive irritant effects. Aklief should not come into contact with the eyes, eyelids, lips, or mucous membranes. If the product enters the eye, wash immediately and abundantly with lukewarm water. Excessive exposure to sunlight, including sunlamps or phototherapy should be avoided during the treatment. Use of a broad-spectrum, waterresistant sunscreen with a Sun Protection Factor (SPF) of 30 or higher and protective clothing over treated areas is recommended when exposure cannot be avoided. This product contains propylene glycol (E1520) that may cause skin irritation. Aklief also contains 50 mg alcohol (ethanol) in each gram which is equivalent to 5% w/w. It may cause burning sensation on damaged skin. Pregnancy, Breast-feeding and Fertility: Orally administered retinoids have been associated with congenital abnormalities. When used in accordance with the prescribing information,

topically administered retinoids are generally assumed to result into low systemic exposure due to minimal dermal absorption. However, there could be individual factors (e.g. damaged skin barrier, excessive use) that contribute to an increased systemic exposure. Pregnancy: Aklief is contraindicated during pregnancy or in women planning a pregnancy. If the product is used during pregnancy, or if the patient becomes pregnant while taking this drug, treatment should be discontinued. Breast-feeding: A risk to the suckling child cannot be excluded. A decision must be made whether to discontinue breast-feeding or to discontinue/abstain from Aklief therapy taking into account the benefit of breast-feeding for the child and the benefit of therapy for the woman. To avoid the risk of ingestion by, and/or contact exposure of, an infant, nursing women should not apply trifarotene cream to the chest or breast area. Fertility: No human fertility studies were conducted with Aklief. After oral administration of trifarotene to dogs, findings of Germ cell degeneration were observed. Effects on ability to drive and use machines: Aklief has no or negligible influence on the ability to drive and use machines. Undesirable Effects: The most “commonly” reported adverse reactions (occurring in ≥1/100 to <1/10 patients) of application site irritation, application site pruritus and sunburn (see table below) occurred in 1.2% to 6.5% of patients treated with Aklief cream in clinical studies.

Table of “commonly” reported adverse reactions of patients treated with Aklief cream in clinical studies System Organ Class Adverse reactions General disorders and administration site conditions Application site irritation, Application site pruritus Injury, poisoning and procedural complications Sunburn Prescribers should consult the Summary of Product Characteristics (SmPC) in relation to the uncommon (≥1/1,000 to <1/100) and rarely occurring (≥1/10,000 to <1/1,000) adverse reactions as reported in these studies. Packaging Quantities and Cost: 1 x 75g multidose container with airless pump; £ 27.75 excluding VAT. Marketing Authorisation Number: PL 10590/0071. Legal Category: POM. Marketing Authorisation Holder: Galderma (UK) Limited, Evergreen House North, Grafton Place, London, NW1 2DX, United Kingdom. Further information is available from: Galderma (UK) Ltd, Evergreen House North, Grafton Place, London, NW1 2DX, United Kingdom.

Telephone: +44 (0)300 3035674. Date of Revision: July 2023.

Adverse events should be reported.

Reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

Adverse events should also be reported to Galderma (UK) Ltd: E-mail: medinfo.uk@galderma.com Tel: +44 (0)300 3035674

References: 1. Kasser M et al. J Cosmet Dermatol. 2020;00:1–6. 2. Stein Gold L et al. Dermatol Ther (Heidelb) 2021;11:661–664 3. Blume-Peytavi U et al. JEADV 2020, 34, 166–173. 4. Bell K et al. Annals of Pharmacotherapy 2021;55(1) 111–116 5. Aklief Summary of Product Charactistics. Available at: https://www.medicines.org.uk/emc/product/13881/smpc#gref. Accessed: Oct 2024 GB-AFC-2400106 I October 2024

GALDERMA

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Patient Safety Complications It is widely recognised that avoiding complications is preferable to management, thus extensive knowledge of facial structures and vascularity is indispensable.3

Pre-treatment considerations and antisepsis

Avoiding Upper and Mid-Face Complications Dr Karla Murta explores the potential complications in the upper and mid-face, alongside techniques to mitigate these risks It is undeniable that upper and mid-face injectable treatments create impressive results in rejuvenation and can be provided to patients with minimal downtime. Botulinum toxin, dermal fillers and collagen stimulants are amongst the common treatments used in the upper and mid-face, and they can provide substantial aesthetic improvement due to reduction of rhytids, volume restoration and improving facial contour.1 However, these procedures are not without risks. The anatomy of these areas is challenging due to the proximity of critical anatomic structures, including numerous blood vessels and nerves. The risks encompass bruising, swelling, infection, asymmetry, vascular occlusion and, in rare cases, blindness.2,3,4 This article aims to provide insight into avoiding complications associated with injectable treatments in the upper and mid-face, and the proper techniques to avoid them occurring.

Understanding the anatomy of the upper and mid-face Containing the forehead, eyes and temporal regions, the upper face is limited superiorly by the hairline margin, inferiorly just under the lower eyelids at the glabellar, and laterally by the temporal region.2 The injection areas of interest in the upper face include the forehead, glabellar complex, temples, tear trough and periorbital zones.

The mid-face area begins at the glabellar superiorly and terminates at the subnasale, inferiorly just under the nose. The ears encompass the lateral borders of the central face.

This central area of the face contains the nose, cheeks and ears.2 The clinically significant regions of the mid-face are the cheeks, nose, piriform fossa and nasolabial folds.

The primary vascular supply to the face originates from the external carotid artery and its branches.2 The common carotid artery ascends cranially, and bifurcates into the internal and external carotid arteries. The external carotid artery subsequently gives rise to several branches, including the superior thyroid, lingual, facial, ascending pharyngeal, occipital, posterior auricular, maxillary and superficial temporal arteries. Among these, the facial, superficial temporal and maxillary arteries serve as the principal vessels responsible for facial perfusion. The superficial temporal artery courses toward the temporal and forehead regions, primarily supplying these areas. The facial artery (FA) – the main source of blood flow to most of the medial face – travels toward the lips and nose.2 The maxillary artery provides vascularisation to both the cheek and deeper facial structures. Venous drainage of the face predominantly occurs via the common facial vein, which ultimately drains into the internal jugular vein.2 Practitioners must consider these arteries while delivering injectable treatments.

Aesthetics | November 2024

Prior to treatment, antiseptic solution should be used to clean the treatment area, which should be free of makeup.4 Although there is little evidence to support special skin preparation, alcohol swab preparation pads are frequently employed.4 One of the general principles for reducing infections is to use 70% isopropyl alcohol with 2% chlorhexidine gluconate for efficient skin antisepsis.5,6 Sterile dressing trays, drapes and disposable nonsterile gloves can also help provide a clean work environment.6 Selecting the right technique for each area is crucial, and takes into account the region to be treated, injection depth, volume injected and the needle’s technical qualities.7

Complication avoidance Numerous complications can be avoided by using a conservative approach when it comes to the quantity of substance utilised and the injection depth.7 Careful adherence to rheological and anatomical parameters for each different area is also crucial.

Forehead and glabellar In the forehead and glabellar, the frontalis muscle, positioned in the upper third of the face, originates from the galea aponeurotica beneath the coronal suture, and connects to the skin around the eyebrow.10 It interweaves with the fibres of the procerus, corrugator and orbicularis oculi muscles.10 This is a common site for toxin injections aimed at reducing wrinkles and frown lines. However, these areas can present complications such as incomplete response, eyelid or brow ptosis and lack of expressivity.9 Eyelid ptosis, which can vary from slight drooping to complete eye closure, occurs because of impairment of the upper eyelid levator muscle. This type of ptosis can also arise when toxin is injected near the glabellar, as the toxin may migrate through the orbital septum, leading to weakening of the levator palpebrae superioris muscle.10 This is more likely to occur when the toxin is injected near the bony supraorbital margin at the mid-pupillary line, or when large volumes of diluted toxin are used in this area.10 This issue can be avoided by injecting the frontalis muscle at least 2-3cm above the supraorbital margin, or 1.5-2 cm above the eyebrow.10 Conversely, a raised appearance of the eyebrow tail may result if the lateral portion 45

Patient Safety Complications of the frontalis muscle is not treated while the medial portion is injected. To prevent this, it is recommended to treat both the elevator and depressor muscles simultaneously to avoid unbalanced muscle activity.10 Eyebrow asymmetry, which may occur due to differences in the injection site, dosage or anatomical variations, can also happen. A common form of asymmetry is the ‘Spock’ or ‘Mephisto’ brow, characterised by an exaggerated curvature of the lateral brow. This results from imbalance between inactivation of the central frontalis muscle and continued activity of the lateral portion, which raises the brow’s tail. This complication can be resolved by administering a small additional dose of toxin to the active lateral region of the muscle.10 Other, less common complications can occur, such as diplopia, which may result from toxin diffusion or accidental injection into the orbit, affecting the extraocular muscles, typically the lateral rectus muscle.10 Lagophthalmos may arise due to paralysis of the orbicularis oculi muscle, causing weakened function and difficulty in fully closing the eyes, leading to ocular dryness.10 Palpebral ectropion can occur in patients with eyelid laxity when injections are administered in the pre-tarsal region near the lower eyelid margin.10 Prominence of the palpebral bags may also occur due to increased laxity of the orbicularis muscle, which causes the fat pads to project outward.10 Additionally, lymphatic drainage in this area may be compromised, leading to eyelid oedema, particularly in patients with significant orbicularis muscle laxity and long wrinkles extending to the malar region.10

Temples The temporal region has a vascular supply originating from both the internal and external carotid vascular zones.13 Ophthalmic artery circulation is associated with the temple area artery circulation via the supraorbital, zygomatico-temporal, zygomatico-facial, superior and inferior palpebral and angular arteries (via the

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transverse facial and infraorbital) – a complex network which practitioners have to be very well aware of prior to treatment.14 Treatment can be administered to the anterior temple to provide volumising effects, including the subdermal technique, low supraperiosteal technique (one up and one over technique) and high supraperiosteal technique (3PF = three-point full face). In addition, the supra-auricular lifting technique (dynamic three-dimensional lifting) and temporal lifting technique (posterior temporal supra-SMAS minimally invasive lifting) can be administered to the posterior temple and mainly cause a lifting effect of the mid- and lower-face.12 Techniques to avoid complications here include:

· Use blunt cannulas instead of needles

to reduce the risk of vascular injury while injecting more superficially.14 · When injecting with a needle, if necessary, aspirate.14 · Inject small amounts of filler slowly and carefully to monitor correct placement.

Emerging research suggests that it is safer to administer small aliquots of 0.1ml at each injection point, followed by needle redirection without withdrawal, aspiration and subsequent injection, rather than delivering larger volumes or boluses at fewer injection sites.14

Periorbital area The orbicularis oculi muscle is a flat, wide sphincter muscle surrounding the eye, consisting of three primary sections: the palpebral, orbital and lacrimal portions.10 The exact cause of tear trough deformity (TTD) – the most common cosmetic concern in this region – remains unclear.

However, several contributing factors have been suggested, including gender differences, congenital or age-related maxillary hypoplasia, laxity of periorbital retaining ligaments, cutaneous elastosis, changes in superficial and deep fat compartments and genetic predisposition.15

The anatomy of these areas is challenging due to the proximity of critical anatomic structures, including numerous blood vessels and nerves 46

Aesthetics | November 2024

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Treatments around the eyes include toxin to the orbicularis oculi muscle to improve crow’s feet rhytids, and tear trough fillers to address under-eye hollowness and dark circles. These procedures are highly sought after but can lead to complications such as bruising, infections and oedema.

Treatment with toxin may lead to smile asymmetry,10 and tear trough filler to vascular compromise.15 Techniques to avoid periorbital complications include:

· For toxin treatment, the injection points

must be at least 1cm laterally to the bony orbit, and not close to the inferior margin of the zygoma.6 · Choose hyaluronic acid (HA) fillers with a lower G prime / lower viscosity for safer injection as they cause fewer adverse effects.15 · Use a cannula to reduce the risk of vascular complications when performing dermal filler.15 · Ensure deeper injections of filler to avoid the Tyndall effect – a blue discolouration that appears beneath the skin when HA is injected too superficially.15 Filler must be deposited superficial to the orbital septum – a thin fibrous layer originating from the periosteum along the inferior and superior orbital rims.15 The injection is placed at the supraperiosteal level, between the orbicularis retaining ligament and the zygomatic cutaneous ligament.15

Cheeks An important anatomical concept involves the five-layer structure of the cheeks, extending from bone to skin. It includes deep static fat compartments, which are separated from the more superficial, mobile fat pads by a thin muscular layer.16 Dermal filler treatments for increased malar projection and full upper cheeks are important indications due to the considerable contribution to a youthful appearance.16 However, cheek augmentation of this nature may cause complications that include filler being applied too superficially, contour irregularities, asymmetry and vascular occlusion.4,15 In the deep fat injection technique, the product is administered slowly and with low pressure, using a bevel-down needle inserted at a 90° angle to the skin surface until bone contact is made.16 In general, I find that injection volumes as small as 0.2ml per fat pad are sufficient to achieve visible improvement, though patients with more significant volume loss may require 0.3ml or more per compartment. Notably, injecting larger volumes into the medial suborbicularis oculi fat compared to the

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lateral SOOF enhances anterior projection, while increasing volume in the deep medial cheek fat creates a fuller mid-cheek, allowing for personalised treatment plans. Following the injection, gentle digital massage helps smooth the filler and reduce visible irregularities, especially in patients with thinner skin.16 In general, fillers which are characterised by a high G’ and high tensile strength are well-suited for injection into the deep static fat pads.16 These fillers offer robust and long-lasting structural support to enhance malar projection. The deep static fat compartments of the mid-face can be safely treated using either a bolus injection with needle or a fan-like technique using a cannula.16 To minimise the risk of complications in this area, consider:

· Use a deep supraperiosteal injection technique to place the filler on the bone slowly and at a low pressure.16 · At the cheek apex, aspiration is highly recommended before injecting the filler due to its proximity with the infraorbital artery and its branches.16 · Regularly reassess to avoid asymmetry during treatment.

Nasolabial folds Few recent anatomical studies indicate that in most individuals, the facial artery follows the nasolabial fold, terminating at either the angular artery (36.6%), lateral nasal artery (48.6%) or superior labial artery (8.5%).16 However, a small percentage (6.8%) have a hypoplastic FA that ends at the inferior labial artery.16 Additionally, in about 30% of individuals, the FA splits into a nasolabial trunk and an infraorbital trunk, with the latter ascending vertically toward the nasojugal groove.16 The nasolabial fold represents the most medial superficial fat compartment of the mid-face.

This rectangular fat pad is bordered by the nasal sidewall, the levator labii superior alaeque nasi muscle and the nasolabial septum on the medial side, and by the medial cheek septum, infraorbital fat and the medial cheek fat on the lateral side.16 Patients frequently worry about prominent nasolabial folds as they are the one of the first outward manifestations of facial ageing. Fillers in these folds can smooth deep lines, but Drug

Dosage

Quantity

ACE Guidelines

Adrenaline

1:1000/ml

2

Anaphylaxis

Hyaluronidase

1500 I.U.

4

Hyaluronidase

Aspirin

300mg

4 x 75mg

Timolol eye drops

0.5%

1 x 5ml

Vascular occlusion Visual impairment Visual impairment

Loratadine or Cetirizine

10mg

1

Allergy/Angioedema

Sodium bicarbonate

Dissolve powder

50g

Chemical peels

Saline eye wash

10ml

2

Sharps and splash injuries

Table 1: Ideal emergency kit components according to Aesthetic Complications Expert (ACE) Group World Emergency Kit Guidelines19 Drug or Device

Anaphylaxis

Vascular Occlusion

Visual Impairment /Blindness

Telephone to call 999 Adrenaline Hyaluronidase Blood pressure monitor Guedel mask Pulse oximeter Aspirin 300mg Strong paper bag Cold/hot pack Oxygen, mask and tubing Timolol 0.5% eye drops Must contain

complications such as overcorrection and vascular compromise have been described.17 Techniques in this area to negate complications include:

· Use a linear threading or fanning

technique to distribute the filler evenly, with maximum volume of 0.1ml per time.17 · Whenever feasible, opt for blunt, flexible micro-cannulas and non-traumatic, flexible blunt-tip needles to reduce the risk of intravascular injection.17

Constant vigilance Monitoring of signs of complications, including vascular embolic events, while injectable procedures are being performed is essential for good practice.

The natural progression of these events, if left untreated, begins with brief blanching (lasting only a few seconds), followed by livedo reticularis (which can persist for several days), leading to blister formation by day three.18 This is followed by crusting, necrosis, sloughing and eventual healing through secondary intention – a process that can take six weeks or more.18 Typically, blisters appear after approximately three days, with visible necrosis usually occurring after day six.18 However, signs of ischaemia are usually detectable from the onset if carefully observed.18 Being prepared to administer hyaluronidase in case of this event can prevent long-term adverse effects.3 Tables 1 and 2 highlight the medications and devices that an emergency kit should contain, and the steps to be taken in the event of a complication.19

Maintaining consistent safety Injectable treatments in the upper and mid-face offer significant aesthetic benefits, but come with potential risks that practitioners must carefully navigate.

By understanding the intricate anatomy, employing precise techniques and adopting a conservative approach, medical professionals can minimise complications and ensure patient safety to the best of their ability.

Dr Karla Orsine Murta Dias is an aesthetic practitioner and clinical trainer at Harley Academy. She is the medical director at Dr Karla Clinic, in Marylebone, London. She also works as an ophthalmologist at Moorfields Eye Hospital NHS Foundation Trust. Dr Murta is dedicated to advancing the field through research, education and patient care.

Qual: MD, Medical Residency in Ophthamlology, PGCert (Aesth)

Guedel airway

Key:

Patient Safety Complications

Should contain

Useful to have

Table 2: Emergency kit and application for each complication19

Aesthetics | November 2024

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Dual Wavelengths Two clinically proven wavelengths (532nm & 1064nm) in one system.

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25+ Treatments Versatile device addressing a wide range of skin concerns.

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After

Photos courtesy of Dr. A. Hussein. Individual results may vary.

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After

Photos courtesy of Dr. N. Chiang. Individual results may vary.

"excel V+ has become a cornerstone of our practice. Demand for treatments was so high that we invested in a second device. For anyone serious about skin rejuvenation and vascular treatments, this technology is essential. ©2024 Cutera Inc. All rights reserved.

Dr Rishi Mandavia ENT, Head and Neck Surgeon

Scan or visit cutera.co.uk to enquire today

A Clinic Essential A robust and reliable tool for any growing aesthetic practice.

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Case Study: Treating Periorbital Veins Dr Massimiliano Cariati, Dr Tatiana Lapa and Dr Rishi Mandavia explore the use of vascular laser to treat red and blue veins around the eyes The term periorbital veins describes veins located around the eye area, in particular those of the upper eyelids and/or visible under the eyes.1 These veins may become prominent over time due to several factors such as ageing, genetics, sun exposure and lifestyle choices.1,2 The skin around the eyes is thin and delicate, making these veins more apparent, frequently leading to a blue or purple discolouration of the area that many may find unsightly. Whilst prominent periorbital veins are a purely cosmetic issue, they can contribute to a tired or aged appearance, meaningfully affecting confidence and therefore quality of life.3 As the literature explored in this article will demonstrate, historical treatment approaches have previously offered poor risk/reward ratios. In our experience, vascular laser offers a minimally invasive, highly effective and safe solution, making it a desirable treatment choice for both practitioners and patients.

Infraorbital blue

Infraorbital red

Supraorbital blue

Supraorbital red

Handpiece

Coolview

Coolview

Coolview

Coolview

Wavelength (nm)

1064

532

1064

532

Cooling (Cº)

5-10

5-10

5-10

None

Spot size (mm)

3-6

5

2.5-4

2

Fluence (J/cm3)

110-135

8-10

90-125

11.5-13

Pulse duration (ms)

20-30

8

20-25

9

Table 1: Range of treatment parameters with Excel V+ vascular laser; these parameters will also apply to the same type of energy used through a different device11

Available treatment options Traditional treatments for periorbital veins have included sclerotherapy, surgical removal and laser treatments with various technologies. Each of these methods has its own set of limitations and potential risks.4,5 Sclerotherapy This involves injecting a solution of either polidocanol or sodium tetradecyl sulfate into the veins to cause them to collapse and fade. While very effective for veins in the legs, its use around the delicate eye area is limited by the risk of complications such as skin necrosis (and associated scarring), hyperpigmentation and inflammation.4,5 Surgical removal Surgical excision of periorbital veins is a more invasive option that requires precise skill and dedicated specialist training to avoid damaging the surrounding structures. The risks include scarring, infection and prolonged downtime.4,5 Alternative laser technologies Various generations of lasers and other laser technologies, as discussed below, may be used to treat periorbital veins. The safety and effectiveness of these devices, as well as the evidence to support their use in the scientific literature, is variable.

Nd laser (1064lnm): The Nd laser penetrates deeply into the skin, making it effective for treating deeper veins, including those around the eyes. It works by targeting the haemoglobin within the blood vessels, causing the veins to collapse and eventually be absorbed by the body.7 Aesthetics | November 2024

Case Study Periorbital Veins Pulse dye laser (PDL) (585-595 nm): PDL is effective for targeting blood vessels by delivering bursts of light energy that selectively target the blood vessels without damaging the surrounding skin. This causes the vein to clot and be absorbed by the body over time.8 Diode laser (800-980 nm): The diode laser targets haemoglobin in the blood vessels and is particularly effective for treating smaller veins, including those around the eyes.9 KTP laser (532 nm): KTP laser is a green light laser that is absorbed well by haemoglobin, making it effective for treating superficial blood vessels. It is particularly useful for fine, superficial periorbital veins.10 Vascular laser (1064/532 nm): This dual wavelength vascular laser represents a potentially significant advancement in the treatment of periorbital veins. The laser system combines two alternative wavelengths – 532 nm and 1064 nm – to allow for precise and effective treatment of various vascular conditions, including blue and red periorbital veins.11 The laser’s dual wavelengths offer versatility in treating different types of veins. The 532 nm wavelength is ideal for superficial veins and smaller vessels, in particular for red veins of the upper eyelid; the 1064 nm wavelength penetrates deeper, targeting larger veins, typically blue in colour. This combination ensures the opportunity for comprehensive treatment of periorbital veins regardless of their depth, ranging between 0.2 and 3mm in measured diameter on both the upper and lower eyelids.11 Our recent review of the scientific literature and our own published experience demonstrate this technology’s effectiveness in reducing or eliminating periorbital veins.11 Patients typically notice a significant improvement (often complete resolution) after one session, with full results visible after a few weeks as the body naturally absorbs the treated veins.

The mean number of treatment sessions required over our own case series was 1.5, and ranged between one and three in the published literature.11 Treatment of blue periorbital veins (using the wavelength 1064 nm) appears safe in Fitzpatrick skin types I-V, and treatment of red veins (using the 532 nm wavelength) in skin types I-IV.7

The vascular laser procedure Patients undergoing treatment for periorbital veins with this technology can expect a straightforward and relatively quick procedure. In our clinic, we use Excel V+ from Cutera, but there are other technologies available.

49

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Case Study Periorbital Veins

Consultation The process begins with a face-to-face consultation where the practitioner assesses the patient’s medical history, mental wellbeing, skin type, recent sun exposure, skin damage and the extent of the vein visibility to determine suitability to treatment, as these factors can amount to a contraindication. At the time of the initial consultation, a skin patch test for the parameters considered appropriate for treatment is carried out in an effort to determine skin response and safety of treatment. A minimum of 24 hours must pass between this test and the procedure, with the ideal timescale being one week.

Preparation On the day of the procedure, the site of the previous patch test is assessed for any adverse response to treatment. If no concerns are reported by the patient or identified by the practitioner, the treatment area is cleansed with hypochlorous solution (we use Clinisept+, for example), and the patient is fitted with protective eyewear to eliminate the risk of ocular injury by laser.12 For patients requiring treatment of veins within the orbital rim, COX2 intra-ocular shields are utilised to enhance safety. Intraocular shields are not always needed, as when the veins are peripheral, the treatment can be carried out using routine laser safety goggles. This involves the use of 0.5% Tetracaine eyedrops ahead of shield fitting, and antimicrobial prophylaxis with Chloramphenicol 1% ointment.12 Treatment The practitioner uses the selected laser handpiece (as determined and planned on the basis of initial response at the time of patch-testing) to deliver targeted pulses of laser energy to the veins (Table 1). The dual wavelengths are adjusted based on the size and depth of the veins being treated. The laser is delivered in short pulses along the length of the target veins. The integrated cooling system ensures patient comfort and protects the skin.11 The procedure often takes less than 30 minutes, and patients describe it as a ‘snapping’ sensation.

Post-treatment care After the treatment, patients might experience some redness, swelling, itching, burning, or temporary lightening or darkening of the skin, which typically resolves within a few hours.12 Patients are recommended to avoid direct meaningful sun exposure and to use sunscreen (SPF50+) to protect the treated area. If intraocular shields were used, patients are discharged from clinic with a prescription of Chloramphenicol 1% ointment to be applied topically two to three times a day for five days.11,12 Post-treatment follow-up Patients are routinely brought back for review on average four weeks after treatment to assess effectiveness and results, and to schedule any further sessions if required. If a second treatment session is required, this is typically carried out a minimum of six weeks post initial treatment, to allow for a full skin cycle to pass between one treatment and the next. In most cases results are long-lasting, however there is a possibility of recurrence. In these circumstances, repeat treatment is possible once six weeks has passed.

Patient experiences and results In our experience, patient satisfaction with this treatment for periorbital veins is high, with many reporting a significant improvement in their appearance and confidence. Most patients report a relatively painless procedure and a high degree of satisfaction with the results achieved after just one or two sessions (Figures 1&2).

In our published case series, the mean number of sessions required for treatment was 1.5, the mean percentage improvement of periorbital vein appearance as assessed by a clinician was 75-100% and the mean patient satisfaction score on a scale of 1 to 3 (3 being completely satisfied) was 3. In some cases, we combine this procedure with tear trough filler if the patient is looking for further rejuvenation.

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Before

After

Diversifying vein treatments The success of the 1064/532 nm laser in treating periorbital veins is aligned with a broader trend toward non-invasive, highly effective aesthetic treatments.

As technology continues to advance, we can expect further innovations that will refine and enhance the treatment options available for various vascular and dermatological conditions.

This reported approach represents an effective option in the treatment of periorbital veins, geared towards those seeking to improve their appearance and confidence with minimal risks and downtime.

This modality not only addresses a common cosmetic concern, but also exemplifies the potential of laser technology in the field of medical aesthetics.

Dr Massimiliano Cariati is a consultant oncoplastic breast surgeon and aesthetic doctor, with an award-winning research background. He has a specialised interest in facial and body rejuvenation, and in the use of novel surgical and non-surgical technology and devices.

Qual: MBBS, PhD, FRCS Dr Tatiana Lapa is an aesthetic practitioner and founder of Drs Tatiana + Rishi Advanced Aesthetics. She is an international key opinion leader for dermal fillers, as well as for energybased devices.

Qual: MBBS, MRCG, BSc, MSc Dr Rishi Mandavia is an ENT Surgeon with a specialist interest in facial plastic surgery. He is the managing director of Drs Tatiana + Rishi Advanced Aesthetics Clinic in London.

Qual: MBBS, MRCS, BSc, MSc, PHD

After

Figure 1: 25-year-old patient before and six weeks after one treatment session with Excel V+ for red periorbital veins

The skin around the eyes is thin and delicate, making periorbital veins more apparent

Figure 2: 38-year-old patient before and four weeks after one treatment with Excel V+ for blue periorbital veins

Aesthetics | November 2024

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Treatment Focus Male Periorbital

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Anatomy

Treating the Male Periorbital Area Dr Kam Lally explores key considerations for treating the male periorbital area using dermal fillers The number of men seeking aesthetic treatments has grown significantly in recent years, with an estimated 40% of men interested in having a cosmetic surgical procedure.1 The global male aesthetics market increased by 18% between 2020 and 2023.2 In particular, the popularity of injectable soft tissue fillers with the male patient has surged. Traditionally associated with women, it is steadily gaining interest among men as one of the fastest-growing categories of aesthetic treatments.3 Recent statistics show that male patients currently represent 13.5% of the global dermal filler market, which presents aesthetic practitioners with a huge opportunity to capture this growing demographic group.4 Due to its prominence and expressiveness, one of the most common male aesthetic concerns is the periorbital area (particularly lateral canthal lines and tear troughs).5,6 This article discusses the considerations that should be taken when treating the male periorbital area with dermal filler, as well as considerations in consultations, product selection, treatment considerations and complication management.

Consultation considerations The consultation process is key to determining the motivations, goals and concerns of the patient, as well as offering an informative experience that results in a successful treatment outcome. When consulting male patients, it’s essential to take their unique anatomical structure, alongside their personal preferences, into consideration so that a tailored treatment plan can be developed.7 Perception and preference When consulting male patients, it is important for practitioners to acknowledge that the perception of male patients in the medical aesthetics arena has changed.

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Research shows that men want to improve their appearance and fight the signs of ageing.8,9 There are several contributory factors to this, including changing gender norms, a desire to appear younger, competition in the workplace, increased media focus on the male appearance, growing societal acceptance of cosmetic procedures and the availability of minimally invasive options with reduced downtime.10,11 Additionally, it’s important to note that men want an element of plausible deniability that affects their choice of treatment. They want instant results, with no downtime so they may immediately go back to work without it looking like they’ve had any work done.12 Discussing treatment goals and outcomes is particularly important as each patient will have a slightly different interpretation of what they feel defines male attractiveness.

Some have described it as an ‘appreciation of symmetry, balance and harmony’, as well as a ‘balancing act between femininity and masculinity’.13,14 However, it has also been identified that it is important for many male patients to retain their masculinity and not over-feminise their features.15 Ethnicity Recognising and considering the average facial characteristics of diverse ethnic groups when providing aesthetic procedures is crucial to treatment outcome, as studies highlight variations in preferences and features among different populations.16,17 For example, ‘African males tend to have thicker facial tissue than any other ethnic group, whereas Japanese males have thinner tissues than most other groups’.18 Facial features play a significant role in shaping the perceived ideal appearance of individuals and what they want from treatments, with notable distinctions between Asian and Caucasian men, encompassing differences in eye shape and facial structure preferences.19 Aesthetics | November 2024

Anatomical considerations should be specific to the periorbital area. Periorbital anatomy between men and women exhibits distinct differences that are significant for both clinical assessment and treatment.

Osseous anatomy, muscle mass, skin thickness and adipose distribution should all be considered to enable a tailored treatment plan to be formulated for each patient.20,21 Fundamental differences in the osseous anatomy between men and women contribute to the distinct facial characteristics observed in each gender.

The male periorbital region is characterised by a more prominent supraorbital ridge and pronounced orbital depth, giving the impression of a more intense eye expression. The brow is more horizontal (as opposed to arched in females), sitting at the level of the supraorbital rim. The lateral canthus also tends to be level, and the zygomatic arch is more pronounced.22-24 Additionally, the orbicularis oculi muscle is generally thicker and more robust in men. This can affect the dynamic rhytids formed around the eyes (such as lateral canthal lines), making them deeper and more resistant to treatment. Periorbital skin in men is generally thicker and contains a higher density of collagen fibres compared to women. This increased thickness provides greater structural support and can influence the way dermal fillers are distributed and retained in the tissue.25,26 Furthermore, men have less subcutaneous fat which can also translate into the formation of deeper, more severe rhytids.27 However, men are less prone to significant fat loss in this region, which can result in less pronounced under-eye hollows, but can also lead to more noticeable tear trough deformities due to the natural contour of the facial bones.28

Dermal filler benefits and product selection Dermal fillers are an ideal treatment modality for male patients thanks to their quick application, minimal downtime and comprehensive rejuvenating benefits.

Results are long-lasting – typically between six months to two years depending on the product used, indication treated and the patient’s individual needs.

Other treatment modalities such as polynucleotides have increased in popularity when treating the periorbital area, primarily due to their liquid form carrying less potential risk of adverse events (such as a vascular occlusion or the Tyndall effect) than HA based gel fillers.29-31 Additionally, platelet-rich plasma and polydioxanone threads (non-barbed)

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Treatment Focus Male Periorbital

overlying tissues, reducing the appearance of tear trough deformities and hollowness.

After

Figure 1: Patient’s palpebromalar grooves and lateral canthal lines were treated with Teoxane Teosyal Puresense Redensity 1 and Teosyal Puresense Redensity 2. Images courtesy of Dr Navid Alizadeh

techniques can also be used to improve the area.32,33 However, all of these more 'regenerative' treatments require multiple visits (usually a minimum of three) and the volumisation observed is very subtle.

It is also important to remember that when a dermal filler is injected into the face, it is subjected to a wide range of facial movements and pressures that occur when you express emotions, talk and eat.34 These can alter the behaviour of the filler. Fillers need to be designed with facial dynamics in mind so that they seamlessly flow with facial expressions, adapt to different levels of stretch and strength, and resist deformations and pressures from skin layers for natural and long-lasting results.35,36 Practitioners should consider this when choosing the most suitable filler brand for their male patients, and select one that adapts to movement and enhances facial expressions without erasing them.

Specifically, it’s beneficial to choose filler with high malleability to spread evenly across the periorbital area, and that offers low hygroscopy to minimise oedema, low exertion of pressure on surrounding tissues (which could impair lymphatic drainage) and minimal cross-linking (to reduce risk of the Tyndall effect).37,38

Technique Technique should be adapted according to the individual patient following a full and thorough consultation that determines their needs and expected outcomes. It is important not to overfill when injecting male patients, as this may over-feminise the face (unless this has been specified). Smaller volumes are generally required as men a more angular.39 Additionally, due to anatomical and ageing differences, injections are not performed in the same regions for men and women, so it’s important that healthcare professionals are aware of these differences in technique and adapt accordingly.40 Tear trough techniques My preferred technique when treating the tear trough is: 1. Use a small volume of gel - 0.1–0.5ml per tear trough. My preference is to use Teosyal Redensity 2.

2. Use a 25G cannula 38-50mm in length. My preference is to use a cannula as opposed to a needle in the region as cannulas are blunt-tipped and lower the risk of inadvertently entering a vessel, especially as we approach the medial canthus.41-43 Additionally, as we are deep on the periosteum, the cannula will transfer across its surface more smoothly, thus reducing discomfort compared with a needle.

3. Inject slowly to help to minimise pressure. Higher injection pressures are correlated with an increased likelihood of adverse events.

4. Use a deep supraperiosteal (direct) / suborbicular (indirect) technique: a. Supraperiosteal: the filler is placed directly above the periosteum, the dense layer of connective tissue covering the bones of the orbital rim. This is the deepest accessible plane, just above/on the bone. This technique provides foundational support and helps to lift the

b. Suborbicular: places filler in the suborbicularis oculi fat (SOOF) plane, beneath the orbicularis oculi muscle but above the periosteum. This technique targets the deep fat pad that contributes to the volume loss exaggerating the tear trough deficiency. Restoration provides structure and support to smooth the transition between the lower eyelid and cheek (lid-cheek junction).

5. When treating the male tear trough, it is advised to inject the lateral aspect of the zygomatic arch to give the cheek an inferomedial apex – a distinctly masculinising feature.44 Lateral canthal lines For the crow’s feet (Figure 1), I use the below technique: 1. Focus on the dermis or superficial subcutaneous tissue in the areas where crow’s feet lines radiate from the lateral canthus.

2. Use a 30G needle. In my experience, this is the best option as it provides a good compromise between comfort and minimising trauma for the patient. Additionally, this means that the extrusion force is lower (when compared with a finer needle), thus making injection more comfortable for injector and patient.

3. Use minimal gel volumes, typically 0.1-0.3ml per side, to achieve subtle improvements without bulkiness.

4. Inject filler in small aliquots, assessing the result after each injection to ensure even and natural correction.45-47

Aftercare and complication management The general aftercare and complication management remains the same with any patient following a dermal filler procedure. Patients should apply cold compresses to reduce swelling and bruising, avoid touching or applying products to the treated areas, avoid sun exposure and refrain from strenuous activities for 24-48 hours.48 Pain tolerability can vary between individuals, so over-the-counter pain relief may be beneficial. Immediate follow-up appointments should be scheduled to monitor progress, check symmetry and address any concerns. Given the male preference for a quick return to work, these sessions will ensure timely intervention and optimal results while minimising the amount of downtime required.

Understand the needs of male patients The combination of growth in the global male patient segment and the continued interest in injectable soft tissue fillers within this patient group presents aesthetic practitioners with a significant opportunity for growth. To fully capitalise on this opportunity, healthcare professionals need to consider the specific needs of male patients, ensuring that their unique anatomical structure, ethnicity and personal preferences are all taken into account.

Product considerations should be bespoke to the individual, and treatment and product options should be well-researched and scientifically sound to ensure that the highest standards of safety, efficacy and technique are achieved for optimal patient outcomes.

Dr Kam Lally graduated in medicine from the University of Oxford and went on to complete an academic post with an honorary lectureship at the University of Leicester. He is a GP, medical director of Aestheticology Clinics UK, and global key opinion leader for Teoxane. He is also the Royal College of General Practitioners (RCGP) national aesthetic medicine lead.

Qual: BMBCH, BA, MRCGP, PG DIP AES MED

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Case Study Clinical Practice News Nodules Treating

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Case Study: Management of Nodular Complications After Toxin Dr Laila Hassan presents a case series investigating rare nodular complications following botulinum toxin injections Botulinum toxin A (BoNT-A) is widely used for aesthetic treatments, but despite its broad safety, rare complications such as nodule formation can occur post injection.1 Although this can happen due to several reasons, including improper injection technique, product impurities or individual patient factors, this side effect has recently been linked to patients with recent COVID-19 infection or vaccination.

This article presents a case series focusing on two specific cases from Pakistan. It explores the occurrence, management and potential causes of nodule formations while drawing insights from the analysis of all 26 cases.2-5

Differential diagnosis When evaluating complications related to BoNT-A injections, particularly nodules, it is essential to differentiate between various possible conditions:

· Granulomas: Immune response to BoNT-A; typically diagnosed

through clinical history and biopsy · Sarcoidosis: Requires systemic evaluation and imaging to confirm · Lump formation: Could result from incorrect product placement or an immune reaction · Local inflammation/nodules: May arise from improper technique or localised immune response

Linking COVID-19 to aesthetic complications Aesthetic practitioners and infectious disease specialists have interacted greatly during the COVID-19 pandemic, primarily due to the transmission risk of SARS-CoV-2 during cosmetic and aesthetic procedures. Issues such as increased inflammation, altered immune responses and the potential for adverse reactions to injectables have been observed in individuals who have recently been infected with or vaccinated against SARS-CoV-2.6,7 For instance, patients with a history of COVID-19 may experience heightened inflammatory responses to BoNT-A injections, leading to complications such as nodule formation or granulomas.

Additionally, the immune response triggered by vaccination can

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Non-compliance or delayed follow-up care resulted in longer resolution times, extending to several months affect the efficacy and safety of cosmetic procedures, necessitating careful assessment and management by practitioners.7 Therefore, practitioners should apply all precautionary measures to minimise the potential risks of viral transmission. These include patient screening for COVID-19 history, the use of personal protective equipment (PPE), strict hand hygiene, disinfection of surfaces and tools and minimising aerosol-generating procedures.8 If unusual reactions occur in previously treated areas of the body, particularly in individuals with a history of SARS-CoV-2 infection or COVID-19 vaccination, consultation is advised.

There is evidence linking nodule formation following BoNT-A injections and recent COVID-19 infections in several instances reported from various locations in Pakistan.9,10 These findings imply that the changed immunological milieu following COVID-19 may play a major role in the development of such problems, even in patients without a history of adverse reactions to BoNT-A. Proteinous or crystalline forms of BoNT-A may cause a foreign body reaction that results in the development of granulomas.11,12 This complication can be influenced by the interaction of these two ingredients or by complexing proteins present in the product.

Without testing both products separately on the same person, it is difficult to determine which of the two – bovine serum albumin (BSA) or human albumin solution (HAS) – is the cause of this kind of reaction.

This observation is consistent with other research that observed modifications in the immune response after viral infections, which may result in granulomatous responses or hypersensitivity.13 The treatment of these nodules has varied depending on the case; nonetheless, oral and topical steroids, antibiotics and occasionally intralesional steroid injections have shown positive results for most patients.13

Case report Patient characteristics Among the cases reviewed, the patients ranged from mid-30s to mid-60s, with a higher incidence in women. Out of the 26

Patients with a history of COVID-19 may experience heightened inflammatory responses to BoNT-A injections, leading to complications such as nodule formation or granulomas 54

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Case Study Clinical Practice News Nodules Treating

Treatment protocols and effectiveness In April 2024, a notable case from Karachi involved a patient with a complex history of COVID-19. Following treatment, the patient developed nodules that required intervention. These were effectively treated with Danzen DS, an anti-inflammatory enzyme known for reducing inflammation, alongside topical Effigenta cream, which combines antibiotic and steroid properties.13 A course of antibiotics and oral steroids were also used. The nodules resolved within two to three weeks, demonstrating the efficacy of this combined treatment approach.

Some patients received oral or intralesional steroids to address the nodules. When treatment was initiated promptly, nodules typically resolved within a week. However, non-compliance or delayed follow-up care resulted in longer resolution times, extending to several months. For further reference, studies highlighting the efficacy of these treatments can be found in recent dermatological literature and clinical practice guidelines.13

Long-term monitoring and follow-up

Figure 1: A 45-year-old female, who had previous COVID-19 infection, experienced nodules 24 hours post-BoNT-A injection in April 2024

cases, seven patients had a history of COVID-19 infection prior to receiving a BoNT-A injection. Additionally, 96% of the patients had been vaccinated against COVID-19 an average of three to six months before their BoNT-A injection.

Clinical insights and observations Nodule formation occurred within 24 hours of BoNT-A injections for 25 patients and resolution times ranged from one week to one year. Several key observations include:

· No consistent BoNT-A brand was linked to the nodule formation

· Changing the saline brand for reconstitution appeared to

prevent further cases in some patients Due to varied patient responses and nodule resolution times, practitioners should conduct thorough pre-procedure consultations, considering infection history, COVID-19 vaccination status and current medications. Proper follow-up and patient compliance are crucial to minimising adverse outcomes.

Case study 1 A woman in her mid-40s who had recently recovered from a COVID-19 infection experienced nodules shortly after undergoing BoNT-A injections for several face regions (Figure 1).

Allergic and hypersensitive reactions to BoNT-A, while rare, have been documented. Reports include transient localised responses, such as diffuse acneiform eruptions on the forehead, with severe systemic reactions like anaphylaxis being uncommon.

Although the patient had a history of regular BoNT-A treatments, recent COVID-19 infection and her current regimen of steroids, antibiotics and painkillers may have altered her immune response, contributing to nodule formation. Initial treatment with hydrocortisone and antibiotics showed some improvement.

However, non-compliance and subsequent burn marks hindered recovery.9,11

This case series has a few drawbacks despite its insightful observations. Selection bias may be introduced by the retrospective nature of the study and its reliance on reported cases. The capacity for the findings to be broadly applied is limited by the small sample size. Additionally, the lack of established diagnostic criteria for nodular formation following BoNT-A injections, along with insufficient data from non-compliant individuals, further restricts the conclusions. More research with larger sample sizes, standardised treatment plans and controlled variables is required to fully comprehend and manage this uncommon complication.

Nodule duration varies from one week to a year, highlighting the complexity of immune reactions and individual patient responses.

This emphasises the need for tailored management plans that account for medical history, recent infections or vaccinations and patient compliance, which can improve healing and reduce complications.17

Drawing on research Recent research has shown that COVID-19 can lead to alterations in the immune system, which may affect healing and inflammatory responses in various medical and aesthetic procedures.14 Studies have identified changes in cytokine profiles and immune cell activity in individuals recovering from COVID-19, which can potentially influence the outcomes of aesthetic treatments. It further discusses how these immune changes can lead to increased inflammatory responses, impacting healing times and the likelihood of complications. Other studies explore the effects of prior COVID-19 infection on cosmetic procedures, finding that patients who had recently recovered exhibited longer healing times and a higher incidence of adverse reactions.13-16 This case series highlights the uncommon but significant complication of nodule formation following BoNT-A injections.

Factors such as patient history, recent COVID-19 infection and injection techniques may contribute to these adverse outcomes.

While most cases were successfully managed with steroids, antibiotics and proper follow-up, this complication necessitates further investigation.

Dr Laila Hassan is an aesthetic physician with 12 years of experience as a laser therapist. She is the founder and CEO of Zee Aesthetic Clinic in Pakistan and serves as the director of education and development for the American Board of Laser Surgery (ABLS) in Pakistan. She is also an authorised master trainer for Nubway lasers in China..

Qual: AAAM, ABLS, MBBS, NUST

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Advertorial Asclepion Lasers

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Case Study: Treating Rosacea with the Novel QuadroStarPRO YELLOW Nurse prescriber Charlotte Guest discusses how she treated a case of rosacea using a novel laser device, the QuadroStarPRO YELLOW from Asclepion Laser Technologies.

The frequency at which rosacea occurs in the general public is unclear and often overlooked, but a recent systematic review and meta-analysis estimated a global prevalence of 5.46% of the adult population is affected.1,2 Multiple topical and oral agents have been prescribed over the years for the treatment of rosacea.3,4,5 Furthermore, licensed light-based procedures have also been used which includes pulsed dye lasers (585–595 nm), intense pulsed light (IPL, 500–1200 nm), APTD (577 and 585 nm), krypton (568 nm), potassium titanyl phosphate (KTP, 532nm) and ND:YAG (532 and 1064 nm) lasers.5-8 However, the novel FDAcleared QuadroStarPRO YELLOW with a 577 nm wavelength widens treatment options for practitioners when treating rosacea, superficial red vessels and benign pigmentated lesions and melasma.

Case study A 74-year-old female presented to the clinic with concerns of persistent rosacea. On examination, the patient had Fitzpatrick type II skin with moderate, non-transient flushing to her mid-face and chin (Figures 1&2). The patient reported this prolonged centrofacial erythema started approximately 40 years ago, with triggers including extremes of ambient temperatures and alcohol. She reported no papules and pustules or dryness which can be common features of rosacea.2,6,7 Following examination, her rosacea classification subtype was marked as erythematotelangiectatic, and severity graded ‘moderate’.9 The impact of the rosacea on the patient’s psychological health was scored as ‘severe’ on the Dermatology Quality of Life Index (DQOLI), with the patient reporting reduced social interactions.10

History of rosacea The patient reported having an even skin tone until her mid 30s when she started noticing persistent flushing to the mid-face, which became increasingly worse despite trying oral Tetracycline and topical Metronidazole between the ages of 35–40. The Tetracycline caused unpleasant side effects including nausea, hence the patient discontinued treatment. This was followed by IPL in her late 50s which resulted in her terminating the course of treatment as she found it too painful. As the condition worsened, it began to cause significant psychological distress and low mood due to comparing her skin to others.

The treatment plan The patient was fully informed about the treatment that had been recently FDA-cleared, and felt this was a treatment she wanted to proceed with. It was decided that up to six sessions of QuadroStarPRO YELLOW was a suitable option for this patient’s presenting concern. This particular laser enables fast and effective treatment on skin types I-IV due to lower levels of melanin absorption compared to 532 nm wavelength lasers.11,12 It has shown 40% higher blood absorption, lower melanin absorption and fewer side effects compared to other laser treatment options.11-14 Less fluence is required when using this particular device, resulting in a more comfortable treatment with equally as effective outcomes.11-14 56

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Treatment and aftercare

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A test patch had been performed with no adverse reactions. Prior to starting the treatment, photography and skin analysis scans were performed.

No anaesthetic was required pre-treatment.

Four treatments were carried out at four to six Figures 1&2: 74-year-old patient before and one month week intervals. after four treatments with QuadroStarPRO YELLOW The patient reported a pain severity of 3 out of 10 on the numerical rating scale (NRS) depending on the area treated, but did comment the mild discomfort was transient while the laser was firing.

Following each treatment, the skin was cleansed, alongside SHEALD Recovery Balm by iS Clinical and Viderm SPF50. The patient’s skin was more pink immediately following treatment, but this resolved within two hours. Aftercare was advised including avoiding strenuous activity for 24 hours, and using a gentle skincare routine.

The patient saw an improvement in her symptoms following each treatment, and apart from worsening erythema initially, experienced no other side effects and tolerated the treatment well.

The results At one month after four treatments, the severity of the patient’s non-transient rosacea was now ‘absent’ (Figures 1&2). The impact of the rosacea on her psychological health was scored as ‘nil’ on the DQOLI, with the patient reporting more confidence during social interactions.10 It was recommended that she would likely benefit from one maintenance session every six months.

With minimal adherence requirements, rosacea treatment using QuadroStarPRO YELLOW is an attractive treatment option for patients who cannot tolerate lots of downtime or side effects due to busy lifestyles. This does not replace the other licensed light-based treatments, but provides an alternative, more comfortable treatment option for rosacea. Similarly to other laser treatments, patients need counselling on the potential side effects associated with this type of treatment and ongoing maintenance. However, it highlights a novel laser option for the treatment of rosacea and superficial red vessels. This case study has shown the potential of this technology.

Charlotte Guest is a registered adult nurse with experience in cardiothoracic, emergency and pain management. She started her practice in medical aesthetics in 2017, and works at Phi Clinic.

Quals: RGN, INP, MSc This advertorial was written and supplied

by Asclepion Laser Technologies Contact the Asclepion UK team on 020 7193 2003 or at hello@asclepionuk.com to hear more

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Clinical Papers Abstracts

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

Title: Bridging the Gap Rather Than Filling the Entire Valley – Anatomic Insights When Treating the Medial Infraorbital Region Authors: Bernadini F, et al.

Published: Journal of Cosmetic Dermatology, August 2024 Keywords: Injectables, Infraorbital Region, Tear Trough In the September edition of the Journal of Cosmetic Dermatology, an Italian oculoplastic surgeon Dr Francesco Bernardini and his colleagues published a single-centre case series of 123 tear trough patients who were treated with an interesting approach – a horizontal submuscular 25G cannula approach from lateral. Upon entering the cannula in the lateral infraorbital region and feeling the discrete loss of resistance, the introduction angle of the cannula was flattened and advanced into a medial horizontal direction without touching the bone.

From an anatomical perspective, the tip of the cannula passed through the skin, through the malar fat pad and penetrated the orbicularis oculi muscle; this was perceived as the loss of

resistance. Upon reaching the sub-orbicularis oculi plane, the cannula entered the sub-orbicularis oculi fat (also termed the SOOF) and was advanced in this plane. The cannula did not penetrate the midfacial extension of the superficial lamina of the deep temporal fascia which represents the fascial boundary between the SOOF and the prezygomatic space, and therefore did not reach the supra-periosteal plane. The cannula was then advanced medially until reaching the tear trough.

The axis of the tear trough points from the medial canthus toward the mandibular angle, and can be compared to a valley that has an oblique longitudinal axis. Standard cannula-based treatments of the tear trough targets the area from the midface, with the axis of the tear trough corresponding to the axis of the incoming cannula. Dr Bernardini’s approach advances the cannula almost at a perpendicular angle to the longitudinal axis of the tear trough, forming a bridge that crosses from one side of the valley to the other side. This is why the title of the publication was ‘Bridging the Gap Rather Than Filling the Entire Valley’.

The advantage of this technique is that less product than usual is needed to achieve satisfactory aesthetic outcomes, which was measured in this study to be on average 0.26 score. In addition, the authors reported a statistically significant improvement in the tear trough depth (before 2.12 vs. after 1.15), hyperpigmentation score (before 2.19 vs. after 1.31), intraorbital fat pseudo-prolapse severity (before 1.88 vs. after 1.14) and wrinkle severity of the lower eyelid (before 1.51 vs. 1.12). The authors verified the submuscular product placement via ultrasound, and therefore provided a comprehensive analysis of their technique. Future studies will need to be conducted to identify the difficulty of the learning curve and how other injectors adopt this technique.

Title: Efficacy and Safety of Cell-Assisted Acellular Adipose Matrix Transfer for Volume Retention and Regeneration Compared to Hyaluronic Acid Filler Injection

Title: Interplay Between Health-Promoting Lifestyle, and Cognitive Emotion Regulation with Risk of Cosmetic Surgery Seeking in Young Women

Authors: Jin X, et al.

Published: Aesthetic Plastic Surgery, October 2024 Keywords: AAM Transfer, HA Fillers, Volume Restoration Abstract: Cell-assisted acellular adipose matrix (AAM) transfer

Authors: Faezi F, Amiri S.

is a novel technique for soft tissue volume restoration, where AAM acts as a scaffold for tissue proliferation and promotes host cell migration, vascularisation and adipogenesis. This study aimed to evaluate the efficacy and safety of in vivo cell-assisted AAM transfer compared to hyaluronic acid (HA) filler injection.

Human adipose tissue was used to manufacture AAM, and murine adipose-derived stem cells (ASCs) were prepared. Nude mice were divided into four groups: AAM transfer (AT), ASC-assisted AAM transfer (CAT), HA filler injection (HI) and ASC-assisted HA filler injection (CHI). The AAM retained its three-dimensional scaffold structure without cellular components. AT/CAT showed lower volume retention than HA/CHA; however, CAT maintained a similar volume to HA. Histologically, adipogenesis and collagen formation were increased in AT/CAT compared to HA/CHA, with CAT showing the highest levels. CAT also demonstrated superior angiogenesis, adipogenesis and gene expression, along with lower Il-6 expression, higher Il-10 expression and reduced capsule formation, indicating better biocompatibility. Cell-assisted AAM transfer is a promising technique for volume retention and tissue regeneration, offering a safe and effective alternative to HA filler.

Published: Aesthetic Plastic Surgery, October 2024 Keywords: Cosmetic Surgery, Lifestyle, Mental Health Abstract: This study investigated the relationship between lifestyle and cognitive regulation of emotion, and the risk of seeking cosmetic surgery in young women. The outcome variable in this research was cosmetic surgery seeking. The association between sociodemographic and health behaviours with risk of cosmetic surgery seeking was the hypothesis being investigated.

The multinomial logistic regression was used to examine the association between health promotion lifestyle and cognitive emotion regulation with cosmetic surgery seeking. Patients who were underweight was associated with cosmetic surgery seeking.

Other risk factors were former smoking, alcohol use and poor sleep quality. An increase in poor lifestyle is associated with an increased risk of cosmetic surgery seeking. On the other hand, adaptive cognitive emotion regulation protects against cosmetic surgery seeking. The results of this study show that lifestyle and adaptive cognitive emotion regulation play a significant role in people who were looking for cosmetic surgery. Therefore, like in other areas of disease and health, lifestyle and adaptive cognitive emotion regulation are important in cosmetic surgery, and it is necessary to pay attention to the effects of each of them.

Aesthetics | November 2024

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Professionalism Revalidation

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your DB which you automatically connect to. Those doctors solely practising aesthetics and working independently can find it difficult to find an appropriate designated body as they do not quite fit into any of the categories within the connection flowchart. If this is the case, you can apply to connect with a GMC-registered ‘Suitable Person’ to act in the role of your DB and your Responsible Officer (RO) in one.2 Once connected with a DB, you are required to submit evidence demonstrating that you comply with the GMC’s standards in the ‘Good Medical Practice’ guidance.3 This evidence is mostly in the form of your completed and signed-off annual appraisal document, usually on an e-portal system commissioned by the DB. You will be allocated an appraiser by the DB and meet annually.

Understanding Your Revalidation

A normal appraisal portfolio is divided into sections and includes:4

· Your scope of practice, which is any activity that requires you to have a medical licence to practise

Dr Andrew Cooney and aesthetic nurse Olivia Day outline how practitioners can complete their annual appraisal and revalidation The terms ‘appraisal’ and ‘revalidation’ bring on a sense of doom for most healthcare practitioners. For years now, annual appraisal and revalidation has been a fact of life to retain your licence to practise, whether you are a doctor, nurse, dentist or allied health professional (AHP). Given the significance of this process, it is surprising how little attention practitioners pay to it, despite the possibly catastrophic consequences of non-engagement.

Each regulatory organisation has its own process for revalidation or the renewal of your licence, but a central theme is that practitioners must provide evidence of good practice. This can be in the form of a practice logbook, a summary of continuing professional development (CPD), a reflection on last year's personal development plan (PDP), a reflection on a case or any adverse events or incidents, compliments, and if mandated, a multi-source feedback exercise.

Here, we outline the revalidation process for each main profession in the medical aesthetic specialty, and provide advice for completing it successfully.

What is revalidation?

Revalidation and renewal is the process that health professionals must undergo to maintain their registration and demonstrate that they are still able to practise safely and effectively.1 The purpose of revalidation is to provide greater assurance to patients and the public, employers and other healthcare professionals that licensed healthcare professionals are up-to-date and fit to practise, with no concerns around their work. It is a key component of a range of measures designed to improve the quality of care for patients. The process varies by profession.1

achieve it for some reason · CPD summary with points or attained hours. There used to be a minimum of 250 points required per five-year cycle, but this number has now been removed · Reflection on any adverse incidents, complaints or poor outcomes · Any quality improvement activity · Any patient or colleague feedback and your reflection on the feedback. This can be in the form of your formal multi-source feedback on an online platform, or feedback and reviews of your practice · Next year's PDP suggestions, looking at areas that you want to develop · Probity and health declarations It is important to describe and reflect on your input into each category. For example, why you chose your CPD activity, what you have learnt and what you have put into practice. Has there been any learning from your PDP or quality improvement activity, and most importantly, has there been any learning from any adverse events or outcomes?

Every five-year cycle, this evidence is then collated with any other information about you that is held by governing bodies and submitted to the GMC in the form of a revalidation recommendation. This recommendation is submitted by an officer appointed by the DB and GMC to be your revalidation representative. The officer is called an RO or Suitable Person,5 depending on your connection. In most cases, your RO is linked to your employer. If you cannot find a DB, the Suitable Person acts as both DB and RO, and will submit the revalidation recommendation.5 A revalidation recommendation can:5

· Confirm that you are revalidated for five years · Defer your revalidation for up to a year for various reasons, such as a break in practice

· Report your ‘non-engagement’ with appraisal and/or revalidation

Doctors For doctors, your revalidation has been devolved from NHS England and the General Medical Council (GMC) to Designated Bodies (DB). A DB is an organisation which employs doctors and is permitted to have a prescribed connection with them for the purpose of revalidation. You ‘connect’ with the most appropriate designated body on your GMC online portal.1 The DB is usually your employer or your NHS trust.

If you work for the NHS or the Armed Forces, this is almost always 58

· The summary of your last appraisal · Review of last year's PDP in terms of achievements or failing to

You will be informed of the revalidation decision within a week by email from the GMC. However, if the decision is that you need a deferral or a non-engagement, this should have been discussed with you before your RO sends the decision to the GMC. Practitioners absolutely do not want to go down the non-engagement route, as your livelihood can be suspended or taken away.5 It is rare for this to happen, but the GMC investigation can be painful, so it’s better to prevent any risk.

Aesthetics | November 2024

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Nurses

registration renewed, you’ll need to:7

For Nursing and Midwifery Council (NMC) registered nurses, the process is different.

Revalidation is every three years. To renew your licence, nurses must fulfil the revalidation requirements to show you are keeping their skills and knowledge updated, and maintaining safe and effective practice.5

· Submit a compliant annual CPD

These requirements include:5

· 450 practice hours · 35 hours of CPD, including 20 hours of

participatory learning · Five pieces of practice-related feedback · Five written reflective accounts on any activities or clinical episodes that you felt were important · A reflective discussion on the above accounts with an NMC registrant; an NMC form is completed by the registrant · Health and character declaration · Your professional indemnity arrangement The health and character declaration sits within the NMC online application. Rather than a character reference, you are stating your fitness to work and whether you have received any new criminal convictions. Your submission is reviewed by a confirmer. The confirmer is the professional who reviews your provided information, signing with their signature and NMC pin (or an alternative regulated healthcare professional).11 They are confirming that you have adequately met the requirements to revalidate, that they have assessed that you have had an appraisal (this is not mandatory) and assessed your full form employment history.

statement if you are mid-cycle · Make a compliant end-of-cycle CPD statement if you have just finished a five-year cycle · Ensure you have completed at least 10 hours of verifiable CPD in the last two-year period (unless you are in the first year of your first cycle)

Allied health professionals For AHPs, revalidation or renewal of your registration is regulated by the Health and Care Professions Council (HCPC).8 You are required to renew your registration on a two-year cycle. This cycle time is specific to your specialty. You should collect evidence of good practice over this two-year period. Ideally, you collect information every month that supports your practice.

This includes learning, CPD, reflection on a case or incident or feedback from colleagues. On your renewal, you must sign a declaration online.

I would advise that all practitioners create an appraisal or similar evidence and activity folder, or have a live portfolio online

In the application, you are required to state if you have any condition which could affect your ability to practise safely and effectively; if you are managing your health condition and/or disability so that you can practise; if you are of good character; whether you have received a police charge, caution, conviction or conditional discharge; and if you have ever been subject to a finding that your fitness to practise is impaired by a body responsible for regulating or licensing a profession.

Each year, professionals are randomly chosen by the NMC for a verification process. The NMC will request further details of your submitted information before renewing your registration. Once the conditions are satisfied, your licence will automatically be renewed.

The declaration states that you have:8

· Continued to practise your profession · ·

Dentists Dentists must follow the General Dental Council (GDC) standards and the nine principles of professionalism.6 It is not a requirement to undergo an annual appraisal, but dentists have to submit an annual reflective CPD log that meets the GDC standards.7 In order to have your GDC

· · ·

since your last registration Met the HCPC’s standards of proficiency for the safe and effective practise of your charge Had no change relating to your good character (this includes any disclosable conviction or caution) Had any changes to your health that may affect your ability to practise safely and effectively Continued to meet the HCPC’s standards for continuing professional development Appropriate professional indemnity cover Aesthetics | November 2024

Professionalism Clinical Practice News Revalidation · The HCPC randomly selects 2.5%

of practitioners to submit their CPD evidence portfolio. Outcomes can be that standards are fulfilled or not fulfilled.

In the 2020 to 2022 cycle, 0.9% of operating department practitioners were removed from registration and 15.8% deferred.9

Considerations for all professions I would advise that all practitioners create an appraisal or similar evidence and activity folder, or have a live portfolio online. This will help you get into the habit of adding pieces of evidence into your folder every week or at least every month, making the process far simpler and preventing that last-minute panic as your appraisal or renewal date approaches. For doctors, it is worth revisiting your PDP to check on your progress. For nurses, it is valuable to try to undertake the five reflective accounts early in the three-year cycle. Similarly for AHPs, it is prudent to complete your reflection earlier rather than last minute.

Going forward The bottom line is that the requirements are what they are, and as a healthcare professional, they need to be adhered to. Practitioners should ensure they are prepared to submit evidence that demonstrates they are still able to practise safely and effectively, in line with the requirements outlined above.

Dr Andrew Cooney is a Responsible Officer for Harley Academy Designated Body, as well as a GMC Suitable Person for doctors practising aesthetics and who have had training at Harley Academy. He is a consultant in intensive care medicine and anaesthetics. He has been appraisal lead for his local trust, the associate dean for revalidation at HETV, associate medical director for his local trust and honorary lecturer in Professionalism .

Qual: MBBS, FRCA, FFICM Olivia Day is an aesthetic nurse and owner of Visualise Aesthetics. She has a first-class honours in Adult Nursing with over six years’ experience at Addenbrookes Cambridge University Hospital and Milton Keynes University Hospital. She is currently in the final stages of completing the Level 7 Combined Injectables and Dermatology at Harley Academy.

Qual: BSc

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CQC Registration Debunking Myths

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The general rule of thumb is that any non-surgical treatment delivered by a medically-qualified professional to treat a medical condition requires registration.3 In the UK, medically-qualified health professionals includes GDC dentists, GMC doctors/surgeons, NMC nurses, GPhC pharmacists and HCCP allied health professionals such as podiatric surgeons and paramedics.

CQC Registration

Surgical procedures are considered invasive, regardless of how minor they may seem, and as such, both cosmetic and medically indicated surgery requires registration. Examples of regulated treatments include:3

Debunking the Myths of CQC Registration

· Botulinum toxin injections: Clinics

Clinic management specialists Niamh Curley and Michelle Cook simplify CQC registrations for compliance in aesthetics The world of aesthetics is ever changing, with more people than ever before seeking a wide range of treatments to enhance their appearance. In January 2024, UK insurance firm Policy Bee reported that 7.7 million people in the UK had an aesthetic treatment in the last 12 months, and 13.9 million are considering having one in the next 12 months.1

·

The surge of popularity has brought with it a whirlwind of confusion and misconceptions, particularly around regulation and the role of healthcare regulators around the UK. This includes the Care Quality Commission (CQC) in England and their counterparts in Wales (Healthcare Inspectorate Wales), Scotland (Healthcare Improvement Scotland) and Northern Ireland (Regulation and Quality Improvement Authority).

The fear of navigating regulatory waters can be overwhelming, but in this article, we will show you that with the right guidance, it doesn’t have to be. We will clarify the role of the CQC in England, and break down key steps and resources that can help clinics confidently navigate regulatory requirements.

·

Understanding the role of the CQC The Care Quality Commission is the independent regulator of health and social care services in England. Its primary role is to ensure that providers of these services meet their published standards of safety, effectiveness and quality.

It provides assurance to patients that the clinic meets national standards for safety, hygiene and quality of care. For clinic owners, their registration demonstrates a commitment to patient safety and legal compliance when offering regulated treatments. It is worth noting, if your clinic doesn’t provide regulated treatments, CQC registration is not necessary.

Many clinics misunderstand the extent of the CQC’s involvement when it comes to medical aesthetic treatments. While not all aesthetic treatments require CQC regulation, those that do must comply for several reasons. These include the safe storage and administration of prescription-only medication, the legal patient consent processes that clarify the medical risks and side effects of certain treatments, clear medical emergency policies and procedures including the equipment and drugs available to address such situations, and many more.2 It is illegal to offer regulated treatments in an unregulated setting. This can lead to significant legal repercussions, including fines, closure of the clinic and untold damage to a clinic or practitioner’s reputation.3

What treatments are regulated by the CQC? One of the biggest misconceptions is around which treatments require CQC registration.

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·

·

offering this prescription-only drug for the treatment of medical concerns such as hyperhidrosis, bruxism/ temporomandibular joint disorders (TMJ) disorders, migraines etc. must be CQC-registered. Although this injectable is considered minimally invasive, it carries considerable medical risk if injected incorrectly. CQC registration ensures that practitioners administering this drug meet the required standards of competency and safety to reduce risks where possible.

Surgical procedures: Any minor surgeries, including mole/lesion excisions and scar excisions, require CQC registration. The CQC requires strict infection prevention and control policies and protocols to be in place to maintain a safe and sterile environment, no matter how minor the procedure may seem.

Intravenous nutrition therapy (IVNT): Offering prescription-only drugs intravenously for wellness or medical interventions requires strict adherence to CQC guidelines.

IV bags and medications must be temperature-controlled and stored according to specific protocols to ensure safety and stability, as outlined by the CQC’s medicines optimisation team.

Thread lifting (all types of threads): The insertion of PDO/PLLA/Mono/ PCL threads by a medically-trained professional is considered a minor surgical procedure by the CQC, and as such follows the same set of requirements for surgical procedures.

Prescription medications and skincare: Prescribing any medication or medical-grade skincare for the treatment of a medical condition or skin condition such as acne, rosacea and hyper pigmentation is CQC-regulated. Prescribing carries significant responsibility, and the incorrect prescribing of inappropriate medications or medical-grade skincare

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can have serious consequences for patients. CQC regulation ensures that prescribers are qualified and adhere to safe prescribing practices.

It is important to regularly check CQC guidelines, as regulations evolve and different treatments may full under the scope in the future. The CQC’s website is a valuable resource, with information and standards easily available.3

Common misconceptions As with any vibrant and rapidly growing specialty, misconceptions can run rife. By debunking some of these myths, we hope that clinics can explore their regulatory requirements and unlock their full potential in confidence.

“My clinic offers non-surgical treatments, so we don’t need to register” Many clinics believe that because they are not offering surgical procedures, they are exempt from CQC oversight. However, as outlined above, many non-surgical treatments, especially those that are invasive or involve prescription-only medicines, do require registration.

“Registration is too complicated and expensive” Another common belief is that the CQC registration process is a bureaucratic nightmare, fraught with complexities and hidden costs. While it’s true that the process can be detailed and thorough, it’s not insurmountable. The key to success is understanding what is required and having the right support. This can involve setting dedicated time aside to researching and learning the regulations, or onboarding a person or specialist company to help you navigate and understand the process. The costs associated with CQC registration are a small price to pay for the peace of mind that comes from operating legally, ethically and being fully compliant.4 Avoidance of CQC registration can be understandable. The process can feel like a whirlwind, with numerous forms to fill out, inspections to prepare for and standards to meet. Clinics may worry about the impact of an inspection on their business, or they may be overwhelmed by the amount of paperwork involved. Additionally, there is often confusion about what exactly needs to be done to meet CQC standards, which will be discussed later.

This fear is compounded by a lack of clear information. Many clinics simply don’t know where to start, and the thought of navigating the process alone can be daunting. It’s not uncommon for clinic owners to feel like they’re being pulled in a hundred different directions, trying to keep up with patient demands while also

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ensuring they’re compliant with regulations.

“We’ve never been inspected, so we don’t need to worry” Some clinics operate under the radar, assuming that if they haven’t been inspected, they are safe from regulatory scrutiny. This is a dangerous assumption.

The CQC has the authority to carry out inspections at any time, and failure to comply with registration requirements can lead to severe penalties, including the closure of the clinic, prosecution of the owners and fines.3

Simplifying registration process Registering is the easy part, staying compliant as processes evolve can be more challenging. In 2024, the CQC launched a new online registration portal, streamlining the application process and reducing paperwork.5 The length of time it takes is dependent on the person who has taken on this task. Of course, using a specialist compliance company to assist in this process will reduce this time. The portal guides applicants through each step, outlining the required documents for submission, including the seven core policies listed below: Safeguarding Medicines management Infection control Governance Consent Equality, diversity and human rights Recruitment In addition to these policies, you are required to have on hand your insurance cover quote or policy, proof of registration with the Information Commissioners Office (ICO) and a financial viability statement from an accredited accountant; the CQC supplies the template for this.

· · · · · · ·

Once your applications have been submitted through the portal, they will go through an initial verification process which can take four to six weeks. Once verification has been confirmed, the application is passed to an inspector who will get in touch and arrange your registration interview and inspection. There is no guaranteed time frames for registration – it can take up to four to 10 months, depending on how busy the CQC is.5

Registering and proposed aesthetic regulation The UK government is set to introduce a new licensing scheme for non-surgical cosmetic procedures in England. This means that practitioners will need to be licensed to perform certain treatments like botulinum toxin injections, fillers and laser hair removal.6 Aesthetics | November 2024

CQC Registration Debunking Myths Here’s how it ties in with CQC registration:

· Complements CQC registration: The

licensing scheme will work alongside CQC registration for certain treatments which have yet to be confirmed. Clinics offering these treatments will need to be registered with the CQC and practitioners will need to be licensed.

This dual approach strengthens patient safety by regulating both the environment and the individuals providing treatments. · Focuses on practitioner, not just the clinic: While CQC registration focuses on the premises and overall service provision, the new licensing scheme will focus on individual practitioners.

This adds another layer of safety and accountability. · Raises the bar for practitioner standards: The licensing scheme will set specific qualification requirements and standards of practice for practitioners, ensuring they have the necessary training and competence to perform procedures safely. · Addresses specific treatments: The licensing scheme will initially focus on higher-risk non-surgical treatments, such as those involving injectables or lasers.

There will be a requirement for these treatments to be performed in a CQC-regulated setting.

A pathway to compliance In summary, understanding UK aesthetic regulations and the role of healthcare regulators is essential. With the right guidance, clinics can confidently navigate compliance, ensuring safe, high-quality patient care and outcomes.

Niamh Curley is a healthcare management consultant with extensive experience in private healthcare, particularly in London’s Harley Street. Since 2018, she has run a successful consultancy specialising in clinical governance and business development. In 2023, she co-founded Aesthetics Comply to simplify CQC registration in the aesthetics sector.

Qual: BA(Hons) Michelle Cook brings extensive experience in aesthetics clinic management across London and Surrey. A former CQC registered manager, she cofounded Aesthetics Comply recognising and experiencing the need for support in navigating CQC registration in order to simplify the process for others in the industry.

Qual: Diploma Management and Leadership

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Aesthetic Clinical Practice Trends News Group Insights Clinic

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starting to see the more ‘fake’ look as a negative thing that they want to avoid, and are erring towards prevention instead,” she shared.

Cost of living concerns The overall trends in medical aesthetics in the UK cannot be discussed without addressing the monumental impact the current economic climate is having on consumer patterns. Gill said, “If you have a proper, honest conversation with most clinic owners in the field, they’re finding it difficult at the moment, no matter what price point they’re working at. If your trading figures are slightly down, it’s not just you – almost everyone will be feeling the same.”

Keeping Up With The Latest Aesthetics Trends Representatives of the UK’s top clinic groups share their insights into what patients are thinking in 2024 It is no secret that the aesthetics field is constantly changing. Consumer behaviour is easily influenced by social media trends and external factors like the economy, thus practitioners and clinic owners have to be continually adapting to keep up with what patients want.

At CCR 2024, three of the UK’s biggest clinic groups were invited to participate in a panel discussion to share their insights on the latest trends in the sector, chaired by journalist and BCAM ambassador Alice Hart-Davis. In this article, chief operations officer at The Private Clinic Chris Gill, head of sales and operations at Laser Clinics UK Sadie Van Sanden Cooke and dental surgeon at Therapie Clinics Dr Farah Kanji reflect on their thoughts.

Patient demographics The first trend is a potential shift in the kinds of people coming into aesthetic clinics. Gill shared that an increasing number of younger patients are showing an active interest in aesthetics. He said, “Our premium, most expensive brands are still seeing an average patient age of 51, with some younger patients and a fairly large proportion of older women as well. Meanwhile, our more mid-range clinics with lower prices and a greater focus on skin health are seeing patients as young as 18, 19, 20 coming in the door. Where price allows, we’re definitely seeing younger people coming into the market, driven mostly by what they see on social channels.”

Conversely, Dr Kanji shared that she had experienced the opposite, saying, “Five to six years ago, I was seeing a lot more younger girls coming in asking for lip filler, which I think was fuelled by social media trends around figures like Kylie Jenner. That was a struggle for me because I would often turn them away as I didn’t think they were suitable, but I am seeing less of those kind of patients now.” She commented that today, social media is still playing a part in patients’ decisions, but in a more positive way. “I am seeing more patients – including men – coming in with some advance knowledge of hormonal changes and skin health,” she said.

Dr Kanji went on to say that there is still variation in trends across the UK, with the north generally leaning towards the more filled, ‘Love Island’ look. “My patients in London are 62

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He went on to say, “We even see the Government’s Budget announcement having an impact on people’s spending behaviours – sometimes people are more cautious in the weeks leading up to the Budget and then there’s a bit of a spike afterwards.”

Dr Kanji shared that both COVID-19 and the cost of living crisis made her nervous that patients might decide they don’t need aesthetic treatments any more. “However,” she said, “as anyone who has had toxin will know, you keep wanting to come back for more, so even though I have some patients who are struggling a bit financially, we try and help them through finance packages and reduced treatment plans. I try and give them the confidence that whatever they can afford will still help them feel better.”

Van Sanden Cooke shared that Laser Clinics’ footfall has dropped in recent months, especially in branches situated in shopping centres as people’s expendable income has decreased. She continued, “Our average transaction value has definitely gone down too; people are still having treatments, but they’re being more conscious about how they approach their treatment journey.”

Marketing The fact that the average person now has less money to spend on treatments means marketing strategies have to adapt.

Van Sanden Cooke shared that Laser Clinics has shifted its promotional targets to accommodate this, saying, “In recent months, we have been using our marketing to try and home in on new patients, because we understand that our current clientele might be up against the cost of living crisis and less able to spend how they used to.”

Diving deeper into this, she shared that social media – either paid or unpaid – is a huge form of marketing now, and for it to be effective, it has to be authentic.

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She said, “People are very keyed up to when they’re being sold to, and it will actively turn them away. Balancing our national branding with the individuality of each branch is a delicate dynamic, but one which is crucial to attract new patients and keep them engaged.”

Gill explains that targeting the right messaging to the right people is the key to success in marketing. “Data segmentation is super important. We break our data down using several parameters, including the first treatment they booked with us, their recent spend, their lifetime spend and various booking patterns.

This allows us to both target patients appropriately, and see what areas we need to improve in,” he said. He went on to explain that this detailed level of data segmentation is best implemented when a clinic is newly established, but it can be reverse-engineered with a bit of investment.

He concluded, “I don’t condone the scatter-gun approach of trying to attract as many patients as possible just for the sake of adding more names to your data list. I’d rather attract 10 high-quality patients than 100 unreliable ones, as this is the best way to generate more long-term revenue.”

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Gill commented, “The biggest recent trend we have seen is much higher demand for regenerative treatments like polynucleotides or biostimulators and less demand for filler treatments. The growth of regenerative options as opposed to traditional injectables is beginning to filter into consumer behaviours.”

However, he did emphasise that perceived trends should be balanced against the reality of how patients are spending.

He shared that across Private Clinics, “Polynucleotide treatments have gone up 300%, but they’re only worth 4% of our overall revenue. Toxin and fillers are still worth 65%, so they cannot be ignored – they’re still the fundamentals of a clinic.”

Dr Kanji has certainly observed the regenerative shift, sharing, “Toxin is still the number one treatment I’m offering, but polynucleotides have overtaken fillers in terms of patient demand. From a clinical perspective, I now know that using regenerative approaches like polynucleotides to rejuvenate the skin, rather than overfilling as was the tendency in the past, is going to create better results, so I often do recommend this.”

Dr Kanji added, “My key piece of advice is that it’s much cheaper to keep your existing patients than to attract new ones.”

She shared that she takes the time during her routine appointments to find out what patients really want and educate them on their other options. She remarked that it’s easier to increase revenue this way as you already have a trusting relationship with the patient, saying, “I think you’ll be surprised to see how many of your patients say ‘yes’ to new treatment options after chatting through them.”

However, it was noted that patients can feel like they are being sold to when being offered new treatment modalities such as these. All the speakers acknowledged that active upselling is one of the top factors likely to deter patients from engaging with new modalities, or even returning to clinic at all, so it is a delicate situation to navigate. Van Sanden Cooke advised, “For me, during my work in aesthetics, I don’t believe in selling. You have to educate – if you educate the patients on what treatments are available instead of selling it to them, they can make the informed decision for themselves.”

Regenerative treatments

Maintaining stability

All speakers remarked that the growing regenerative approach is causing a significant shift in their clinics.

One of the most significant developments in the world of aesthetics this year was the sudden closure of sk:n clinics across

Medical aesthetic trends cannot be discussed without addressing the monumental impact of the current economic climate on consumer patterns

Aesthetic Clinical Practice Trends News Group Insights Clinic the UK.1 While the group was fortunately later acquired by Optical Express, it raises the question of how clinics can retain a sense of stability in an increasingly unpredictable landscape.

Dr Kanji shared, “I have seen that patients have been more wary of purchasing treatment packages recently, so it’s all about reassuring them. We do this by emphasising that Therapie is a family-run business, and all the clinics operate in a tight-knit and supportive structure.”

Gill further commented, “I think it’s about understanding where you fit into the market in your area. The Private Clinic is a more premium provider, and we’re well aware of that and lean into it, so we strive to be the most ‘reassuringly’ expensive of the clinic chains available.” He said this principle can also apply to independent clinics – sticking to your niche and feeling confident in this can be the best approach to retain stability.

Van Sanden Cooke explained that Laser Clinics has had to close branches before, but that there is no shame in it. She said, “We have learned from mistakes that we’ve made before, especially in terms of wanting to expand very quickly. It has to be quality over quantity.”

Adapting to ever-evolving trends The key takeaway from this insightful panel was that in the aesthetics specialty, there is likely to always be something in a state of change. Whether it be clinical developments, social media trends or economic circumstances, it is crucial for practitioners and clinics alike to keep their fingers on the pulse. Nevertheless, the speakers all concur that you should not stray too far from your key values and unique selling points in an attempt to keep up – your identity and treatment offering is what will keep your patients coming back time and time again.

14 & 15 March 2025 Business Design Centre, London The Call for Papers to speak on the In Practice Theatre at ACE 2025 is open now. Go to aestheticsconference.com to submit your abstract by November 29.

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Aesthetics | November 2024

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In The Life Of

Aesthetics

Dr Sophie Phillips completed her member of the faculty of dental surgery qualification with the Royal College of Surgeons of Edinburgh and obtained a Master’s in restorative and aesthetic dentistry. Initially, her foray into aesthetics was gradual, but it quickly became a passion that led to establishing her own clinic Six Aesthetics in Hertfordshire.

Dr Phillips’ day starts by looking after her two young children, having breakfast and dropping them off at nursery before heading to her clinic.

Her daily routine is far from monotonous. “I typically have a mix of new and existing patient consultations, as well as a variety of treatments, which keeps things fresh and exciting,” she notes.

Whether she’s discussing a treatment plan or performing a delicate procedure, Dr Phillips notes that she thrives on the diverse challenges her role presents. Occasionally, she sneaks out for a frothy coffee from a local café, a little ritual that revitalises her spirit.

Throughout the day, she emphasises the importance of patient communication. “Understanding my patients’ needs and expectations is crucial. I really take the time to listen and tailor my approach,” she explains. She adds that considering a patient’s anatomy during a consultation is key. She explains, “Not only does it help reduce complications, but it also boosts your confidence as a practitioner, which in turn instils trust in your patients.”

A cornerstone of her practice is her commitment to continuous learning, particularly through educational platform Spark by Allergan Aesthetics. “Having access to on-demand content and virtual product specialists means I can expand my knowledge and skills without disrupting my busy schedule. It means that I can just pencil a little bit of learning into a lunch break or a gap in between patients.” She notes that this flexibility allows her to stay updated with the latest techniques and products, which she can then apply to her patient care.

Dr Phillips adds that where possible, she also tries to incorporate aesthetics events into her busy schedule. “Building professional relationships with other aesthetic practitioners can feel daunting, but it’s an invaluable part of your journey. I find that face-to-face interactions make all the difference; they help me connect with others in a way that feels genuine and reassuring,” she reflects.

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Dr Yasmin Tayeb After working across general practice, hospital dentistry and maxillofacial surgery, Dr Yasmin Tayeb transitioned into aesthetics, combining her dental expertise with a newfound passion for enhancing patients’ self-esteem.

Dr Sophie Phillips and Dr Yasmin Tayeb discuss their typical days learning through Spark by Allergan Aesthetics Dr Sophie Phillips

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She begins her day getting her children ready for school.

However, stepping into her clinic transforms the hectic energy into calming focus.

“As soon as I enter, it feels like a peaceful oasis,” she shares.

Her day kicks off with a team briefing, where she and her staff review the patient schedule and discuss potential challenges.

“Being on the same page is crucial,” she emphasises. “We aim to enhance each patient’s experience and ensure we’re fully prepared.”

Dr Tayeb emphasises the importance of thorough patient consultations, a pivotal part of her practice. “This is where trust is established,” she explains. “I want my patients to feel valued and assured that we are dedicated to their care, not just for today, but for the long term.”

Her day is filled with back-to-back appointments, leaving little time for breaks. “I thrive on the energy of the clinic,” she says, relishing the intensity of her work. She notes that she has seen a real change in patient interest in recent years. “I love the fact that we’ve moved away from big cheeks, big lips – that Hollywood look. I love the fact that now we’re going into the natural look, and we are focusing on rejuvenation.”

Dr Tayeb adds that throughout the week, in between clinic appointments, she dedicates time to enhancing her skills. She reflects, “In a field that is so fast paced, it’s amazing to be able to come into clinic and do your treatments. But every week I like to ask myself: have you allowed yourself a little bit of time to see where you can improve individually or what new treatments are out there?” A vital component of her education is the Spark by Allergan Aesthetics platform, which she uses to access on-demand content and connect with virtual product specialists. “When I first started in aesthetics, Spark was an invaluable resource,” she recalls, “It provided safe, reliable information that helped me build my confidence. In a field that can feel isolating, having that support is essential.”

She emphasises the importance of ongoing education for patient results and trust, noting, “Staying informed is key to delivering the best care.” She adds that Spark enables her to learn at her own pace, from a range of practitioners. She says, “By watching these remote videos or talks and so on, you can actually see if someone else has got a different way of doing the treatments you do – it means you can pick and choose skills and techniques from a range of top practitioners in the specialty.”

Register on Spark by Allergan Aesthetics today to access FREE on-demand videos & content. Spark by Allergan Aesthetics is an educational website that contains promotional materials available to healthcare professionals only.

©AbbVie 2024. All rights reserved.

Material produced and funded by Allergan Aesthetics, an AbbVie company. Intended for UK healthcare professionals. www.allerganaesthetics.co.uk UK-AGNA-240301 Date of preparation October 2024

Allergan 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.

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Aesthetics | November 2024

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“In medical aesthetics, patient wellbeing should always come first” Dr Pamela Benito shares how her personal experience with atopic dermatitis fuelled her passion for medical aesthetics Dr Pamela Benito is a London-based aesthetic practitioner and Teoxane trainer, who integrates her medical background with a focus on skincare and non-invasive treatments. Dr Benito, born and raised in Madrid, spent most of her academic years there. Her battle with atopic dermatitis sparked her interest in skincare and nutrition, initially leading her towards dermatology.

However, due to fear of disappointment in never finding a permanent solution for her dermatitis, and her loss of faith in dermatologists during her youth, she decided to pursue Dental Surgery at Alfonso X Elsabio University in Madrid, qualifying in 2006. “One of the things I am obsessed with is people’s smiles. I want to help people feel better, happier and more confident – especially because that was my challenge growing up,” she says.

In 2008, Dr Benito moved to New York to complete a Master’s degree in Aesthetic Dentistry from New York University (NYU), and qualified in 2011. “Academically, it was amazing and as an experience, it remains one of my favourite chapters to date,” she reflects. Dr Benito has been registered to the General Dental Council (GDC) since 2007, and in 2011 she was offered a position at the Dental Lounge in South Kensington. She recalls working in both the dental surgery and facial aesthetic fields at the clinic, stating, “I was on emergency call for dental surgeries at their Baker Street clinic twice a week. Sometimes, I would get a call at 2am and would have to go in – I did that for a few years.”

Eventually, she was offered the role of medical director at a Medispa near Southgate. She says, “This is when I began performing more advanced aesthetic procedures, including chemical peels, mesotherapy, microneedling and platelet-rich plasma (PRP) treatments.

As my training advanced, I began working at Cosmesurge in Harley Street to do threads part-time.” After years of building her patient base, Dr Benito opened up her own clinic, Clinic Shiro, in 2023.

With a strong foundation in skincare, she combines medical-grade products and vegan options to cater to her diverse clientele, underscoring her holistic approach with a long-standing commitment to IV supplementation. During patient consultations, she dedicates an entire hour to understanding each individual’s needs and lifestyle, emphasising that this initial consultation and assessment is crucial. “Often, they come in for one thing, and we end up exploring treatments that align more with their overall wellness,” she explains.

With three years of experience working with the London Academy of Aesthetic Medicine (LAAM), Dr Benito has expanded her focus and passion towards education. She has contributed to training academies, including mentoring for Level 7 students, and is part of the Teoxane faculty, providing training sessions in London.

“I’ve always enjoyed teaching,” she says, noting, “During my own training, I often felt uncertain after short courses due to the lack of hands-on practice. My aim is to provide the guidance I wish I had, such as the critical knowledge of anatomy, minimising the risk associated with injectable treatments and to even learn how to dissolve fillers in cases of an adverse event or emergencies.”

Aesthetics | November 2024

In Profile Dr Pamela Benito In the rapidly evolving landscape of medical aesthetics, Dr Benito remains committed to ensuring her approach upholds the highest safety standard. “In medical aesthetics, patient wellbeing should always come first,” she says, “and that means thoroughly vetting any new products or techniques before integrating them into practice.”

As she explores new developments like exosome therapies, she says, “It’s important to approach these innovations with caution. We need to know the quality and safety of these products and devices, and treatment protocols need to have the clinical evidence that they have effective outcomes and safety.”

Dr Benito also enjoys regular speaking engagements, such as her recent talk at the Clinical Cosmetic Regenerative (CCR) Congress, touching on injectable considerations for upper face facial rejuvenation. She expresses her admiration for her fellow presenters, including Dr Elizabeth Hawkes, Professor Alwyn D’Souza, Dr Catherine Fairris, Dr Souphi Samizadeh and Dr Kuldeep Minocha, noting, “It’s an honour to be alongside an esteemed group of contributors.”

Reflecting on her career so far, Dr Benito names consultant plastic surgeon and former president of the British Association of Aesthetic Plastic Surgeons (BAAPS) Mr Rajiv Grover as a significant mentor.

“He’s one of the best plastic surgeons,” she says, explaining how Mr Grover’s guidance has shaped her professional journey. “He’s always been incredibly helpful with advice, and I’ve learned so much from him.”

Looking back on her path into aesthetics, Dr Benito’s advice to her younger self is simple: “Keep working hard. It takes time, but it’s worth it in the end. It’s also important to understand that everyone sees things differently, and not every patient will be the right fit for you.”

She concludes that while medical aesthetics is a challenging field, “like everything in life, it’s also a beautiful one.”

If you could choose a career outside the medical field, what would it be?

Something in the fashion industry or interior design! I like beautiful things!

What is the most recent treatment you have added to your clinic?

The medical ozone therapy.

It’s an exciting addition to our wellness portfolio.

Do you have a mantra you stick to?

I read a book called The Monk Who Sold His Ferrari, and the word ‘Kaizen’ was in it. It means continuous improvement within yourself – that is my mantra.

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The LastPractice Clinical Word News Consultations Health

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The value of integrating health services

The Last Word Dr Kamran Amjed shares an experience which shaped his view that aesthetic clinics should always screen patients medically as well as cosmetically The aesthetics specialty has long been associated with beauty and confidence, but the evolving landscape of medical aesthetics now intertwines these goals with holistic health. At my clinic, we recently witnessed the profound impact of this integration firsthand when a routine aesthetic treatment led to a life-saving medical intervention.

This case highlights key factors that are increasingly vital in today’s aesthetic practice: the importance of thorough consultations, and the value of offering a broad range of health services alongside aesthetic treatments. I argue that health checks and services should remain at the forefront of medical aesthetic consultations and clinics.

Uncovering a life-threatening condition A 39-year-old male patient visited the clinic for a seemingly simple laser hair removal treatment. During his session with our clinic therapist, he casually mentioned experiencing ongoing chest pains. This was not his first bout of discomfort; he had been experiencing these pains intermittently for weeks. However, despite his significant resources, he had yet to seek medical advice, citing a hectic schedule, regular international travel and the challenges of arranging an NHS appointment.

Recognising the potential severity of his symptoms, our therapist immediately recommended a consultation with me following his treatment, as I always believe consultations should be for overall health, not just aesthetic goals. This philosophy is embedded in our practice.

After conducting a comprehensive health check and reviewing his medical history, I decided to order a series of diagnostic tests, including a full blood workup and a CT angiogram. Within three days, the results were in, revealing a 90% blockage in his coronary artery – a condition that could have led to a fatal heart attack if left untreated.

I immediately referred him to a top cardiologist, and within two days, he was started on life-saving medication. Just two weeks later, he underwent surgery to have two stents inserted – a procedure that undoubtedly saved his life.

The importance of thorough consultations This incident underscores the critical role that thorough consultations play in medical aesthetics. When training other practitioners, I always emphasise the need to be vigilant, to ask the right questions and look beyond the immediate aesthetic concerns presented by the patient. A well-conducted consultation can uncover underlying health issues that might otherwise go unnoticed, allowing for early intervention and potentially life-saving outcomes. Asking about lifestyle factors such as smoking, drinking, exercise, travel, mental health and more can be helpful indicators here. To allow for this, I believe all members of staff, medical and non-medical, should receive consultation training that covers aspects of lifestyle medicine.

In this case, had our therapist not engaged in a detailed conversation with the patient about his overall health, we might have missed the signs of a serious cardiovascular condition. This story serves as a powerful reminder to all practitioners in the aesthetics field that our role extends beyond enhancing physical appearance – we are also gatekeepers of our patients’ overall health and wellbeing.

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The approach of integrating health services into aesthetic clinics is becoming increasingly relevant as the specialty shifts towards a more holistic model of care. Offering services such as health checks, blood testing and access to private diagnostic scanning allows us to address our patients’ needs comprehensively. I strongly believe all medical aesthetic clinics should be offering these services. It has to be acknowledged that they do require extra time and team training to implement, but they help separate you from an already saturated aesthetics market, making patients feel they are receiving enhanced care. The availability of these services was crucial in this patient’s case. Because we could offer immediate health assessments and coordinate advanced diagnostic procedures, we were able to provide swift and effective care.

This integration of services reflects a broader trend in the field towards holistic health, where aesthetic clinics are not just about enhancing beauty, but also about ensuring the overall wellbeing of patients.

Equally important is our ability to refer patients to the appropriate specialists when needed, ensuring a comprehensive approach to their health; clinics should have referral pathways in place if needed. I believe this is a hugely positive shift that is going to transform the level of care we can provide to our patients.

A new standard in aesthetic medical practice This patient’s experience is testament to the evolving role of aesthetic clinics in today’s healthcare landscape. By prioritising thorough consultations, integrating health services with aesthetic treatments and addressing unique health needs, clinics are setting a new standard in care.

This holistic approach not only enhances patient outcomes, but also reinforces the idea that beauty and health are intrinsically linked. As the aesthetics field continues to evolve, we must remain committed to offering comprehensive, patient-centred care that addresses both the aesthetic and health needs of our patients.

Dr Kamran Amjed is the founder and medical director of The Medika Clinic in Manchester. With a background in both aesthetics and holistic health, Dr Amjed is dedicated to promoting a comprehensive approach to patient care. He also leads the Consultation Catalyst Training Program, where he trains practitioners to conduct thorough, patient-focused consultations.

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