Aesthetic Medicine May 2020 by Aesthetic Medicine

INSPIRING BEST PRACTICE IN MEDICAL AESTHETICS

May 2020 | aestheticmed.co.uk

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INSPIRING BEST PRACTICE IN MEDICAL AESTHETICS

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CONTENTS

IN THIS ISSUE...

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INSPIRING BEST PRACTICE IN MEDICAL AESTHETICS

Contents MAY

SAY CHEESE PLANNING A SMILE MAKEOVER

GET A HANDLE ON IT DERMATOLOGY FOR HANDS May 2020

May 2020 | aestheticmed.co.uk

11 COVID-19 SPECIAL: ON THE NHS FRONTLINE Dr Ravi Brar shares his experience, plus Dr Sophie Shotter, Dr Ahmed el Houssieny and Dr Tijion Esho

EDITORIAL Georgia Seago, Deputy Editor E: georgia@aestheticmed.co.uk T: +44 (0) 20 3728 9063

E: vicky@aestheticmed.co.uk T: +44 (0) 7931 924 322

15 COVID-19 SPECIAL: ACCOUNTING Phil Elder suggests a different way of looking at your clinic’s finances

6 NEWS The latest news from the industry

FIRST RESPONSE CORONAVIRUS SPECIAL

Vicky Eldridge, Consultant Editor

4 EDITORIAL BOARD Meet our editorial advisory board

18 COVID-19 SPECIAL: PR & MARKETING PR expert Lucy Hilson on what you can do to keep patient communication going

ADVERTISING Jack Diamond

E: jack@aestheticmed.co.uk T: +44 (0) 207 349 4792

MARKETING Jennifer Shutter

E: jennifer@aestheticmed.co.uk T: +44(0)203 841 7361

PUBLISHER Mark Moloney

E: mark@aestheticmed.co.uk T: +44(0) 207 349 4790

DESIGN AND PRODUCTION Daniel Parker

daniel@professionalbeauty.co.uk

PRINTING Pensord Press pensord.co.uk SUBSCRIBE Annual subscription UK: Print £44, DD £39.50, Digital £10. Europe: £59; outside Europe: £67.50. To receive your copy of Aesthetic Medicine every month call 01371 851875 or see escosubs.co.uk/aestheticmedicine The publisher accepts no responsibility for any advertiser whose advertisement is published in Aesthetic Medicine. Anyone dealing with advertisers must make their own enquiries. Professional Beauty Group 25 Allington House High Street Wimbledon Village SW19 5DX

Aesthetic Medicine • May 2020

CONTENTS

IN THIS ISSUE...

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24 COVID-19 SPECIAL: FINANCE Advice on how to handle things financially by Reece Tomlinson

32 SKIN BOOSTERS Dr Anna Hemming compares different skin boosters on the market 37 MUSCLESTIMULATION DEVICES We look at why muscle stimulation is taking over as the most popular method of body contouring

28 HAND DERMATOLOGY How to look after the hands without compromising on hygiene, for both your patients and yourself

42 SOCIAL PROOF Alex Bugg examines social proof and how you can put it to use in your marketing 44 PRODUCT NEWS The latest product launches 46 TREATMENT FOCUS The Frax Lip Treatment by Nordlys

48 CASE STUDY Aesthetic therapist Sherine Vassel on how she achieved lifechanging results for her patient using SkinPen 50 SMILE DESIGN Dr Yasmin Shakarchy and Dr Ben Reyhani present the nine key elements of a successful smile makeover

58 LIPOSUCTION A new laser-assisted liposuction system has the potential to improve the procedure overall, says Dr Yannis Alexandrides 64 MYOMODULATION Dr Steven Harris sets out the most popular theories behind myomodulation

Welcome to the May issue of Aesthetic Medicine I won’t use the words “unprecedented” “tough times” or “weather the storm” here – I think we’ve all had our fill. However, the first section of this issue is dedicated to helping our readers – whether you’re a clinic owner, practitioner, aesthetic therapist or supplier, get through this. Pages 11 to 26 are filled with practical, easilyimplementable and honest advice on how we can keep going, and in some cases, re-build. 24

In the rest of the issue, we push onwards and upwards with clinical, treatment and business content to inform and inspire – perhaps needed now more than ever. Dr Anna Hemming’s article comparing skin booster products on page 32 to 34 should help you decide which to train and invest in for your patients, while Dr Yannis Alexandrides (pages 58 to 60) introduces a new advancement in laser-assisted liposuction; and Dr Steven Harris (pages 64 to 68) goes on an in-depth exploration of myomodulation, exploring common theories and presenting his own hypothesis. This month, we’re also bringing you an overview of the ideal approach to smile design by Dr Yasmin Shakarchy and Dr Ben Reyhani (pages 50 to 54); and a look at some of the muscle-stimulation body-contouring devices available on the market (pages 37 to 40). I hope this issue will help reignite any excitement, passion and positivity that may have temporarily become lost in recent weeks. We’re here for you, and we’ll make it through. Please get in touch with any thoughts or feedback – I’d love to hear from you: georgia@aestheticmed.co.uk georgia@aestheticmed.co.uk Georgia – Deputy Editor

Aesthetic Medicine • May 2020

0208 748 2221 info.uk@venusconcept.com www.venusconcept.com

FINALIST 2019

CO N T R I B U TO R S

EDITORIAL ADVISORY BOARD

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Meet the experts The Aesthetic Medicine editorial board includes some of the leading names in aesthetics. Their clinical expertise and diverse range of specialties will help ensure the magazine meets the needs of its readers.

DR NICK LOWE

DR ULIANA GOUT

DR SOPHIE SHOTTER

Dr Nick Lowe is a consultant dermatologist at Cranley Clinic, London and clinical professor of Dermatology at UCLA School of Medicine, Los Angeles. He is a Fellow of the Royal College of Physicians, American Academy of Dermatology and American Society of Laser Medicine and Surgery. He has authored more than 450 clinical and research publications, 15 scientific and five educational books.

Dr Uliana Gout is the founder of London Aesthetic Medicine Clinic & LAM Academy. She sits on the Board of the British College of Aesthetic Medicine (BCAM) and has recently been elected president. She also acts as a BCAM Appraiser for the GMC. She sits on the Board of the International Peeling Society. She has co-authored numerous medical textbooks.

Dr Sophie Shotter is the founder and medical director of Illuminate Skin Clinic in Kent. In 2019, she was invited to join the Allergan faculty board, having been mentored by Dr Mauricio de Maio. She is also on the board of the International Association for the Prevention of Complications in Aesthetic Medicine (IAPCAM). In 2017, she won Businesswoman of the Year at the Kent Women in Business awards.

DR STEVEN HARRIS

DR SHIRIN LAKHANI

DR RAJ THETHI

Dr Steven Harris has been practising aesthetic medicine at his clinic in North London since 2004 and has gained an international reputation for producing natural looking results. His original approach and techniques include Facial Reshaping with Myomodulation and the Nonsurgical Lip Lift (NLL). Dr Harris is also a trainer and educator. His regular educational posts can be viewed on Instagram: @drharrisclinic

Dr Shirin Lakhani has an extensive background in medicine, having worked both in general practice and in a hospital environment. She is also a trained anaesthetist. In 2013 she founded Elite Aesthetics in Kent. She also practices from the renowned Cranley Clinic in London. She has a specialist expertise in intimate health and appears regularly on television and in the press as well as speaking at medical conferences worldwide.

Dr Raj Thethi graduated from Leeds University Medical School in 2013, having completed an additional BSc (Hons) 1st Class Degree in Anatomy. On completion of his surgical training in the Yorkshire Deanery he qualified as a Member of the Royal College of Surgeons (Edinburgh). He has completed a Level 7 accredited course in Aesthetic Medicine. He is an aesthetic trainer and has been published in several aesthetic industry journals.

MR ALI GHANEM

DIJA AYODELE

EMMA DAVIES

Mr Ali Ghanem is a consultant aesthetic plastic surgeon and clinical senior lecturer in plastic, reconstructive and aesthetic surgery at Barts and the London School of Medicine & Dentistry, as well as visiting professor and head of department of Aesthetic Medicine at the College of Medicine and Dentistry, Ulster University. He is qualified in Medical Law and Ethics, Surgical Science and Developmental and Stem Cell Biology.

Dija Ayodele is an aesthetician and founder of the award-winning educational platform Black Skin Directory (BSD). With more than 10 yearsâ&#x20AC;&#x2122; experience, her Kensington-based clinic is a go-to destination for patients of colour seeking skin rejuvenation treatments and advice for their skincare needs. She speaks regularly at both industry and consumer events and in 2019 launched a pioneering sunscreen campaign for black skin.

Emma Davies has specialised in aesthetic medicine since 1998. She was a committee member on the RCN Aesthetic Nurses Forum from 2000-2010; founder member and secretary of the British Association of Sclerotherapists (2003-2010) and founder member and past chair of the British Association of Cosmetic Nurses (20102014). She is currently clinical director of Save Face and vice chair of The Aesthetic Complications Expert Group.

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N E W S A N D A N A LY S I S

INDUSTRY NEWS

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Brits put faith in doctors ahead of politicians and fellow citizens to get through pandemic 77% of UK residents are confident that doctors and other healthcare professionals will eventually resolve the covid-19 crisis. A survey conducted by YouGov for Stada, the parent company of consumer products manufacturer Thornton & Ross, found that three-fifths of Brits questioned (out of more than 2,000) are also putting their hope in the pharmaceutical industry to develop a vaccine. Meanwhile, less than half (49%) said they trust their fellow citizens to follow the rules and regulations set out by the Government to slow the spread of the virus. Trust in politicians to lead us out of the pandemic is relatively strong in the UK – 35% of Brits said they trusted the Government to take control of the situation. Compared to our European neighbours, this figure is almost double that of Spaniards who said the same (18%), and far higher than the 15% of Italians who put faith in their politicians.

E-commerce sales tool launches specifically for aesthetic clinics to help drive revenue To help support aesthetic clinics through the covid-19 pandemic, digital creative agency Blowmedia has developed an e-commerce sales tool specifically aimed at the market. SkopBot – which stands for Skin Shop Bot – is billed as the “first-ever” automated sales bot designed for aesthetic clinics with no existing e-commerce functions. SkopBot was created to give clinic owners a more affordable and easierto-implement alternative to a full e-commerce website setup, which still provides a viable cash-flow lifeline while clinics are closed. The service is created bespoke and set up for a clinic in 48 hours for an initial flat fee of £300. SkopBot doesn’t need to be supervised or operated by an employee – it is entirely automated with pre-defined questions to channel customer website visits into a skincare purchasing funnel. A small monthly licensing and maintenance fee is required on a noncontractual basis to enable the Blowmedia team to manage the system. Tracey Prior, operations manager at Blowmedia, said: “The team at Blowmedia were keen to support clinics during this crisis. Our first step was to move to a non-profit business model across the board at Blowmedia, and our second step was creating this game-changing product, not to drive profit, but to help the whole industry survive and thrive through this difficult time. “Both these initiatives will hopefully help our clients to enjoy stability, and in some cases growth, throughout this uncertainty.”

Dija Ayodele develops facial treatment initiative to give back to NHS workers Dija Ayodele, Aesthetic Medicine editorial board member and founder of Black Skin Directory and West Room Aesthetics, has launched an initiative to thank and reward frontline NHS staff. The Nightingale Treatment is inspired by images of NHS workers showing the skin damage caused to their faces by continued use of PPE. Once socialdistancing rules are lifted, Ayodele wants to gift skin treatments to NHS staff members to help rejuvenate their skin. Each front-line NHS worker will be entitled to one treatment on production of official NHS ID. Ayodele commented: “The best wayI know how to give back is to use my skills to bring together colleagues and brands in the industry to create this initiative - The Nightingale Experience.” Ayodele welcomes inquiries from other brands and clinics who wish to participate. Contact her on hello@dijaayodele.com

Aesthetic Medicine • May 2020

N E W S A N D A N A LY S I S

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Study seeks to understand impact of coronavirus on mental health 3,000 UK adults are taking part in a study led by the University of Glasgow into the mental health effects of covid-19. Aiming to understand the impact of the pandemic and strict social distancing measures on mental health indicators such as anxiety, depression, loneliness and self-harm, as well as positive mental wellbeing, scientists will track the participants over the next six months and beyond, during and after the lockdown period. Study lead Professor Rory O’Connor, from the University of Glasgow’s Institute of Health & Wellbeing, who is leading the study, said: “In this study, we aim to understand the psychological impact of covid-19 on adults across the UK. By tracking a representative sample of the UK public, we will be able to identify who is most vulnerable and what helps to keep people safe and well.”

Novel investigational treatment for covid-19 patients developed Biotechnology company Tiziana Life Sciences has developed investigational new technology to treat covid-19 infections, which consists of direct delivery of anti-IL-6 receptor (anti-IL-6R) monoclonal antibodies (mAbs) into the lungs using a handheld inhaler or nebuliser. Patients infected with covid-19 are known to develop an uncontrolled immune response (cytokine storm), which results in excessive production of pro-inflammatory cytokines and other proteins such as interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-a) and Granulocyte-Macrophage ColonyStimulating Factor (GM-CSF). Gabriele Cerrone, chairman of Tiziana Lifesciences said, “Direct delivery of anti-IL-6R mAb to the lungs using a portable handheld inhaler or nebuliser is a rapid and immediate therapy for children and adults infected with covid-19. Importantly, this treatment with our fully human anti-IL-6R mAb (TZLS-501) has the potential to be a long-term therapy to halt progression and reduce mortality in patients with covid-19, as a portion of the population may not opt to utilise a vaccine.”

US beauty and personal care sales take coronavirus hit

INDUSTRY NEWS

NEWS IN BRIEF DR NYLA RAJA DONATES SALARY TO NHS WORKER Dr Nyla Raja, founder of Doctor Nyla clinics and medi-spas, has donated her April salary to a struggling NHS worker. Dr Raja made the announcement on her Instagram saying, “Covid-19 has had a huge impact on both families and businesses, so I want to make the situation a little easier for someone who is struggling.” The recipient asked not to be named.

HEALTHXCHANGE OFFERS PRESCRIBING SUPPORT To help practitioners who are struggling to continue prescriptive skincare services because their usual prescriber is no longer available, Healthxchange is offering a prescribing support service. A fully-subsidised medical prescriber will be available via remote skincare consultations, ordering on the Healthxchange e-pharmacy and sending products such as Obagi Medical, direct to the patient to ensure those on prescribed medicine can achieve the planned treatment outcomes. Sign up for prescribing support by contacting clinicalteam@healthxchange.com

NEWS IN PICS To show its support for the NHS, Harpar Grace has put together Care & Compassion Kits containing Travel Cleansing Complex, Travel Sheald and Copper Firming Mist. The brand put a call out to its medical practitioners and partners who are returning to the frontline to support the UK to bring the kits to their NHS departments. They offered the packs to six ambassadors and each included 20 of each of the products. Pictured here is the team at the Royal Shrewsbury Hospital.

The US cosmetics and toiletries market is on track to experience the sharpest decline ever recorded in more than 60 years due to the covid-19 pandemic, according to analyst Kline. Previously forecast to grow at a CAGR of 3.8% through to 2023, Kline has revised its forecasts for the $75 billion US market in a new report, Impact of COVID-19 on the US Cosmetics & Toiletries Market. It has now predicted a 2.5% decline, with the best-case scenario reflecting a 1.5% gain and the worst-case scenario at an 8.1% drop. However, it has also described the industry as “fairly recession proof” and has predicted that it will recover within three to five years.

Aesthetic Medicine • May 2020

N E W S A N D A N A LY S I S

INDUSTRY NEWS

NEWS IN BRIEF 3D-LIPO ACHIEVES ISO13485:2016 CERTIFICATION Aesthetic devices manufacturer 3D-lipo has achieved ISO13485: 2016 certification, in line with changes to the Medical Device Regulations, implemented from this month. As part of a two-year project, 3D-lipo has developed and embedded a complete quality management system. Following auditing by BSI (British Standards Institution), this work culminated in the achievement of EN ISO 13485:2016 certification in February 2020. This audited standard is specific to the medical device industry and enforced by the Medical and Healthcare Regulation Agency.

EXPERT FACIALIST ANDY MILLWARD INTRODUCES BYONIK Industry expert facialist Andy Millward has taken on the Byonik laser device, distributed by Pure Swiss Aesthetics, at his clinic in Birmingham. “My initial thought was that it may not have been great timing just taking on a new device a week before lockdown. However, after a little more thought, I realised it’s actually perfect timing as I’m going to rely on my Byonik more than any of my other treatments when I reopen,” said Millward. “Now more than ever our clients are going to need therapeutic, non-invasive and non-wounding treatments that support skin function and repair.”

FILLMED TO EXCHANGE OUT OF DATE STOCK FOR FREE Injectables brand Fillmed has launched a scheme to support clinics though the pause in business due to lockdown. The company will replace any brand of filler stock that becomes out of date during lockdown (up to 30 June 2020) with new stock of its Art Filler. Practitioners simply need to ship expired products to Fillmed in order to receive the exchange, with a maximum of five boxes per clinic. Anyone interested should email info.uk@fillmed.com

Aesthetic Medicine • May 2020

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Aesthetic Medicine to bring education and engagement to AM Virtual Event Aesthetic Medicine and headline sponsor Inmode is hosting five days of online activity for our community from Monday, May 11 to Friday, May 15. We will soon launch a full schedule of webinar sessions from expert KOLs covering the wide scope of the industry and editorialled content, plus exclusive offers from industry-leading brands via our Facebook channel’s dedicated Virtual Event group. We will be offering free, daily CPDaccredited* education through a series of webinars with fantastic speakers, offering inspiration, business and financial advice. Sign up for free: news.aestheticmed. co.uk/am-virtual-week-signup *Subject to all webinars being approved for accreditation.

CPD service issues guidance on nonmedics training in aesthetics The CPD Certification Service has been working with influencers in the aesthetics industry to help improve the training, competency and proficiency of non-medically trained practitioners, stressing that it does not “condone poor practice”. It has now produced a document to ensure the public is not misled into believing CPD certification ensures safe and effective treatment outcomes or is a replacement for primary qualifications. The document states that “CPD should be delivered to those with prior qualifications and experience” and that course materials relating to procedures such as dermal fillers and botulinum toxin should refer to the regulatory framework approved by the PSA (Professional Standards Authority).

First UKAS-accredited certification in aesthetics launches Independent international certification body IQ Verify has received UKAS accreditation for its Level 4 in Skin Rejuvenation Techniques for Aesthetic Practitioners qualification. Having been through a rigorous 10-month programme of testing and review by independent ISO and industry experts, the Level 4 qualification is now deployed against the internationally-recognised standard ISO17024:2012. Candidates are required to undergo a process of periodic recertification – something that IQ Verify hopes will help overcome longstanding issues within the aesthetics training sector. “We see this achievement as a real step in the right direction in raising the QA bar to recognised standards of aesthetic personnel competency,” commented Laurence Clarke, scheme development manager at IQ Verify.

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COVI D -1 9 S PECIAL

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Duty of care Dr Ravi Brar is one of the many aesthetic practitioners who has offered their skills to help NHS doctors fight coronavirus. Here, he tells us how his working life has changed.

eflecting on this unprecedented climate that we are all being asked to navigate, I am quite simply overwhelmed and proud to witness the profound unity among our profession. As of the time of writing (when AM went to print) there are 2.99m worldwide cases of covid-19, with 875,000 who have recovered and 207,000 mortalities. In the UK alone, the figures currently stand at 153,000 who have tested positive to the virus and 20,732 deaths. These numbers will only increase. We are in uncharted waters and very few could have predicted the consequences of the worrying news that came out of China on New Year’s Eve, 2019. We have seen how the NHS has had to drastically change to respond to the pressure it is under. Speciality training in hospitals is being halted and doctors, including consultants, are being re-trained in acute medicine to cope with the rising number of patients presenting at A&E. Moreover, 15,000 retired staff have been asked to return. I experienced this first-hand in my hospital dermatology department; we are being redeployed into A&E to create teams of doctors from different specialties. This results in essential clinics and wards to be managed by the remaining consultants on a rota basis.

My GP consultations have also drastically changed. We are moving away from face-to-face consultations and primarily implementing e-consultations, telephone triaging and teleconsulting. As a result, only patients with acute symptoms are being asked to attend the GP clinic for reviews where it is felt they cannot be managed remotely otherwise. We have also set up special “hot” rooms dedicated for patients that we are concerned about in view of covid-19. This will stay the case until we are on the other side of this pandemic. Rewinding four months when we at sk:INSPIRE had initially heard what was taking place in Wuhan, we had a meeting to ensure that we tightened up our protocols, as we have numerous clients who travel from abroad. We also decided to go through our business continuity plan. We are a new, growing company, so we needed to ensure we had planned for future months, accounting for the volatile situation. As time went on, we saw how the pandemic was taking hold. Furthermore, London was fast becoming the epicentre, with the pressure on the NHS growing. It also meant that despite our tight protocols, we could not guarantee the safety of our patients or staff, as they could be exposed while travelling to and from the clinics.

Aesthetic Medicine • May 2020

COVI D -1 9 S PECIAL

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BACK TO THE START

On 20 March, three days before Boris Johnson announced the national lockdown, we took the decision to suspend our aesthetic work so we could redeploy and focus on helping our colleagues in the NHS. This was meant to be a landmark weekend for us, as we were planning to relaunch our clinics after a year of hard work in building and rebranding our business. However, we did not hesitate in taking this step. As a team of doctors and nurses, we felt it was our duty to ensure we were available to the NHS during its time of greatest need. The decision was made easier by the fact that our clients have been very supportive and understanding. They have been reassured that although we are now working to help the NHS in A&Es, urgent care centres and at general practices, they are still able to reach us for advice.

pandemic. Here at sk:INSPIRE, even though we have closed our physical doors, we still take the time to engage with our existing customers who are able to contact us for virtual skin advice where possible via video consultations. When not working on the front line, I have regular meetings with my co-medical director and staff, making use of virtual means such as Microsoft Teams. We make time to ensure that we all are keeping well – both mentally and physically. We constantly review and update our business continuity plans for the next 12 months to ensure that we can hit the ground running when this pandemic is over. I’m also taking this time to stay up-to-date with new treatments, products and techniques. I take part in webinars, CPD online learning and review my educational material. We have also tasked our marketing team with reviewing our website and social media, ensuring it is ready for when we do relaunch. Most importantly, I would encourage my colleagues and friends in the aesthetic field and in the NHS – when you’re not working, use the extra time to focus on your health and your family.

“In my hospital dermatology department we are being redeployed into A&E to create teams of doctors from different specialties”

BRACE FOR IMPACT

The weeks and months ahead will be tough for all businesses. Insurance provider Hamilton Fraser ran a survey between 22 and 24 March and received 1,360 responses from aesthetic practitioners. The results showed that of those surveyed, 99.8% reported that their practice had been affected by the current pandemic. Moreover, the survey showed that 80.5% of practitioners had closed their clinics, 67.3% had a reduction in revenue and 63.3% had a reduction in enquiries. Worryingly, 48.8% reported that they are at risk of going out of business. These numbers have most certainly gone up since the lockdown imposed by the Government. These staggering statistics highlight the significant impact the virus is having on the industry.

TIMES ARE CHANGING

In these uncertain times, we are facing questions that we do not necessarily have the answers to; the pandemic has shown us how quickly things can change. We have to ensure that we adapt to the changing times but more importantly, put our clients, staff and families first until we are over this

MOVING FORWARD

Covid-19 will ultimately have an enormous impact on economics, health care and businesses of all types. The Government will need to plan how to rebuild the country and reports are already suggesting that the pandemic will have a greater effect than the 2008 recession. We, as practice owners, should be ready to not only go back to our normal clinic regimes, but also be ready to deal with inevitable changes. This can be done if our foundations are solid and we have good planning in place. However, until the day we have beaten this invisible enemy, we should continue to offer our services to the NHS. Together we are stronger and only together can we get through this. Practitioners who want to volunteer their skills to the NHS can still sign up at: england.nhs.uk/coronavirus/returningclinicians/

Dr Ravi Brar is medical director of sk:INSPIRE Medical Aesthetics. A member of the Royal College of General Practitioners, he has a special interest in dermatology, having completed postgraduate studies in Clinical Dermatology from Queen Mary University London. His patient-centred ethos is to naturally enhance and define, helping his patients to look and feel their best.

Aesthetic Medicine • May 2020

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COVI D -1 9 S PECIAL

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Three other aesthetic doctors share their experiences of returning to the NHS amid covid-19 DR SOPHIE SHOTTER:

“We’ve repurposed the clinic as a not-for-profit private GP service. We’re mainly operating over Zoom, but in person if we’re needed, with two GPs and myself as appropriate. It’s for people who can’t get their usual medical care through the NHS, and it’s become busier. I’m also doing a few remote skincare consultations but my

DR AHMED EL HOUSSIENY:

background is in intensive care and anaesthetics so, when it became clear how bad things were going to get, I couldn’t sit back and watch. I’ve returned to the ICU at my local NHS hospital and I’m on the rota. “It’s something I never thought I’d be doing, but it feels totally right. There are moments that are terrifying and it’s strange assuming that I’m going to catch it at some point in the environment I’m putting myself into – we’re all social distancing but there’s me walking right into it and playing with airwaves on people we know have covid-19. My trust is really well organised though, and we’ve got good enough PPE, not perfect but enough. The night shifts are weird – that’s something I loved leaving behind.”

“I actually never stopped doing my anaesthetic work for the NHS alongside my aesthetics practice, so it was just a matter of diverting all my time and energy to the NHS. I’m covering departments like theatres, intensive care and maternity. I am lost for words to describe the experience. All I can say is that is has

DR TIJION ESHO:

“At the start of the pandemic I had closed my clinics to hand them over for use to help triage patients if needed, and we donated gloves, masks and equipment to local hospitals to help as much as we could. Unfortunately, my son ended up getting admitted to ICU and was on a ventilator for five days. Luckily, he pulled through, but while we were on site for those days we saw the real pressure of what the NHS was facing; something you get shielded from in private clinics. Despite already volunteering I knew I had to do more and hence the took the decision to return to the NHS. “On the clinic side we are still actively volunteering, giving supplies to hospitals and vulnerable patients. In addition to this I’ve been working both in A&E as a ward doctor and have been spending a lot of time on telephone GP triage choosing

Aesthetic Medicine • May 2020

been very hard on everyone, and what has kept me going is a very strong sense of duty as a medic. I feel definitely changed by this. I’m humbler and have learned to cherish the things we take for granted. Throughout all of this so far, the key message for me is that the real heroes are the people who stood up and helped each other.”

who can or can’t come to hospital. It’s been more emotionally than physically draining. Never as my time as a doctor have I seen something change the lives of so many patients and families so quickly. Then you come home and look at your own family and worry for them. You just have to take each day as it comes and try to remain positive. “This has changed me as a father. Together with my son going into hospital this whole thing has made me stop and realise tomorrow is never promised and to be more present in the moment. My life is normally so crazy that sometimes I don’t get the time to appreciate what I have or what I’ve achieved, both professionally and personally. Taking the time to pause and focus on my family has really been life changing. “I think the biggest lesson I’ve learned from this so far has been economic and something I’ve always known, but that the pandemic has reinforced. I’ve always said is that it’s important to be more than just a clinic. You need to have a digital presence and develop multiple revenue streams to prepare for uncertainties. No one could have predicted this, but having those things has helped us as a business and a family to cope financially through this.” AM

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ACCOUNTING

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A different perspective Phil Elder suggests looking at your clinic’s finances slightly differently during lockdown, by focusing on where you spend your time

here’s a saying in business: “Turnover is for vanity, profit is sanity”. We’re all facing uncertain times with the current situation; and regardless of what government support you may or may not have received, or the size of your clinic; whether you’re a large, multi-site business or a solo practitioner, now more than ever you need to be focusing on profit. For many years we have seen booming growth within the aesthetics market, and while I am confident that the industry will recover well, we need now to look at the bottom line profit of our clinics and businesses. We’re all very much focused upon what our outgoings are while we weather this storm, but it’s also a great opportunity to look at your clinic and see where you can streamline and re-structure. Most importantly,

are all of your outgoings actually serving you in the best way? Remember, your clinic is there to support you and your aspirations, not the other way around.

TURNOVER VS. PROFIT

As any business owner will know, turnover is what you take through sales and treatments – i.e. you charge £300 for a treatment and treat 50 patients; therefore, your turnover is £15,000. Your profit is the actual money left after you have taken all of your costs into consideration. Things like the cost of performing any treatment, rent or lease on premises or equipment, heating and electricity, stationery, printing and marketing costs and even coffee for your patients. However, what is often overlooked is your time.

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ACCOUNTING

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value; if any of those tasks can be achieved for less, we can increase profit. Even in the current climate which may see a significant reduction in patients, we could still look to maintain the current profit levels with reduced input of our time. Consider the lifetime value of a patient. Bearing in mind the above cost to acquire a new patient, it is far simpler to look after your existing patients and add value than the costly exercise of acquiring more. Can you increase the number or frequency of treatments they are already having? Can you add additional product ranges to appeal to and help those patients? Can you work with other businesses to cross-refer services?

“We need now to look at the bottom line profit of our clinics and businesses”

What people tend to miss is the time they put into their clinics and businesses. Ordering, marketing, doing your bookkeeping, training staff, commuting between various sites; it all adds up. It’s surprising what an hour here and there can suddenly become. Try keeping a diary – lockdown is the ideal time to map out what your average week looks like. How many hours to you spend on each task? What is your actual profit divided by the number of hours you work? These figures can later be used to identify your actual hourly rate.

COST PER CLIENT

Another element we want to be looking at is cost per client or patient. How much is the true cost of acquiring another client? A great starting point for working this out is how much you spend on advertising. How many hours do you or your staff spend on booking initial consultations, and how many of these do you perform yourself, including those that don’t or can’t go on to have treatments with you? This all adds up. For example, if you spend £100 per month on advertising plus one hour of your time proofreading and amending the advert per month, and this amounts to four phone enquiries at 15 minutes each or two initial consultations at 30 minutes each (if offered for free), and one of those consultations goes ahead with a treatment costing £300, for example, this is turnover. In total it has cost £100 and three hours of your time, plus the time to perform the treatment – maybe a further 30 minutes. Even excluding any other costs to your clinic, you have only earned £57 per hour. While this is neither good or bad, we need to think about what can we do to increase this

Things to consider: 1. Seeing as I have a loyal client base, do I need the expensive premises? Would I lose many patients if I was to downsize or change location? 2. Could I possibly share premises with another complimentary business, therefore sharing costs and cross-referring patients to each other? 3. Can I automate anything within the business process to save time and increase productivity, like the booking procedure? If you increase something – like your number of leads – by a small percentage at planned stages, the results compound over time to really add up to something worthwhile.

FOR EXAMPLE: ADD 10 % Number of leads 50 Number of leads 55 Conversion rate 25% Conversion rate 27.5% Patients 12.5 Patients 15 Treatments 2 Treatments 2.2 Av. treatment £250 Av. treatment £275 Revenue £6,250 Revenue £9,075 Profit margins 50% Profit margins 55% Profit £3,125 Profit £4,991.25

Try this exercise out yourself with your own figures and I’m certain you will be amazed the figures after increasing each area by just 10%. Even if you can’t increase every element by 10% at the moment, focus on those that you can; can you convert more patients that come for an initial consultation? Can you increase the average treatment price by adding a homecare product? You’ll soon see that small increases in different areas can get big results. AM

Phil Elder is a multiple business owner. His portfolio includes Neos Clinic, an aesthetics clinic in Ipswich owned with his wife, accountancy practice RSZ Accountancy and a finance company. Phil brings his passion for life to his insights and advice into how to structure companies, tax savings and business efficiency. Contact Phil: philipelder.co.uk

Aesthetic Medicine • May 2020

C O M M E R C I A L F E AT U R E

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JETT MEDICAL

Fire and ice How Jett Medical’s Fire and Ice technology is sculpting the bodies and faces of the future

imes are tough for many businesses right now, with a lot of aesthetic companies trying to ease the burden for their customers and help them to get back on their feet again and thrive post-covid-19. One such company is Jett Medical. “We believe clinics will see a boom in trade post-lockdown and it will be the clinics who have proactively communicated with clients and incentivised them with new and interesting treatments and offers”, says Jett Medical director Alexandra Cutler. “We realise that times are strange for everyone right now, so we are offering clinics up to three months’ free finance and huge discounts during lockdown so they can be ready to bounce straight back.” Jett Medical is well-known in the industry for its awardwinning plasma device and training. The company had an amazing year last year, winning two industry awards for safety and training within the plasma space. It also launched two new devices. The JETT Proffi has five power settings compared to the JETT Medical at eight, and was launched to fill a gap in the market after the company observed that more than a third of sales were to clinics which had already purchased an AC plasma pen yet felt the need to upgrade to the JETT Medical, either through poor training or poor device quality. Research showed that the sole reason for the impulse to buy an AC device over the JETT Medical Advanced DC technology plasma pen in the first place was price. However, for many this turned out to be a false economy as they ended up paying out twice in

order to offer their clients a safe, effective treatment with little to no downtime. Both JETT Pens come with five treatment heads offering not only the Plasma Spark but also the non-invasive, no downtime Plasma Push, also known as Plasma Vibration for skin tightening and firming, and electro-mesotherapy. Jett has also launched TruCryo, an advanced cryo technology manufactured in the UK for sculpting the face and body. We have all seen the old cryo devices with the big bulky cups for fat freezing. TruCryo is the next generation of cryo, taking body and facial sculpting to the next level. TruCryo uses a range of powered spray nozzles and tactile ice massagers that allow you to adapt your technique from getting rid of fat to reducing fine wrinkles and tightening skin. The device looks like a futuristic laser, using ice cold gas to spray the body with high pressured CO2. Because it’s hand-held, the treatment can be applied evenly to any part of the body, including the buttocks, thighs, bingo wings and even the face and jawline. Frotox or the cryo facial is a great way to finish off cryo sculpting. Faces can be revitalised and jawlines can be tightened after just a quick treatment. The treatments are supper fast, enabling you to treat a whole face in less than six minutes and the stomach in under 10 minutes. To achieve thermal shock the cold must be applied rapidly, so treatments per area are done in no longer than 90-second blasts. The company recommends five treatments three to seven days apart, giving the fat cells time to start dying and pass through the lymphatic system ready to target a new layer of fat during the next session. So why not expand your treatment menu with JETT’s FIRE and ICE – direct current technology, Plasma Pens and TruCryo, the new advanced technology to sculpt the face and body. AM

jett-medical.co.uk | trucryo.com Sales@Jett-Medical.co.uk | 020 8050 1684

Aesthetic Medicine • May 2020

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PR & MARKETING

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Survive to thrive PR expert Lucy Hilson on how to keep communicating with patients effectively to emerge with a strong business post-covid-19

Aesthetic Medicine â&#x20AC;˘ May 2020

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PR & MARKETING

eing forced to close for an unpredictable period of time has led to many aesthetic clinics cutting back on outgoings. In some cases, this has meant putting paid-for services such as PR, marketing and social-media management on hold. We are living in uncertain times and while it’s understandable that this unknown territory is creating a lot of fear for businesses, it’s also really important to think long-term. This is a crucial time to keep communicating with clients as well as increasing pipeline generation so that, when things go back to normal, your business is still thriving. In recent weeks, we at Cosmetic PR have certainly seen some clients embracing this window of opportunity, with an increase in demand for digital marketing, such as generating successful social media campaigns, updating websites and blogs, creating and distributing e-shots and newsletters and creating content and graphics ready for when their business gets back to normal. We’ve also been spending time planning in influential PR campaigns for bigger projects in the future, as well as perfecting our strategies and working on some exciting behind the scenes launches. Taking the right actions and finding the right message can be challenging, especially in a fast-changing situation such as this. If you’ve had to put a pause on PR and marketing activities for the coming months, there are some things you can do yourself to keep at the forefront of clients’ minds. Being on lockdown is also a great opportunity to do those things you never had time to do, such as planning and creating quality content for your website, writing blogs or planning in your relaunch for when things settle. Continuing with PR and digital marketing through this period could potentially be the deciding factor in whether businesses make it through the tough times ahead. Whether you have a hired PR team or you’re attempting it solo, here are a few things you can do to keep on top of your game throughout this time.

OPEN A VIRTUAL CLINIC

One thing that’s already proven to be successful for many is setting up a virtual clinic where doctors and therapists can log in and perform remote consultations with patients from the comfort of their own home. Arranging FaceTime, Skype, Zoom or WhatsApp video calls is a great way of letting clients know they’re still important and keeping a part of your business alive during this time. Home skincare plans are becoming increasingly popular too and are a great way of helping clients keep on top of their skincare needs. Video consultations will allow you to formulate treatment plans, resulting in sales of skincare products and supplements, which you can post direct to clients at home. You could also link your virtual clinic to social media and do live Q&As, online treatment demos (on yourself or a family member) or create lots of brilliant educational videos for clients.

KEEP YOUR SOCIAL MEDIA GOING

With so many people spending more time at home, internet usage is even higher than normal. Keeping on top of social media and delivering compelling content is key for communicating your updates during the covid-19 pandemic. It’s also an effective way for you to keep in touch with clients and give them engaging content. If you’ve had to cut back on paid-for social media services, it’s important you continue to update your social platforms regularly (at

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PR & MARKETING

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least once a day) with quality content that entertains, inspires, educates, and informs. These tactics will help you create an ongoing relationship during, and even after, the coronavirus pandemic. Social media channels are also a great way of getting in front of the press as many journalists look to social media as a source of inspiration and feature ideas.

SEND NEWSLETTERS

If you already have a strong client database, newsletters are a brilliant way of getting your message to clients, and also a perfect opportunity to keep them informed on clinic updates for when things get back to normal. Staying in touch will also likely prompt them to come back to the clinic in future. When creating the content for your newsletter try to keep it simple and catchy. Think about what you want your newsletter to accomplish – this should be the first question you ask yourself before you start writing.

GENERATE YOUR OWN PR

By developing a relationship with industry journalists, you can become one of their go-to practitioners for advice on the latest industry developments and trends. An important part of getting your brand into the press is knowing your target market and how you can get your business in front of them. Think about who you want to reach – what do those people want to read? What do they want to watch or listen to? Once you have this in mind, you can start compiling a database of target media titles. While the bigger national newspapers and magazines that you read might be top of your agenda, don’t forget about including some local and regional outlets which can be really beneficial if you’re looking to target people in a specific area. I’d recommend contacting press by email rather than phone to avoid catching them at a busy time or when they are working to a tight deadline. An email usually works best, as you can also ensure you include all the information in one go, rather than missing anything out. Getting a strong pitch idea together and making sure the story angle is right for each publication is key to securing press coverage. Most journalists receive hundreds of press releases and email pitches every day, so making yours stand out is really important. Try to think outside of the box. What does your clinic bring that’s different? Do you have a niche or specialism in terms of treatments you offer? What is your

unparalleled expertise? Start by researching the kind of stories that particular publication usually covers, and keep in mind that different titles have different lead times (monthly magazines work three to six months ahead, whereas online magazines and national newspapers work approximately one to seven days in advance). Building relationships with the press can take months or even years, so don’t be disappointed if your PR efforts aren’t an overnight success. Just keeping churning out brilliant content and great feature ideas. This challenging time won’t last forever, and when business returns to normal you may want to consider using a PR agency as they will already have a bank of contacts, excellent creative mindset and many years of experience in the aesthetics sector.

“This time is an opportunity to sit back, reset and reflect on your business goals”

GET CREATIVE

Remember, this time is an opportunity to sit back, reset and reflect on your business goals and how you can move forward in future. Try to spend time each day working on furthering your business, whether it’s creating new treatment packages, researching treatment systems, new products you’ve been interested in, working on your personal brand, or perhaps setting up the YouTube channel you’ve been thinking about doing for months. It can be difficult to find the time for marketing your business, so try to look at this period as a gift of the perfect time to get started. AM

Lucy Hilson is founder and director of Cosmetic PR, founded in 2015. She has more than 15 years’ experience in beauty PR, working with some of the world’s leading beauty and aesthetic businesses. Hilson is also experienced in developing aesthetic and skincare businesses and has helped many clients take their ideas into reality, from initial concept and brand development to the PR launch and business growth. She has contributed her PR knowledge and experience to publications and websites including Glamour, Metro, MSN, Pure Beauty, Yahoo and Health & Wellbeing Magazine.

Aesthetic Medicine • May 2020

TITE TRIM TONE

www.inmodemd.co.uk info@inmodemd.co.uk +44 (0)20-8965-2594

OLYMPIA LONDON 22 - 23 MAY 2021

UNITING THE AESTHETIC COMMUNITY Learn. Grow. Network. Succeed Join us for.. • Leading brands • Product launches • Live demonstrations • CPD-Accredited education

@AestheticMLive /aestheticmedicinelive aestheticmed_live Entrance policy: The show is open to doctors, dentists, nurses, medical professionals and qualified aesthetic practitioners. Strictly no persons under the age of 18 will be admitted.

/aestheticmedicinelive

COVI D -1 9 S PECIAL

FINANCE

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Tough times Finance expert Reece Tomlinson shares his advice on emerging from the pandemic in a financially-stable position

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FINANCE

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raditionally, the aesthetic medicine industry has been relatively immune to recessions and economic downturns. The average consumer of aesthetic treatments tends to have high levels of discretionary income and considers them as more of a necessity than a luxury, which has allowed the industry to fare well in times of economic hardship, such as the 2008 financial crisis. Yet, with lockdowns, closed borders, closed schools and self-isolation practices being mandated or suggested; the economic fallout from the covid-19 outbreak is in full swing. Regrettably, it is likely that covid-19 will take a real toll on aesthetic clinics, practitioners and suppliers alike. If you think this situation will resolve itself quickly, all you have to do is look at China, which has been battling a largescale outbreak since January 2020, as an indication of what we can expect. Here is some of the sobering economic data coming from China for Q1: new housing starts fell by 44%; retail sales fell by 23%; exports fell by 17% and only 33% of SME’s had returned to work by 26 February, 2020. Throughout my career, I have advised on numerous turnaround scenarios in various industries across Europe and North America. I have direct experience leading, advising and guiding companies through tough situations. As a result, this article outlines some of the learnings from my experience and provides actionable steps that you can take to weather the storm and utilise this time to your advantage so you can exit the covid-19 outbreak in the best position possible. Below are 10 takeaways that you can implement to get through this challenging time:

are critical and which have less of an impact on the business. Although performing an exercise like this can seem like choosing between a myriad of horrible options, it may just be what keeps the business alive.

FIND YOUR ABSOLUTE BASE LEVEL

From my experience, you can shave 20-30% off a company’s operating budget and you can squeeze that down to 50% or more while providing an absolute base level of operations. It may not be ideal, and it may not fit within the current strategic priorities, but doing so may be the difference between staying in business or closing your doors entirely. Know what these options are and be prepared to act quickly if and/or when needed. If you are having trouble determining what and where to cut back, create a list of all of the company’s on-going expenses and ask yourself what is critical, what is somewhat critical and what is non-critical. Cut non-critical costs first followed by somewhat critical and then critical costs.

“Looking for solutions is the quintessential requirement in a turn-around”

BUSINESS CONTINUANCE SHOULD BE YOUR CORE FOCUS

It is likely that the economic impacts of covid-19 are going to be felt for the next six months at a minimum. During this time, if cash becomes severely constrained, it is critical that you understand the priorities required to keep the clinic afloat and as relatively unscathed as possible. These priorities should include everything from which employees are critical, which suppliers to pay first, which pieces of equipment you can afford to go without (in the event you cannot make the payments) and even which roles/positions

PRESERVE CASH NOW

Know your cash runway and prepare a detailed cash flow forecast. Prepare your cash flow projections on a 50%, 75% and even 100% drop in sales while using your base level cost projections. These are all horrible scenarios, however, you need to understand what your cash levels may be and how you can keep the business open during various levels of sales and operating capacities. This is equally important for planning out what the postcovid-19 recovery may look like. The more insight you have into your financial situation, the better.

IF YOU CAN ACCESS CAPITAL, DO IT NOW

If you are approved for an increase in your operating lines or a loan, you may want to exercise that now. If you are having trouble accessing capital, the UK Government has announced relief for businesses. One option is the Coronavirus Business Interruption Loan Scheme. This will provide funding up to £5m and up to £250,000 without personal guarantees. Learn more at .gov.uk/government/ publications/guidance-to-employers-and-businessesabout-covid-19/covid-19-support-for-businesses

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FINANCE

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UTILISE THE JOB RETENTION SCHEME

The Government has also implemented the Job Retention Scheme to assist businesses with the cost of employing staff during this challenging time. Through this scheme, the government will provide furlough funding of up to 80% of an employee’s wage up to £2,500 per month for employees that have been made redundant from 1 March, 2020. Refer to gov.uk/guidance/claimfor-wage-costs-through-the-coronavirusjob-retention-scheme

but a simple measure to follow is to simply be the leader that you would want to have lead you in a situation like this. Communicate with your team, be empathetic, discuss the plans to get through this and provide support as much as you can to those on your team or whom you do business with. You will likely not have all the right answers and the situation may invariably change as we go through this unfolding situation. However, do your best to provide clarity, assurance and recognition for the challenges that your team is going through. Looking for solutions is the quintessential requirement in a turn-around. Whether it is a solutions or a mutually beneficial outcome with an employee, supplier or stakeholder; don’t give up until you find one.

“Create a list of all on-going expenses and ask yourself what is critical, what is somewhat critical and what is noncritical”

COMMUNICATE

As a leader there is no greater thing you can do during challenging times than to communicate. There is no such thing as too much. Communicate with your team, lenders, suppliers, customers and stakeholders. If you find yourself being late on and/or missing rent or loan payments or even payroll, it is best to communicate this as early as possible and attempt to find a solution that may allow the business to keep operating. We are in unprecedented times and lenders, landlords and the like will likely have no choice but to work with you, so do not be hesitant to seek mutually beneficial results.

BE A LEADER

Now, more than ever, your team needs to see that you are there to support them and be there with them when times are tough. Leadership is a complex topic in its own right,

BE OPTIMISTIC

Dealing with the personal, business and financial impacts of covid-19 is very hard and it’s likely that it could even get harder. One of the best things you can do during challenging times like this is to remain optimistic and positive. Being positive not only impacts those around you, it will impact your psyche and ability to handle the stress during this period. What makes the economic impacts of covid-19 unique is that it is impacting nearly every type of business in nearly every sector across the UK. This situation is affecting us all. Remember that you are not alone during this chaos and regardless of how bad it gets, don’t give up. AM

Reece Tomlinson is CEO of Uvence (uvence.co) and RWT Growth (rwtgrowth.com) providing advisory, capital and M&A services for companies in the aesthetic medical space. He holds an MBA, is a chartered professional accountant and has completed extensive executive education. His areas of expertise include executive leadership, strategy development and execution, corporate finance and M&A.

Aesthetic Medicine • May 2020

Higher style. Higher power.

HIGHER iQ Laser hair removal continues to be a huge market. With over 13 million treatments expected in 2020, are you ready to offer your patients the best?1

Enter Elite iQ. Featuring Skintel®, the aesthetic industry’s only melanin reader, Elite iQ enables you to customize treatments based on objective melanin measurements, giving you ultimate confidence in the safety and effectiveness of the treatment. LEARN MORE

1 2020 data. Energy-Based Ax Devices. Medical Insight, Inc. October 2019. *Compared to previous generation devices. The Elite iQ aesthetic workstation is indicated for the following, but not limited to: permanent hair reduction and treatment of veins, noncancerous pigmentation, wrinkles, warts, scars and ingrown facial hairs. Common side effects include redness, swelling, crusting and scabbing. Other side effects may include blistering, burns, hives and lightening and darkening of the skin. Like all medical procedures, not all patients are suitable for the treatment. A qualified practitioner is solely responsible for evaluating each subject’s suitability to undergo treatment and for informing those being treated about any risks involved with the treatment, pre-and postoperative care, and any other relevant information. Individual results may vary and are not guaranteed. ©2020 Cynosure, LLC. All rights reserved. Cynosure, Elite iQ and Skintel are trademarks and/or registered trademarks of Cynosure, LLC. Cynosure, LLC owns exclusive rights to photography. Use of photography without written permission of Cynosure is prohibited. PRD_3507

F E AT U R E

DERMATOLOGY FOR HANDS

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The upper hand Rigorous hand washing and sanitising can make hands red, dry and sore, and exasperate existing dermatitis and skin conditions. Here we look at some skin-saving solutions for hands in the covid-19 age that donâ&#x20AC;&#x2122;t compromise on hygiene

Aesthetic Medicine â&#x20AC;˘ May 2020

F E AT U R E

DERMATOLOGY FOR HANDS

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edical practitioners don’t need to be told that regularly and thoroughly washing your hands is one of the most important things you can do to prevent the spread of infection and protect yourself and others in the midst of the current coronavirus pandemic. However, with people now becoming more and more vigilant and washing and sanitising their hands multiple times a day, many are starting to suffer from dry, cracked, red and sore skin as a result. This is also a huge problem for key workers and NHS staff, with the added irritation to their skin from PPE. Dr Ravi Brar, who practices at MK Smiles in Milton Keynes and holds a postgraduate diploma in clinical dermatology, says, “Repeated exposure to water, soap and alcoholbased hand sanitiser causes dry skin. This can lead to the skin becoming itchy, sore and red, with some developing blisters and painful cracks (fissures). People who have pre-existing dry skin, either due to medical conditions or medication, are particularly susceptible to this. Understandably, this can make following hand washing guidance difficult, but it is important that we continue to follow the advice as much as it is practical.” Dr Nick Lowe, consultant dermatologist at The Cranley Clinic in London, adds, “What causes the dryness is the damage to the delicate skin barrier. The skin barrier is very important. It’s a very thin membrane on the outer part of the skin, which maintains the quality of the skin and its ability to keep itself moisturised. When that’s damaged it can lose water and the skin becomes dry and cracked. “Around 25% of people in the population have a tendency towards dry hands and hand dermatitis. Contact dermatitis is either a result of contact with an allergen, which can cause a reaction, redness, scaling and itching; or there’s primary dermatitis, which is due to irritants, such as soaps, detergents and the alcohol-based antimicrobial cleansers we are now using routinely. If someone also has skin diseases, such as eczema and psoriasis, it can lead to increased pain and soreness of the hands.” With these hand-health safety measures likely to be in place for months to come, avoiding soaps and hand gels is simply not an option. So, as skin specialists, what advice can you give to patients who are suffering with their hands at this time, to minimise the impact on their skin while maintaining high levels of hygiene, particularly, if they suffer from contact dermatitis, eczema or psoriasis?

oils, creating cuts and sores and leaving us susceptible to infection. Skin healing expert Hanna Sillitoe comments, “I advise that people avoid hand washes that contain ingredients such as sodium lauryl sulphate (SLS) and triclosan. There are many brands of soap that have fantastic anti-bacterial properties but are less harsh on skin. Look for a hand soap free from synthetic detergents and preservatives. Most natural washes come fortified with nourishing ingredients such as organic essential oils, aloe vera, chamomile and calendula, all of which replenish our hands to keep skin feeling soothed and soft.” Dr Amiee Vyas, aesthetic practitioner and founder of Doctor Amiee, says, “As trigger avoidance is not possible at the moment, the focus of treatment should be on barrier building and repair with gentle active ingredients, antioxidants and humectants. Using soap substitutes is also key to break the cycle of dryness and dermatitis. The NeoStrata Restore Facial Cleanser works very well as a non-drying hand wash, for example.” Dr Brar also recommends re-washing with an emollient. He says, “After using soap and water, re-wash with an emollient. Dermol lotion is a good option. It has not specifically been tested against covid-19 but is often used in surgical theatres for scrubbing sensitive hands.”

“Around 25% of people in the population have a tendency towards dry hands and hand dermatitis”

2. PAT, DON’T RUB

Rigorously rubbing the hands dry when the skin barrier is already compromised can cause more damage and irritation, so recommend patients pat their hands dry with a soft cotton towel after washing.

1. WATCH OUT FOR HARSH INGREDIENTS AND CHEMICALS

Soap and water is the gold standard for hand washing when it comes to preventing the spread of infection. While it is vital to choose a product that cleans effectively, products with harsh chemicals strip skin of its natural

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F E AT U R E

DERMATOLOGY FOR HANDS

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3. SEEK OUT EFFECTIVE MOISTURISATION

While thick, fragranced hand creams may smell nice, they aren’t always effective. Sillitoe recommends ditching the perfumed products and opting instead for fragrance-free or a fragrance that’s certified as “declarable allergen free”. She says, “While cheap, thick hand creams initially seem to offer relief from painfully chapped skin, petroleum and other chemicals used in cosmetic emollients might actually be making the problem of sore hands worse. These ingredients form a synthetic seal across the skin, blocking pores and further hampering skin’s own ability to produce oil.” Dr Lowe says there are a number of good creams available over the counter which can help. He comments, “We use Cerave a lot for patients with eczema or sensitive skin. The Aveeno brand is also very good, as are as Diprobase and Dermol. Patients with eczema and psoriasis can use these in combination with their prescription creams.” Aesthetic skincare brands also offer a variety of highquality products specifically for the hands and body, and many practitioners are using and recommending powerful facial products as effective hand saviours too. Dr Vyas favours NeoStrata Bionic Face Cream. It provides intense hydration and skin-smoothing effects without irritation. Studies prove this cream is exceptionally mild, non-irritating and helps calm irritated skin and reduce redness. It is fragrance-free, non-comedogenic and nonacnegenic, and contains 8% gluconolactone and 4% lactobionic acid. Aesthetic Soruce also offers Skinbetter Science Trio Rebalancing Moisture Treatment to rebalance a compromised skin barrier and restore moisturisation levels as well as Skin Tech Vit E Anti-oxidant, a moisturising antioxidant which protects the skin from external aggressions and offers immediate and durable moisturising. Harpar Grace offers iSClinical Sheald Recovery Balm and the new Codage Hand Cream. Sheald Recovery Balm is a

gentle fortifying solution which calms and encourages skin recovery and is antimicrobial and fragrance-free. Codage Hand Cream acts like a protective shield and intensely nourishes and soothes. Enriched with active ingredients, it penetrates instantly to leave hands soft and protected, without any oily film. Meanwhile, Priori’s Skin Decoded Hand & Body Replenisher includes high strength lactic acid at 15%, as well as vitamins A, C, E and ProVit A to exfoliate and renew the skin and boost the hyaluronic and collagen response. From ZO Skin Health there is Body Emulsion. The multi-action treatment effectively delivers improvement in the quality, smoothness and overall health of the skin. Developed with specialised enzymes and hydrators to immediately soften and resurface rough, dry skin, it is designed to be used with prescribed treatments for atopic dermatitis, irritant eczema, allergic eczema and keratosis pilaris. Eden Aesthetics has two offerings: Epionce Restorative Hand Cream and Medical Barrier Cream. Restorative Hand Cream contains a blend of active botanical ingredients such as raspberry, apple, rosa canina, flax, date, meadowfoam and safflower to restores moisture and relieve cracked, rough texture. Medical Barrier Cream contains the highest amount of Barrier Repair Technology (BR) in the Epionce line to restore the disrupted skin barrier and accelerate the repair process. Anti-Inflammatory Technology also calms inflammation in patients with atopic skin conditions, like psoriasis and eczema. From Healthxchange comes Obagi Hydrate and Hydrate Luxe, featuring Hydromanil technology, mango and shea butter and avocado oil. Clinically proven to improve hydration levels in skin by helping prevent moisture loss and locking in moisture for eight hours. Hydrate Luxe is designed to be used at night to work during your natural sleep cycle. In a consumer blind study of 31 females with dry/very dry skin, 93% reported that their skin felt deeply hydrated.

“Many practitioners are recommending powerful facial products as hand saviours too”

Aesthetic Medicine • May 2020

F E AT U R E

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DERMATOLOGY FOR HANDS

4. SOURCE HIGH-QUALITY SANITISERS

According to Public Health England, a hand sanitiser should have a 60% or higher alcohol content (most commercial brands contain 60-95%) to kill viruses effectively. While such a strong concentration of alcohol is great at killing bacteria, it’s not very kind or gentle on the skin. Frequent and repeated use of hand sanitisers can aggravate sensitive skin, causing prolonged irritation and chronic dryness. Although people have been buying hand sanitiser by the bucket load recently, the advice is to only use it when soap and water are not available. There are a number of products available through aesthetic suppliers. Clinisept+ can be sprayed directly onto the hands, face and surfaces to provide rapid protection against potential virus contamination. It has been independently tested and been proven to be highly effective in killing all enveloped viruses, including coronaviruses, in under 15 seconds. Dr Sophie Shotter, who has recently returned to the NHS to work in ICU, says, “I carry a bottle of Clinisept+ with me at all times. It is more than 99.99% effective at killing bacteria, fungi, spores and viruses in 15 seconds, which is significantly better than alcohol gel. I’m using this to clean my hands and phone, and I also spritz my face and mouth”. Dr Vyas adds, “Clinisept+ can be sprayed onto the hands and is rapidly antimicrobial. Its hypochlorous nature and oxidising method of action means it can be used repeatedly without pathogens becoming immune to it, and it is also non-irritating and calming to the skin and mucous membranes.” Healthxchange Pharmacy has recently started distributing the latest range from Biotechnology skincare company Thoclor Labs; the third generation of its GF Skin Series, a new antiseptic treatment line containing anti-pathogenic hypochlorous acid, a natural molecule formed by the human body as part of our immune response, as a means of killing a range of disease-forming germs such as bacteria, viruses and fungi. British skincare brand Medik8 also recently launched its Helping Hands project, producing 5,000 units of sanitiser in a bid to tackle the shortage and support the community amidst the covid-19 pandemic. Medik8 Hygienic Hand Rub is 80% ethanol-based, nondrying and non-sticky. The brand distributed products for free to local communities, including to care homes, the homeless, vulnerable people and the police, and made 1,000 bottles available free of charge to the first medik8.com customers.

On-Group also reorganised its production priorities to enable the rapid launch of its new Collagen Hand Gel. The formulation uses 70% alcohol to fight germs and also includes aloe vera and plant collagen to protect and nourish the hands.

5. USE GLOVES PROPERLY

There’s been a lot of conflicting information circulating online about the benefit of wearing gloves. In a hospital or clinic environment gloves would be discarded after each task. If patients are wearing gloves and then going out shopping, it is important to remind them about the risk of cross-contamination by not changing gloves regularly. Many people have bought gloves believing

they will protect themselves but then touch too many things, negating any benefit. Washing hands regularly is a better option. However, wearing gloves can help protect hands when cleaning and washing up to prevent further irritation and damage from yet more contact with detergents. Dr Brar says, “Wearing gloves when hands come into contact with water or detergents (outside of hand washing, i.e. washing up, showering or helping children bathe), will help to keep the skin’s barrier intact.” Dr Lowe recommends wearing cotton glove liners inside gloves, especially for those with a latex allergy. He says, “Latex allergy is very common; it’s estimated that up to 17% of the population have it. It shows up as redness, stinging and itching after you have had the gloves on for a short period of time. The answer is to look for latex-free gloves. The other thing you can do is apply moisturising cream before the gloves, and wear cotton gloves inside the protective gloves. Even if you don’t have a latex allergy, wearing washing-up gloves without protecting the skin can also cause some irritant dermatitis.” Cotton gloves should then be regularly washed them in a gentle detergent if they’re not disposable. AM

Aesthetic Medicine • May 2020

CLINICAL

SKIN BOOSTERS

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PLUMP IT UP

Dr Anna Hemming compares injectable skin boosters, discussing how the products on the market differ and what each is best for 32

Aesthetic Medicine â&#x20AC;¢ May 2020

CLINICAL

SKIN BOOSTERS

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esthetic medicine is one of the most captivating specialties to work in, not only are the majority of our patients healthy, but their conditions are treatable, without invasive medication or surgery. I’ve been lucky enough to be involved in this amazing specialty for more than 12 years, during which time there have been many developments. My practice has evolved from the early days when I started out as an injector to providing my patients with a complete patient journey; looking after their skin, face, body and mind. We should be educating clients that we do not just treat lines and wrinkles, but are able to recondition skin, prevent damage and reverse photo-ageing to slow the ageing process across all skin and subdermal layers. It has become part of my normal practice to hydrate skin. This can be achieved slowly with topical agents and collagen nutrient drinks like Skinade, or more rapidly using injectable hydrators. There are a huge array of injectable hydrating products available ranging from the very light dermal fillers to the skin boosters and bio-remodellers. Over the years these products have been developed with some ranges adapting products to treat a wide portfolio of our patients’ concerns. So, what are the benefits of the different skin boosters and hydrators available, how can we use these to improve skin quality and where else can they be used?

MESOTHERAPY PRODUCTS

In recent years we have started to see more injectable mesotherapy products coming on the market. Some are used with micro-needling, plasma shower or micro bolus injections, as per hydrating fillers. The interesting thing about these ranges is the combinations of ingredients within the products; they are no longer just hyaluronic acid-based. One of the most comprehensive ranges with 14 products covering hydration through to the eye area, cellulite, hair and skin tightening is RRS by Aesthetic Derma. Each has a specific amino acid, skin-whitening ingredient or Silisorg and. DMAE for tightening using combinations is also possible mixing a bespoke set of products for a tailormade personal treatment. These injectables are offered in courses of six or more sessions depending on the concern treated and the products used. There are also handy add-ons for the eye area which help upsell the treatment as well as skincare to go with the treatment plan. RRS is distributed by Aesthetic Source, they offer an excellent training day and support. Mesotherapy products are delivered in courses with weekly or biweekly sessions for the best results. Treatment results are normally assessed after the course has completed with extra sessions optional to take the skin to the next level reaching or surpassing the patients’ expectations.

PHOTOS: SHUTTERSTOCK

DERMAL FILLERS

First on the market were the hydrating filler products, the lightest in the range, like Teosyal Redensity I, Belotero Soft, Restylane vital etc and newer hydrating fillers like Teoxane RHA 1 and Viscoderm hydrobooster from IBSA. With low BDDE cross linking and low cohesive rheology these products do not hold form in the skin, therefore they do not lift or contour and remain in the horizontal plane. Injected in superficial micro boluses spread equally across the treatment area delivering hydration into the skin for quality improvement. These products are still used in many clinics and have courses of treatment offer great results. All the premium dermal filler brands have a hydrating filler within their range. Hydrating dermal fillers tend to last longer in the skin due to their BDDE, although minimal it still helps these noncohesive fillers last a bit longer than other skin boosting products.

PROFHILO HYDRATION AND LAXITY TREATMENT

Finally, I would like to discuss Profhilo. Profhilo is an ultrapure high dose hyaluronic acid bioremodeller, injected into skin acting as a hyaluronic acid moisturising treatment, it really is unique. Profhilo’s hydrating effect works as it stimulates collagen and elastin, attracting water into the dermis. Made with a patented technology called NAHYCO, the result is a gel with prolonged stimulating activity on the dermal cells. Stimulating cell receptors to counteract skin laxity and improve and restore firmness to the skin as well. With 32mg/ml HA and 64mg per treatment Profhilo also contains

Aesthetic Medicine • May 2020

CLINICAL

SKIN BOOSTERS

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Before treatment and immediately after second Profhilo treatment. Dr Anna Hemming, Thames Skin Clinic

contains one of the highest concentrations of HA on the market. Profhilo is made by IBSA Italia and distributed in the UK by HA-Derma. The main aesthetic pharmacies can also arrange training for you. Most Profhilo skin treatments are delivered in a course of two sessions spaced three to six weeks apart to allow for maximum skin hydration and synergistic collagen stimulation. Further treatment may be advised for skin with more advanced sagging, photodamage and ageing. Short courses are ideal – more time effective and spread further apart from meso sessions. The results focus on tightening as well as hydration.

product training before starting to use new products on your patients. Your insurance will need proof of product training, too. Skin boosters can be used to treat many different skin areas. The most common is the face, followed by the neck, décolletage and dorsum of the hands. However, they can also be used on difficult to treat areas, like tightening the skin under the chin (RRS), the upper inner arms, inner thighs, knees and abdomen. They are safe for all skin types, ages and genders.

COMBINATION TREATMENTS

Hydrating dermal fillers can be used in combination with Profhilo, treatment-specific RRS or other mesotherapy products. The advantage of a combination protocol is that each product contributes its best attributes, resulting in premium treatment to suit the individual patient’s needs. For example, dermal filler has longevity, Profhilo has immediate hydration and skin tightening; while RRS can deliver much needed amino-acid complex DMAE, and its biorevitalisation is medium.

WHAT’S THE FUTURE OF SKIN BOOSTERS?

WHERE CAN SKIN BOOSTER PRODUCTS BE USED?

Each product will come with preferred treatment indications and techniques, so it is always best to attend

>> 34

There is a very positive atmosphere within aesthetic clinics this year; we may currently be closed to patients but we have not stopped working for them. When we reopen our doors and welcome our patients back once more, we will benefit from the support our distributors, training companies, conference organisers, and product representatives have been putting together for us. We’ll be armed with new knowledge to share with our patients and a few new techniques, too. Product development never stops, and I predict we will see further advances in hydrating skin boosters to contain growth factors and stem-cell technology. The potential for results with growth factor injectables should be fantastic, enabling us to take PRP treatments to another level. AM

Dr Anna Hemming is the founder of Thames Skin Clinic and The Cosmetic Skin Doctor. She has 22 years’ medical experience with surgical, anaesthetic, gynaecology and emergency department training. For the past 12 years she has immersed herself in aesthetic and regenerative medicine. A highly skilled injector, she treats a wide variety of photo-ageing concerns and skin problems, focused on subtle, natural rejuvenation to reveal younger, healthier and more beautiful skin.

Aesthetic Medicine • May 2020

C O M M E R C I A L F E AT U R E

TESLA FORMER

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TESLA FORMER muscle stimulation TESLA Former is a medical device using the new FMS (Functional Magnetic Stimulation) technology for muscle strengthening, toning and sculpting the body

ESLA Former uses pulsed magnetic fields to effect the motor nerves of the muscles, causing them to contract in the target site.

IT CONTRACTS MUSCLES BUT HOW DOES IT TARGET FAT?

Our muscles can only store a low amount of energy, which is used up within a short period of time. When a muscle is contracting, within a few minutes it depletes the energy it needs; it searches for fuel elsewhere and starts to draw on fat in the targeted area. This is why a reduction in fat and an increase of muscle mass will be seen with treatment. TESLA Former helps reduce recovery time after injuries in muscles, ligaments and the bones. Ellderly people can increase their quality of life through strengthening muscles and ligaments or by managing their physical rehabilitation and pain management needs. Bladder and incontinence problems for people of all ages and sexes are also easily dealt with using the TeslaChair.

UNIQUE FEATURES:

• More than 50,000 contractions in a 30-minute session • In total six applicators available (four body applicators and two built into the TeslaChair) • TeslaChair for core muscle strengthening targeting the pelvic floor, back and abs • 24 different phases of muscle contractions • 200 treatment protocols (aesthetics, physical therapy, sports rehabilitation and gyneacology) • Alternating applicators using higher energy levels • Three Tesla Power and four channels

TESLACHAIR FOR URINARY INCONTINENCE

The TESLAChair was developed for treating weakened pelvic floor muscles and urinary incontinence. The pulsed magnetic field generated by the device causes the muscles of the pelvic floor to contract. This therapy is suitable for all kinds of urinary and faecal incontinence. FMS also helps patients with sexual dysfunction and chronic pain in the pelvic region and lumbar spine. The magnetic stimulation results in increased strength and endurance of pelvic region and pelvic floor muscles.

TESLACHAIR INCONTINENCE & PELVIC FLOOR INDICATIONS: • Urge/stress/mixed urinary incontinence • Incontinence after radical prostatectomy • Faecal incontinence • Regeneration after childbirth • Milder forms of drooping uterus and bladder • Rehabilitation after pelvic ﬂoor surgery • Chronic prostate inﬂammation • Erectile dysfunction

WHAT DO PRACTITIONERS SAY?

“TESLA Former is a great device that utilises functional magnetic stimulation to sculpt the body. The device bypasses the central nervous system to create supramaximal contractions that are impossible to achieve with normal exercise routines. Patients find the treatment very effective, with no pain and no downtime. Most of my patients see and feel a big change after one to two sessions,” says Dr Vincent Wong AM Contact Beautyform Medical: beautyform.co.uk for more information.

Aesthetic Medicine • May 2020

PROUDLY SPONSORED BY

VIRTUAL EVENT

11-15 MAY 2020 Taking place on @aestheticmedicinelive

REACH OUR ONLINE AESTHETIC COMMUNITY • Free daily webinars with KOLs • Audience participation for support and guidance • Daily competitions • Discussion of key topics • Exclusive offers from industry brands

Full programme available online

www.aestheticmed.co.uk/virtualevent

TRENDS

MUSCLE-STIMULATION DEVICES

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Give it some muscle Electro-muscle stimulation is the body-contouring technology du jour. We look at the options for clinics

lectro-muscle stimulation (EMS) has been revived from its heyday through the 80s and 90s, where the technology was applied to heavy “belts” fixed with Velcro designed to tone the wearer’s abdominal muscles, with purported effects comparable to an intense ab workout. Now, leading manufacturers of noninvasive body-contouring devices have adopted and enhanced the basic concept of EMS to offer patients truly impressive results with no downtime and minimal to no discomfort during treatment. A 2016 study that sought to compare the effects of 16 weeks’ whole-body EMS with high-intensity resistance exercise on body composition and strength observed “comparable or at least similar increases of muscle parameters” between the methods. The study’s authors concluded that EMS can be considered a time-efficient and effective option for people seeking to improve body composition.1 Here’s what some of the aesthetic devices brands and distributors have to offer when it comes to EMS.

Aesthetic Medicine • May 2020

TRENDS

MUSCLE-STIMULATION DEVICES

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3D-LIPO POWERSCULPT

•U ses high-intensity focused electro-magnetic technology (HIFEM) •S even different waveforms •E ngages 100% of muscle fibre •O ne 30-minute treatment equivalent to 20,000 crunches or squats •N o exercise required during treatment course, though patients advised to maintain a healthy lifestyle with aerobic or cardiovascular exercise •T reats arms, upper and lower abdomen, buttocks, legs and inner thighs •C an be used as a standalone treatment or to accelerate results of other body-contouring devices.

ADVANCED ESTHETICS SOLUTIONS LIPOFIRM SERIES

• I ncludes the Lipofirm Pro, Lipofirm Med and Lipofirm Med+ •M anufactured by Pollogen •D evices use dynamic muscle activation (DMA) blended with tripollar radiofrequency for TriLipo technology • I ndicated for circumference reduction, cellulite reduction, lymphatic drainage and skin tightening •D MA targets different layers of muscles with electrical current applied directly through non-invasive electrodes, allowing intervals of stimulation and relaxation for effectively elevated muscle workload •S trength, duration and number of contractions can be controlled •A chieves increase in muscle density and volume.

Aesthetic Medicine • May 2020

TRENDS

MUSCLE-STIMULATION DEVICES

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BTL EMSCULPT

•F DA-cleared •D eveloped after technology was shown to have positive results for muscle regeneration among sports players •U ses HIFEM technology to induce supramaximal muscle contractions, building muscle and burning fat •T reats abdomen, buttocks, biceps, triceps and calves •A verage minimum of four 20 or 30-minute sessions spaced two to three days apart.

CUTERA TRUSCULPT FLEX

•W orks with multi-directional stimulation (MDS) •C an create personalised treatments based on patients’ individual goals, shape and fitness level •T hree treatment modes – prep, tone and sculpt – that replicate intensified twisting, squat and crunch actions •B uilds muscle endurance, increases core strength and boosts basal metabolic rate •C an treat eight areas simultaneously.

CYNOSURE STIMSURE

•B uilds tone and muscle in the abdomen, buttocks and thighs •D elivers up to 24,000 muscle contractions in 20 to 30 minutes •U ses 1.0 Tesla per applicator, creating an electromagnetic field that can engage the entire target muscle group •F our pre-set programmes •P atients can be treated through light clothing.

Aesthetic Medicine • May 2020

TRENDS

MUSCLE-STIMULATION DEVICES

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HD AESTHETICS CRYOTONE

•C ombines non-suction cryolipolysis with electrical muscle stimulation • I deal for patients with small amounts of surface-layer fat •F at cells located near the skin’s surface are frozen to approx. -5°C •C an be purchased with two or four pads that deliver both technologies simultaneously •P atients require a course of at least eight sessions spaced once or twice a week for maximum treatment benefits •C an also be purchased with shockwave technology to treat loose skin and reduce cellulite.

EMSLIM

• Distributed by Harley Technologies and manufactured by Dae Yang Medical • Uses high intensity electro-magnetic therapy (HI-EMT) • Uses a specific range of frequencies that doesn’t allow muscles to relax between two consecutive stimulations • A ssisted by a physical training programme specially designed to maximise treatment stimulation • Utilises an optimised water-cooling system to ensure the device can be used effectively for a long period of time.

INMODE EVOLVE

•H ands-free workstation •T reats adipose tissue, tones muscles and remodels skin •U ses bipolar technology to deliver radiofrequency energy and electromagnetic pulses •T reatments can be customised with three pre-set programmes – tite, trim and tone •M ultiple hands-free applicators and adjustable belts to maximise clinician’s time – eight for skin remodelling with radiofrequency, six for radiofrequency and tissue vacuum, four for EMS •R efines appearance and strength of targets muscle groups. AM

REFERENCES 1. Kemmler, W., Teschler, M., Weißenfels, A., Bebenek, M., Fröhlich, M., Kohl, M., von Stengel, S. (2016) “Effects of Whole-Body Electromyostimulation versus High-Intensity Resistance Exercise on Body Composition and Strength: A Randomized Controlled Study”, EvidenceBased Complementary and Alternative Medicine, 2016 (Feb 29)

Aesthetic Medicine • May 2020

C O M M E R C I A L F E AT U R E

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NESSA LASERS

Breath of fresh air Nessa Lasers usuallly manufacturers medical-grade aesthetics equipment, but it’s launch into the UK market has taken an unexpected turn – supplying ventilation machines to the NHS to help tackle COVID-19 instead

ere at Nessa Lasers we manufacture medical-grade aesthetic laser equipment which includes Super Hair Removal, Carbon Peeling, Tattoo Removal and Ultrasound Cavitation machines. All of our products are built in-house at our factories in Turkey, where we have an incredible team of engineers, designers and developers with over 20 years of experience in manufacturing professional laser equipment. With this extensive experience in the aesthetic industry we are now able to offer our machines to the UK and European markets via Nessa Lasers (UK). All of our machines are hand-built with the highest quality components to ensure reliability and consistent results. Whether you’re a small start-up clinic, an established business or a general hospital, our machines will provide your clients and patients with the best results possible time and time again. In light of the current pandemic we are releasing a line of Ventilation Machines solely to help the NHS and General Hospitals around the UK & Europe tackle COVID-19 in this unprecedented time. Current ventilation machines available in hospitals have a maximum of a 14 day run-time before they need to be turned off to cool down. Without constant and consistent respiratory support patients suffering from Coronavirus are extremely vulnerable, which in most cases unfortunately results in the loss of life. Our team of experienced engineers and designers have developed a state of the art cooling system that allows our ventilation machines to run 24 hours a day, seven days a week, 365 days a year. Combined with the highest quality internal components that we use in all of our machines, we are now able to offer a ventilation machine that can be relied on when most needed. Due to the nature of this virus being spread worldwide there is now a huge demand for machines that are not only reliable but effective. We have temporarily stopped

production on all of our laser equipment to allow for the manufacturing of our ventilation machines. We have just secured another two factories to begin mass-production to ensure we can supply the demand. Manufacturing will commence as efficiently as possible, while keeping our technicians in a safe and clean working environment. We have recently updated our website with more information on our new ventilation machine, explaining in depth the different options and capabilities it has to offer. Please visit www.nessalasers.co.uk/nessa-ventilator for more information. Our showroom based in Waltham Cross, Hertfordshire is currently closed to the public due to the governments advice but we are still working safely every day behind closed doors and our manufacturing process is still continuing in Turkey as planned. We are expecting the number of patients around the world to increase over the coming weeks so we are doing everything we can to expand our manufacturing facilities and ship our machines to hospitals as quickly as possible. AM

For more information on any of our products please visit our website at www.nessalasers.co.uk 01992626078 Info@nessalasers.co.uk

Aesthetic Medicine • May 2020

BUSINESS

DIGITAL MARKETING

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Shout about it In the first of this two-part series on utilising social proof in your digital marketing, Alex Bugg introduces the concept and shares easily-implementable ideas

t my talk at Aesthetic Medicine London in March, I discussed using social proof on your website as a way of killing scepticism and telling visitors that they are in the right place for the information or treatment they seek. Social proof is a psychological and cultural concept that people follow the masses. It isn’t a new concept – experiments in conformity have been going on for hundreds of years. It’s the idea that a large number of people in agreement must be right. In marketing, social proof is basically means borrowing authority. It works for the restaurant that you can never get a table at and the blockbuster movies that sell out screenings way in

Aesthetic Medicine • May 2020

advance, and it can also work for service businesses such as aesthetic clinics. Social proof puts peoples’ minds at rest and moves them along the treatment booking process. After all, Allergan claims it takes a patient on average two years from awareness of aesthetics to undergoing treatment. In 1955, McDonald’s franchisee Ray Kroc posted a famous sign outside his Illinois restaurant, referring to the humble hamburger: “Over one million served.” Nowadays, McDonald’s simply has to claim “billions and billions” have been served, after surpassing 100 billion in 1994. This is one famous example of social proof. The psychology of such a vast number suggests to consumers that one million people

BUSINESS

DIGITAL MARKETING

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can’t be wrong; “That hamburger must be delicious, I’ll give it a go”. Buying habits have changed; choice is larger than ever, so social shopping has become more and more prevalent, and as medical aesthetics continues to grow, it’s a buyer’s market with plenty of choice for people. Setting yourself apart from other clinics in your area could come down to your use of social proof.

It’s really important to find the right influencer for you. Retaining the authenticity of your brand-influencer marketing relies massively on trust and seeing if the patients they could attract to your clinic are the kind you want. If your foray into influencer marketing doesn’t deliver on these points, simply don’t invest.

EXAMPLES OF SOCIAL PROOF

With vast amounts of potential social proof to share, how do you know which to use? These are the five pieces of social proof that we at Web Marketing Clinic believe are integral to clinic success:

Social proof can be interpreted in many different ways; it could be through recommendations of friends or strangers, data, ratings, celebrities, experts and personas made to seem “just like you”. Netflix utilises reviews and highlights trending programmes and films in order to guide people to choose what they want to watch among a sea of thousands of hours of streaming. Social proof could already be in action and influencing your aesthetics business. For example, maybe you signed up to demo a device with a manufacturer because a respected doctor with a large following is already using it in their clinic. The authority figure that you respect has swayed this decision. This could apply to clinic purchase decisions, from injectables to consumables and even clinic software.

AWARD WINS

There are many articles discussing the benefits of winning awards, be it industryspecific or locality-specific. The process of entering awards focuses you on recognising your strengths (something that the humble British aren’t always great at), which allows you to extract social proof to display. Then, if you are good enough to win, that validation in itself is great social proof. You have been recognised by a credible third party when compared against peers. The bigger and more recognisable the award source, the more value it holds.

INFLUENCER MARKETING

IN PRACTICE: FIVE TYPES OF SOCIAL PROOF YOUR CLINIC SHOULD USE

1. Online reviews: Obvious. The words and stars that a product or service receive are third-party validation that we almost automatically seek out these days. Studies conducted by marketing software BrightLocal have shown that 88% of consumers look to reviews before buying a product or booking a service. People often hunt around for bad reviews, too. So, responding well to bad reviews shows a business that cares (see the April 2020 issue of Aesthetic Medicine for advice on this). 2 . Video testimonials: The camera doesn’t lie. A video testimonial is considered more believable than words or images in an industry where patient advocacy is integral. A professionally-shot video of a former patient speaking about their experience in their own words, which goes in-depth into the case, can hold a lot of power, especially when it follows the patient’s journey. Make sure you also include before and after shots in the film. 3. Professional affiliations: While laypeople may not know who the BACN, BCAM, BAAPS, BAPRAS, BAHRS, Save Face, ACE Group, etc. are, showcasing these logos demonstrates your set up as a professional and trustworthy business, which is part of something larger. The same applies for logos of well-known and trusted brands, such as products, training companies and insurers. 4 . Media: Appeared in the press? Stating, “as seen in” is a classic marketing application of social proof. Your affiliations may not be recognised, but organisations such as Channel 4, The Times, Tatler, Vogue and of course, Aesthetic Medicine, certainly are. 5. Numbers: Linking back to the McDonald’s example of social proof, big numbers look impressive. Estimate how many patients you have treated over the years, or how many toxin injections you have administered in your career. But don’t over exaggerate. Inflated numbers might look impressive to the general public, but you’ll get caught out by peers who can calculate these numbers from your career path, so don’t lie. AM

“Setting yourself apart from other clinics in your area could come down to your use of social proof”

Although questionable in the industry, influencer marketing shot up in popularity in 2016 and looks like it’s here to stay. While more nuanced clinics aren’t hunting down and giving free facials to every person they find with 1m Instagram followers, utilising already high-profile clients (if they are keen to share) can really help boost your online reach. Companies that are “blowing up” with the use of influencers are now also turning to micro-influencers; people with as little as 3,000 followers online, that seem more accessible and connected with their following. The return on investment can really be worth it, but as with any marketing campaign, it’s vital that you accurately track the work of the influencer, ensure it isn’t harmful to your brand, and calculate the benefits before investing more.

Alex Bugg works for Web Marketing Clinic, a family-run digital agency, which specialises in medical aesthetics. They build websites and deliver award-winning marketing campaigns for doctors, nurses, dentists, distributors and aesthetic brands. Contact her on alex@webmarketingclinic.co.uk or follow her on Instagram: @webmarketingclinic

Aesthetic Medicine • May 2020

PRODUCTS

PRODUCT NEWS

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CODAGE

Codage has launched its new Cleansing Gel, a gentle formula that deeply cleanses normal to combination skin without irritation. Upon contact with water, the melting gel texture transforms into a light foam which unclogs pores and eliminates impurities, excess sebum and pollution particles. Active ingredients include willow tree extract titrated in salicylic acid, zinc, dermo-purifying complex, moringa extract, oligo-elements, aloe vera and niacinamide (vitamin PP). The product comes in a 15ml pump bottle and a 30ml tube, as well as a professional 500ml size.

IMAGE SKINCARE

Image Skincare is introducing two new lines. The Max uses a microburst delivery system to protect its key ingredients until the moment they disperse on the skin. Included in this range is Wrinkle Smoother, combining a wrinkle-fighting peptide, lifting polymer and plant stem cells; and Contour Gel Crème, which targets skin sagging and redefines facial contours. Also new from Image is the Prevention+ line, including an array of suncare moisturisers, such as Hydrating, Tinted and Protection variations, as well as a Lip Enhancer.

CELLUMA

Therapeutic LED light therapy specialist BioPhotas has introduced the Celluma iPRO. Much like the FDA-cleared and Medical CE-marked professional-sized LED panel device Celluma PRO, the iPRO is used for treating a variety of skin, muscle and joint conditions. However, it is battery-powered, meaning it has the added ability of being usable anywhere and at any time. A new battery-powered version of Celluma LITE has also been launched, and this update will be offered to any previously sold device with the exception of the Celluma DELUX.

IS CLINICAL

Sheald Recovery Balm, iS Clinical’s best-selling formulation, has been recently released in a 15g pocket size tube. The aftercare balm prevents scabbing and itching post-procedure, as well as functioning as a daily moisturiser for cracked, dry and compromised skin. Key ingredients include 10% botanicallyderived hyaluronic acid, 8% glycerine for protection during the healing process, 3% oat kernel extract to soothe and calm irritation; and 2% kava kava, which is said to control pain, due to its anaesthetic effects. It also limits itching as the skin heals.

Aesthetic Medicine • May 2020

SKINCEUTICALS

Professional skincare brand Skinceuticals offers broad spectrum SPF50 protection with its new Advance Brightening UV Defense Sunscreen. Tackling areas such as sun induced hyperpigmentation, skin discoloration, rough textured skin and signs of photo-ageing and dark spots, the new dual-action, ultralightweight, residue-free sunscreen combines broad spectrum filters with 1% tranexamic acid and 2% niacinamide to brighten and protect the skin against harmful UVA and UVB rays. Results are said to show in as little as 12 weeks, with premature ageing and future sun damage also targeted.

C O M M E R C I A L F E AT U R E

1023

What is skin biorevitalisation? Biorevitalisation is a preventive and corrective method of skin imperfections with injections of hyaluronic acid. It’s a way of returning life back to skin and it’s a nonsurgical and widely applied way to fight skin ageing and various skin problems in aesthetic medicine. Biorevitalisation can significantly improve your skin condition on any part of your body. For example, face, décolletage, arms, neck, inner arms. After the procedure with with non-crosslinked hyaluronic acid skin regains elasticity and a healthy glow, both attributable to young skin. Rejuvenation is the best way to preserve your skin’s youth.

Indications + Increased dryness caused by free radicals such as stress, sun exposure, smoking… + Skin ageing + Prevention of premature signs of ageing

+ Wrinkle correction + Flaccidity on face, neck and décolletage + Dull skin

Discover the new biorevitaliser TKN HA 3 TKN HA 3 is the latest addition to our portfolio of products with hyaluronic acid. This biorevitaliser is an injectable syringe gel composed of 9mg/ml of non-crosslinked hyaluronic acid. It has the highest molecular weight in the market (3.000 kDa), that is, the most similar to the skin physiological one. Having a larger molecule, its degradation is slower and its effects last longer providing a filler effect. TKN HA 3 can be used on the face, neck and décolletage to prevent and correct signs of ageing.

BEFORE

AFTER 1 treatment

Actions: + Participates in wound healing, allowing cells to migrate to the injured area + Slows down the ageing process, especially the formation of wrinkles + Maintains skin moisture levels as it retains up to 1,000 times its weight in water, improving the moisture content in the skin and strengthening the skin barrier + Stimulates the production of collagen and improves the morphology of fibroblasts + Provides a powerful nourishing action and a lifting and firming effect on flaccid skin + Provides a preventive effect on young skins + It’s the perfect complement to prepare the skin before fillers and Botox and after for a perfect finish Post written in collaboration with Dr. Nima Ostovari

Discover more on toskani.com | Distributed in UK by mabeautyaesthetics.com Ph. 01293 441909

T R E AT M E N T F O C U S

FRAX LIP TREATMENT

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LIP SERVICE The Frax Lip Treatment by Nordlys offers a non-invasive option for patients interested in lip rejuvenation

ip resurfacing is nowhere near as popular as dermal fillers for lip rejuvenation, but for patients seeking a subtler, more natural-looking alternative – or who don’t want to opt for filler straight away – it could be an option to consider introducing in clinic. The Nordlys non-ablative laser system from Candela Medical is the platform behind the Frax Lip Treatment, performed to improve collagen synthesis and increase hydration in the lips, as well as to target small lines around the mouth. The treatment uses the Frax 1550 laser to heat the underlying skin tissue, employing a software algorithm to set parameters that allow the practitioner to control pulse duration and energy intensity. Small pulses of heat into the surrounding tissues of the lips speeds up collagen generation, resulting in a temporary plumping effect without the use of filler. The laser also woks to produce a gentle desquamation of the lips, removing dry, dehydrated cells that can cause lips to appear chapped and feel tight. Patients may also notice their natural lip colour is enhanced post-treatment, thanks to an increase in blood circulation. A combination of fractional and infrared lasers in the device generates heat to tighten the skin surrounding the lips, smoothing fine lines, while SoftCool cooling technology is integrated into the machine to prevent the skin overheating and reduce patient discomfort. The technology sends a focused stream of cool, damp air directly to the treatment area. Patients

Aesthetic Medicine • May 2020

can opt for a one-off 10-minute treatment for temporary results, but are advised to complete a course of five to six treatments spaced four weeks apart for longer-lasting effects. Nurse and advanced aesthetician Sarah Dale has provided more than 120 treatments at her clinic Sarah Dale Aesthetics in Dorset. “It’s a quick treatment to do and gives patients instant results”, she says. “They also tend to report back that their lips feel very hydrated, less cracked and restored with colour. I personally have had five treatments myself and love the results. I had a scar on the inside of my lip which used to affect me when I spoke, but the treatment has completely removed it. I have patients that have stated their fillers have left them with lumps and they much prefer this method of lip plumping.” AM

Before treatment (top) and after treatment (bottom)

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C AS E ST U DY

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Slow and steady Aesthetic therapist and clinic owner Sherine Vassel talks us through her treatment approach for a patient suffering from severe skin damage after contracting chicken pox CONSULTATION

This patient came into clinic presenting with severe hyperpigmentation defects, scarring and dryness of the superficial epidermis after having contracted the varicella zoster virus in the form of chicken pox, likely caught from his four-year-old daughter and confirmed by a general practitioner. The pox spread rapidly; the patient thought it was just an allergic reaction causing a few unsightly spots, but within hours the patient’s skin had become totally inflamed, with more spots growing faster and becoming larger, redder and more irritated by the minute. The patient was a physically fit 33-year-old male with no psychological symptoms. He had a history of frequent migraines diagnosed at the age of 10. He had not undergone any procedures immediately before treatment, and no previous or recent operations. He was not using any professional pharmaceutical or medical aesthetic products. The patient had multiple chemical sensitivity (MCS) allergies to fragrances and household cleaning products. He had washed his face very aggressively using Imperial Leather soap in a bid to keep the skin clean, but this turned out to be the beginning of his worst MCS reaction yet. The patient applied calamine lotion and took co-codamol to assist with a migraine that lasted for eight days. Although he wasn’t able to sleep for more than two hours during the reaction, the patient reported no pain or itching, contrary to usual chicken pox symptoms.

ASSESSMENT

It was clear that the ultimate treatment plan would consist of two things; • consideration and compassion towards the patient’s psychological wellbeing • controlled rejuvenation towards the physiological constraints applied with due diligence towards the health, safety and intricately-controlled wound management of post-inflammation and scar tissue.

Aesthetic Medicine • May 2020

This encompassed several details for consideration which would need to be addressed, such as: • Hyperpigmentation defects from the range of trauma to the wounded cells right through to the proliferation of the body attempting to renew and build new skin cells • The initial obvious dryness of the superficial epidermis due to physiological changes in epidermal water loss and the skin’s inability to adequately retain water within the keratin layers. This meant that the skin appeared dull but most importantly, did not have the vital nourishment required to build a strong foundation for newly-formed and hydrated skin tissue.

CHOICE OF TREATMENT

SkinPen, distributed in the UK by BioActive Aesthetics, is always my preferred choice for skin rejuvenation. It is a precise and controlled method of wound management and skin-cell renewal, which permits little to no heat during the rejuvenation process, unlike chemical peels and lasers which deliver vast effects but do not adequately target the source of targeted cellular renewal so promptly. I have many case studies similar to this one from a range of skin types, colours and tones. It took us three years to decide and acquire the device that we wanted to use for microneedling. It was an important decision as we knew from the start that skin education and patient trust were non-negotiable and imperative to our business. We wanted to ensure that the quality of the microneedles were of the highest precision; there couldn’t be a risk of creating tears or rips in the delicate framework of collagen in the skin. We were impressed by the accurate oscillation of the inner motor of SkinPen Precision to produce fine, measured and precise insertions, which are important factors when applying controlled wound healing methods.

C AS E ST U DY

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Plus, the ability to interchange needling depth within seconds depending upon the lesion or area that you are working on allows you to save time and concentrate your efforts more on providing treatment. The “lock out” feature is also fantastic; once a needle has already been loaded or used for a patient’s treatment, this safety feature does not enable you to reuse the needle again accidentally.

TREATMENT PLAN

Time was a factor; I knew that I had to prepare the skin prior to microneedling, which meant preparing the surface before the first treatment. This is not always necessary with microneedling, but to further facilitate the level of rejuvenation that I wanted to gain, I needed to “test” the hydrolipidic barrier to see if I could first provide exfoliation via gentle, low-level dermabrasion in order to remove surface dead skin; thereby inducing blood flow and oxygen stimulation around the cells. I also wanted to disturb the acid mantle by introducing simple and gentle products for the patient to use over the next few weeks until the next appointment. Patient education was vital to this process. As part of an in-depth, 90-minute consultation addressing physical and mental health, it was necessary for the patient to understand the chemistry of the SkinPen process and the need for not only improving the initial condition of the skin, but the possible outcomes and any contra-actions towards ensuring that this would be a permanent, long-term improvement. Homecare would be gentle and uncomplicated and we

provided all products and tools. I selected simple products to help secure that the patient would stick to an uncomplicated, three-step routine in a bid to strengthen the skin’s barrier. Products consisted of MySkin UK Deep Cleansing Oil for free-radical protection and skin brightening, an AHA toning solution, NeoStrata Enlighten Pigment Controller Moisturiser and the daily application of NeoStrata Enlighten Skin Brightener with SPF40 to act as a skin protector and moisture facilitator, with inclusive tyrosinase inhibitors. The patient was wary of applying SPF to his Fitzpatrick V skin as he did not like the white titanium and zinc casting of physical sunscreens. Enlighten Skin Brightener worked very well. Although this was the best time to act – while the skin was now not in its active stage – I wasn’t concerned about rushing the microneedling process; I testify to having seen the benefits of SkinPen even on clients with years of deep scar tissue. The patient eventually received one medical microdermabrasion prep treatment and three SkinPen sessions spaced six weeks apart to also allow the skin to adjust to the prescribed homecare. The patient is beyond delighted with his results. He reported back that the treatments have had a huge impact on his confidence and social life. It’s important to relate to patients that results vary – many people will see this patient’s “after” images and expect all skins to react the same. I like to maintain a realistic responsibility of expectation to all patients at the beginning of a fruitful consultation. AM

Sherine Vassel is owner and director of MySkin UK, an aesthetic skin clinic in London. MySkin offers advanced treatments including microneedling, chemical peels, machine-based facials and electrolysis. The clinic also has its own in-house product range. Vassel regularly lectures in beauty therapy and was involved in the development of the CPD Aesthetic Therapist programme, for which she was also course leader. Follow MySkin UK on Instagram: @ilovemyskinuk

Aesthetic Medicine • May 2020

CLINICAL

SMILE DESIGN

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PEARLY WHITES Dr Yasmin Shakarchy and Dr Ben Reyhani break down the nine key factors of planning a successful smile makeover

he history of a smile can be traced as far back as 900BC, when the ancient Etruscans carved animal tusks to the form and hue of human dentition. Despite the constant search for beauty, dentistry did not become a recognised speciality until the 18th century. The speciality has since evolved into what we now know as the modern-day concept of cosmetic dentistry.1 Overall, in the last decade, both patient desire and treatment modalities have advanced alongside one another. An individualâ&#x20AC;&#x2122;s face is the richest source of non-verbal information. A smile is considered both a reflection of someoneâ&#x20AC;&#x2122;s personality and the area afforded the greatest amount of visual attention during facial analysis. 2,3 With facial attractiveness having significant effects on interpersonal relationships, positive internal self-image,

Aesthetic Medicine â&#x20AC;˘ May 2020

emotions, cognitions and perceptions, the care given to this area is of utmost importance.3,4 Even more dramatically, it has been noted that a smile can influence external evaluations, professional relationships and opinions on intelligence, empathy and trustworthiness.4,5 Considering all these factors, it is little surprise why patients want such dramatic attention to be paid to their teeth. Despite the well-documented effects of teeth on quality of life, and the positive influence of aesthetic dentistry, guidelines for planning outcomes vary. The dental discipline has of course produced indicators and parameters based on universally accepted rules, but there is a wide variation between professionals. However, there are some overarching factors affecting smile design formed from expert opinion as well as anatomical and physiological information.

CLINICAL

SMILE DESIGN

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THE GOAL

cases where the lip line is high, the gingival aesthetics are paramount to the smile. Considerations must be made regarding the colour, contour, texture and height of the gingival margins secondary to physiological or disease driven processes, which should be addressed prior to treating the dentition. The correction of such situations may not be necessary based on patient desire, but there are a plethora of options available in these scenarios. These range from altering the tooth/gingival proportions, to modifying the hypermobility of the upper lip, thereby allowing less gum to be on display.7

THE MAIN FACTORS

2. Dental midline The interface between the two maxillary centrals is considered the midline. In an ideal scenario, this point should be perpendicular to the incisal plane and parallel to the facial midline. Again, while minor discrepancies are mostly unnoticeable, anything over 2mm is usually noticeable by most people, with dentists more sensitive to minor changes1 (figure 2). Within our assessment we utilise midline structures such as the nasion, rhinon and philtrum for reference posts, except in patients with surgical or traumatic injuries. Diastemas obviously present their own interest, with multiple studies finding these to be an unattractive quality, but there are notable exceptions in some celebrities.8,9 It is interesting to note that maxillary and mandibular midlines do not coincide in three quarters of cases, and therefore the latter should not be used to establish the former.1 Mismatches between these do not affect the overall smile aesthetics.

The ideal outcome of any intervention is to produce a result that is aesthetically beautiful to both the patient and dentist, while ensuring it functions harmoniously within the anatomical structures of the lower face.1 This includes the encircling gingival tissues, oral musculature and skeletal underlay of the area. Form without function, and vice versa, is one of the principle causalities of dissatisfaction following treatment. It is the combination which must be sought, to mimic a natural smile based on specific needs and desires.

One of the principle qualities of any clinician is the ability to examine multiple parameters in unison, from macroaesthetics, including facial profile, to the mini and microaesthetic areas of oral attractiveness, while combining radiographic information, photographic image analysis and patient personality. The process results in a holistic analysis of a patient. Some evidence suggests categorising thought processes into qualitative (visual), semi-quantitative (photographs) and quantitative (instrumentation) measurements. Here is a breakdown of our procedural analysis: 1. Facial components Although we primarily focus on dental composition, there are two features which play an important role in smile design; the lips and facial symmetry. The boundaries of a smile are formed by the lips, with major discrepancies affecting overall aesthetic appeal of any work. Admittedly, small degrees of asymmetry do not play as major a role, but anything upward of a 2.5mm shift to one side will likely require fixing.6 The other factor to consider when assessing lips is the curvature, with upward and straight lips considered cosmetically more attractive than downward turns or a “reverse smile”.7 In conjunction with lip shape, there is also the concept of the lip line. This is the vertical tooth exposure when smiling, generally higher in females than males. With ageing, this exposure can reduce and become more accentuated at rest than when smiling. Moreover, if a greater proportion of lower teeth are visible when compared with the uppers, this again makes the smile appear aged. The hypermobility of the upper lip though can result in a gingival smile with excessive display during social and posed situations, also known as a “gummy smile” (figure 1). The degree by which the upper lip contracts on smiling governs whether the smile is high, average or low. In

Figure 1: Gummy Smile

Figure 2: Midline

3. Incisor-related factors Incisor inclination (both retorclination and proclination) has an overall effect on both the lip line and visual disturbance of the dental midline. There is a 1mm increase in lip thickness for every 3mm of retroclination of the incisors7 (figure 3a). Typically, inclination indicates the loss or gain of space, and correction of such things provides a source of arch space. As a result, establishment of normal incisor inclination is a crucial component to be considered when planning a makeover. There are certain schools of thought which believe the incisal length to be the most important determinant in smile design. The belief stems from using this point as a

Aesthetic Medicine • May 2020

CLINICAL

SMILE DESIGN

parameter when determining tooth proportion and gingival levels, as well as the importance of the centrals providing a crucial focal point of facial analysis. In younger patients, a target of approximately 3.5mm of incisal visibility is considered ideal at rest, with this figure decreasing with age secondary to loss of muscle tone. This is usually achieved with a total length of 10-11mm, with the width falling to approximately 80% of that. The proportion of height-to-width ratio of the anterior teeth typically follows the “golden proportion” 1 (figure 3b). It was Lombardi who pioneered the use of golden proportions in dentistry, describing repeated ratios of the maxillary anterior teeth to optimise dental composition. When viewed frontally, the width of each anterior tooth is 60% the width of the adjacent tooth (figure 3c). Strict adherence can ultimately lead to poor cosmetic outcomes, with factors such as smile arch, lip anatomy, facial symmetry and such playing a role in the creativity required in smile design. But, it is a useful area to understand. Finally, an assessment must include an analysis of incisor overbite. With regards to treatment planning, this provides information related to the severity of malocclusion and arch analysis. In the current population there are reports that the prevalence of malocclusions is as high as 90%, and this has been shown to have a higher psychosocial impact than more minor discrepancies, as well as drawing significant unwanted visual attention. 2,10,11

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4. Canine-related factors The canine “fang” tooth is an important consideration in smile design.1, 12 It is essential both functionally and cosmetically with relation to expression of individual characteristics. The inclination and “sharpness” of the upper canine teeth has important effects on perception of attractiveness. Most people will ask for prominent, sharp canines to be aligned into the arch and made softer and rounder at the tip, so as to create a more aesthetic smile (figure 4).

Figure 4: Prominent Canines

Figure 3a: Proclined Incisors

Figure 3b: Height Width proportions

Figure 3c: Golden proportion

Aesthetic Medicine • May 2020

5. Tooth size/proportions The knowledge of racial variations is important during dental size assessment, with significant variability between ethnic populations and a direct causal relationship existing between tooth proportions and cosmesis.13 Regardless of gender, the central incisor is typically the widest tooth mesiodistally, followed by the canine and then the lateral incisor, though male teeth are normally wider than female. With regards to length, the gradient of size follows the same order and relations as width.13 The incisal embrasures are the small spaces between the teeth at the biting edge. There should be a natural, progressive change in size of the embrasures between the centrals to the canines (figure 5a). Failure to provide this, will result in the teeth appearing too uniform and box-like in appearance, with loss of the individuality of each tooth. If we consider shape, females seemed to prefer a more tapered-ovoid incisor tooth than a square form in most dental literature (figure 5b). These same studies though seem to suggest there is no such thing as the ideal incisor shape, with variations found between both patient and expert preference.14 What appears to be the overriding philosophy is that dental proportion is related to facial morphology, and analysis cannot be considered without addressing both aspects together. What this means is that it is not the actual tooth size but the perceived size and proportion which are important when planning a smile makeover.1 6. Smile arc Having been first quantified by Hulsey, a smile arc can be subdivided into a straight or reverse arc. The former is

CLINICAL

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SMILE DESIGN

sucking, excessive length of posterior teeth and alterations in lower lip musculature.7

Figure 5a: Incisal embrasures

7. Buccal corridor space This is the space between the buccal surface of the posterior teeth and the corners of the lips when the patient smiles (figure 7). First introduced in the 1950s, there are a number of other terms given to this concept, including the lateral dark space and the shadow tunnel.16 This area has a crucial influence on smile aesthetics, as it ensures naturallooking smiles.15,16,17,18 The width of the buccal corridor significantly alters smile attractiveness in different facial types. Most groups, both general public and professional, tend to prefer a mediumsized space, aiming for approximately 15%. There are some variations, such as Japanese and Koreannative patients, who seem to prefer a narrower space, but regardless of these preferences smiles with buccal corridor space were more desirable throughout.18 The reason for this is that these snippets of negative space gives the suggestion of natural depth to a smile.

Figure 5b: Teeth shape

found when the incisal edges of the maxillary anterior teeth are in a straight line to the border of the lower lip (figure 6a), while the latter is where the teeth are curved in reverse (figure 6b). Typically, a reverse smile arc occurs when the central incisors are shorter than the canines, occlusal plane inclination or crown angulations, and the profile is considered less aesthetic than straight smiles.15 There are variations, as with everything, to consider. The curvature of the incisal edges tends to be more pronounced in women, and flattens, regardless of gender, with age.7 Occasionally, dental intervention can unintentionally have negative outcomes with the arc, as does thumb

Figure 7: Buccal corridor (photo curtosey of Ben Reyhani)

Figure 6a: Smile arc - Positive

Figure 6b: Smile arc - reverse

8. Shade While the shape of teeth influences smile cosmesis, it is the shade that seems to have a higher baring on patient satisfaction at the end of treatment. It is important to note that white teeth are associated with higher ratings in intellectual ability, psychological adjustment, relationship status and social competence.19 While this may seem a straightforward matter, tooth colour is highly subjective, with various factors affecting patient perception. These include the reflection and absorption of light, the colour of the surrounding lips and gingiva, as well as variations in skin tone. As a result, shade matching becomes a complex issue, with the cosmetic dentist ideally managing to balance both subjective and objective matters when reaching a conclusion. Incidentally, gender seems to play a role, with females significantly better at shade matching than males (figure 8).19

Aesthetic Medicine â&#x20AC;˘ May 2020

CLINICAL

SMILE DESIGN

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9. Other factors There are two other patient-related factors to consider when planning a smile makeover. Firstly, educational and sociodemographic factors must be understood, with aesthetic scores seemingly decreasing with increasing educational levels. 20 Second is the value of good photography, with image quality having significant effects on the perception of smile beauty. 21 Poor photography of before and after images may result in patient dissatisfaction, even during appropriate and adequate restoration cases. So, it is important for a cosmetic dentist to have the tools to showcase the full range of their work. It is important to remember the significance a beautiful smile can serve in a patient’s life, and the responsibility we possess to provide the best outcome we are capable of. There are still many factors to consider, including proportional assessment tools pioneered by great dentists such as Lombardi and Levin, appropriate recording of information; and the advent of digital technology. We will aim to address all of these and much more in future issues of Aesthetic Medicine, to provide a complete source of information for the budding cosmetic dentist. AM

Figure 8: Shade

Dr Yasmin Shakarchy completed her dentistry training at the University of Birmingham. She is a Member of the Faculty of Dental Surgery (MFDS Ed) and holds a a PG certificate in aesthetic and restorative dentistry. She won Best Young Dentist at the 2018 Dentistry Awards. Instagram: @doctor_yasmin_

Dr Behnoud Reyhani is a partner in Apa Aesthetic Los Angeles, US. The practice is fully dedicated to cosmetic complete mouth rehabilitation. He has been practicing for 12 years with a focus on dento-facial aesthetic harmony as well as periodontal and implant surgery. Instagram: @ dr.benreyhani

REFERENCES 1. Bhuvaneswaran M. Principles of smile design. J Conserv Dent. 2010 Oct;13(4):225-32. 2. Baker RS, Fields HW Jr, Beck FM, Firestone AR, Rosenstiel SF. Objective assessment of the contribution of dental esthetics and facial attractiveness in men via eye tracking. Am J Orthod Dentofacial Orthop. 2018 Apr;153(4):523-533. 3. B hat M, Shetty S, Shetty P, Khan FA, Husain A, Ragher M. Evaluation of Patient and Parent Satisfaction After Orthodontic Treatment/Orthognathic Surgery for Cleft Lip and Palate Deformity. J Pharm Bioallied Sci. 2019 May;11(Suppl 2):S184-S187. 4. U eda Y, Nagoya K, Yoshikawa S, Nomura M. Forming Facial Expressions Influences Assessment of Others’ Dominance but Not Trustworthiness. Front Psychol. 2017 Dec 1;8:2097. 5. Mathias P, da Silva EV, Aguiar TR, Andrade AS, Azevedo J. A Conservative Esthetic Approach Using Enamel Recontouring and Composite Resin Restorations. Case Rep Dent. 2016;2016:1254610. 6. B atwa W, McDonald F, Cash A. Lip

Aesthetic Medicine • May 2020

asymmetry and smile aesthetics. Cleft Palate Craniofac J. 2013 Nov;50(6):e111-4. 7. M anjula WS, Sukumar MR, Kishorekumar S, Gnanashanmugam K, Mahalakshmi K. Smile: A review. J Pharm Bioallied Sci. 2015 Apr;7(Suppl 1):S271-5. 8. C racel-Nogueira F, Pinho T. Assessment of the perception of smile esthetics by laypersons, dental students and dental practitioners. Int Orthod. 2013 Dec;11(4):432-44 9. G eevarghese A, Baskaradoss JK, Alsalem M, Aldahash A, Alfayez W, Alduhaimi T, Alehaideb A, Alsammahi O. Perception of general dentists and laypersons towards altered smile aesthetics. J Orthod Sci. 2019 Aug 8;8:14. 10. S arul M, Antoszewska-Smith J, Park HS. Self-perception of smile attractiveness as a reliable predictor of increased patient compliance with an orthodontist. Adv Clin Exp Med. 2019 Dec;28(12):1633-1638. 11. L ukez A, Pavlic A, Trinajstic Zrinski M, Spalj S. The unique contribution of elements of smile aesthetics to psychosocial well-being. J Oral Rehabil. 2015 Apr;42(4):275-81.

12. T hiruvenkatachari B, Javidi H, Griffiths SE, Shah AA, Sandler J. Extraction of maxillary canines: Esthetic perceptions of patient smiles among dental professionals and laypeople. Am J Orthod Dentofacial Orthop. 2017 Oct;152(4):509-515. 13. J ain S, Reddy M, Raghav P, Jain S, Anjum A, Misra V, Suri R. Assessment of tooth proportions in an aesthetically acceptable smile. J Clin Diagn Res. 2015 Apr;9(4):ZC01-4. 14. H ussain A, Louca C, Leung A, Sharma P. The influence of varying maxillary incisor shape on perceived smile aesthetics. J Dent. 2016 Jul;50:12-20. 15. Gaikwad S, Kaur H, Vaz AC, Singh B, Taneja L, Vinod KS, Verma P. Influence of Smile Arc and Buccal Corridors on Facial Attractiveness: A Crosssectional Study. J Clin Diagn Res. 2016 Sep;10(9):ZC20-ZC23. 16. P isulkar SK, Agrawal R, Belkhode V, Nimonkar S, Borle A, Godbole SR. Perception of Buccal Corridor Space on Smile Aesthetics among Specialty Dentist and Layperson. J Int Soc Prev Community Dent. 2019 Sep 30;9(5):499-504. 17. Nimbalkar S, Oh YY, Mok RY, Tioh JY, Yew KJ, Patil PG. Smile

attractiveness related to buccal corridor space in 3 different facial types: A perception of 3 ethnic groups of Malaysians. J Prosthet Dent. 2018 Aug;120(2):252-256. 18. I oi H, Kang S, Shimomura T, Kim SS, Park SB, Son WS, Takahashi I. Effects of buccal corridors on smile esthetics in Japanese and Korean orthodontists and orthodontic patients. Am J Orthod Dentofacial Orthop. 2012 Oct;142(4):459-65. 19. L abban N, Al-Otaibi H, Alayed A, Alshankiti K, Al-Enizy MA. Assessment of the influence of gender and skin color on the preference of tooth shade in Saudi population. Saudi Dent J. 2017 Jul;29(3):102-110. 20. D indaroğlu F, Özmutlu MK, Işıksal E. The Effect of Educational Status on the Perception of Social and Spontaneous Smiles. Turk J Orthod. 2016 Mar;29(1):10-15. 21. S ajjadi SH, Khosravanifard B, Moazzami F, Rakhshan V, Esmaeilpour M. Effects of Three Types of Digital Camera Sensors on Dental Specialists’ Perception of Smile Esthetics: A Preliminary Double-Blind Clinical Trial. J Prosthodont. 2016 Dec;25(8):675-681.

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Healthxchange Offering financial support for your clinic

DEAR COLLEAGUES, FRIENDS AND PARTNERS, Sometimes in our busy lives we forget to say thank you, so I would like to take this opportunity to personally thank you for supporting Healthxchange over the years. These are challenging times and as a clinician myself, I share your pain. Many of us may be thinking, “How will I manage my debt?” Or, “How will I ever afford to start up again?” Some may even be too embarrassed to make contact; please, never be too embarrassed to talk to us. As you know, our main partner in the market is Allergan. Not only is Allergan a company that has produced best-in-class products to use in our clinics, they also offer the premier educational support system. Now, they are demonstrating a level of understanding and caring for your business in an unprecedented manner. With the incredible support of Allergan, I, as chairman of the Healthxchange Group, would like to pause all debt repayments on your account relating to Allergan products purchased through Healthxchange for the next couple of months. Please make contact with our accounts department via email at helpingourpartners@healthxchange.com so we can initiate and explain this initiative, help manage any other debt, and outline other innovative ways of supporting you; such as direct-to-patient services, future credit and debt rescheduling.

Best wishes, Dr John Curran Chairman, Healthxchange Group helpingourpartners@healthxchange.com

Aesthetic Medicine • May 2020

pharmaceutical excellence in depigmentation 10 MILLION TREATMENTS WORLDWIDE 35 years of innovation experience the results..... now intimate joins the depigmenting solutions family. 10/01/2020 13:00

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CLINICAL

LIPOSUCTION

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TRANSFER TECHNOLOGY Dr Yannis Alexandrides explores latest advances in liposuction, including the introduction of a new device for laser-based fat transfer

iposuction has been a primary component in cosmetic surgery for almost a century and is often the principal procedure in a surgeon’s handbook. Despite its popularity, liposuction has seen a surprisingly low amount of technological advancements since it was first pioneered by Dr Charles Dujarier in 1926. Liposuction gained popularity in the late 1960s in Europe, where surgeons would cut away fat from regions with limited blood vessels. That technique was then discarded in the mid-1970s, following the introduction of cannulas, with advancements in techniques further pushed by Dr Yves-Gerard Illouz and Dr Pierre Fournier, who injected saline and hyaluronidase to dissolve the fat tissue prior to suctioning. Europeans performed liposuction under general anaesthetic up until that point, but in the 1980s American dermatologists pioneered the use of local anaesthetics for

Aesthetic Medicine • May 2020

the operation. This would become known as “tumescent”. Following the introduction of ultrasonic high frequency in 1987 and laser liposuction in 1992, the procedure remained fairly comfortable with its place in the modern market and, interestingly, in 2015, liposuction surpassed breast augmentation surgery as the most commonly performed cosmetic procedure in the US.

NEW TECHNOLOGIES

Alma Lasers introduced BeautiFill, a next-generation fat grafting and liposuction technology, last year to great acclaim. The system is the first laser-based fat transfer technology to standardise the process, time and quality of fat-transfer methods with the least amount of adipose disruption. The system focuses – as good fat transfer should – on better fat quality rather than great fat quantity.

CLINICAL

PHOTOS: SHUTTERSTOCK

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THE TECHNOLOGY BeautiFill combines laser, aspiration and processing into one simple step using a proprietary radial fibre encased in a blunt Mercedes cannula. By using a closed-loop fat transfer method, the system reduces procedure time while ensuring only fat of the highest quality is harvested. Utilising a 1470nm wavelength, the cannula creates an even spread of low-power density emissions. At 1470nm, the wavelength is less absorptive in fat and more absorptive in water; it doesn’t destroy fat cells at the same frequency as other wavelengths. Instead, the radial emission gently detaches fat cells from septal fibres, keeping them intact while enriching fat by detaching SVF cells from fibres and inducing septal fibre retraction due to thermal injury. Essentially, as laser energy is delivered to the tissue, the laser cauterises

LIPOSUCTION

blood vessels rather than causing them to rupture, as with mechanical liposuction. This minimises bleeding, swelling and body trauma, such as hematomas, oedema and bruising, as well as minimising post-operative pain. The real hero of the technology is the cannula. Where once surgeons had to use bare fibres with flat emission, risking penetration through tissue and organs, BeautiFill has a proprietary fibre with a conical tip encased inside the cannula. This offers a high safety profile. This design also allows for a 360-degree radial emission of lowpower density, which targets water and selectively creates a thermal environment that softens and detaches the fat for effortless separation during simultaneous aspiration. Through simultaneous lasering and suctioning, the procedure is simplified and the treatment time significantly reduced.

Aesthetic Medicine • May 2020

CLINICAL

LIPOSUCTION

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THE PROCEDURE There are three components to the procedure The ultra-quiet, powerful aspiration system features three pumps for high powered operation; a peristaltic pump for infiltration of tumescent anaesthetic mixtures, and two aspiration pumps for fat suctioning. Step 1 involves the infiltration of tumescent anaesthetic mixtures, which not only depends on the area but on the surgeon’s preference. Step 2 utilises the unique Angel emitting radial emission fibre, which is integrated into a Mercedes perforated-tip cannula to emit energy in a 360-degree pattern. This allows surgeons to ensure energy is evenly distributed, remove fat cells quickly, cover a greater area of tissue and ensure only the highest quality of fat cells are harvested. These high-grade cells are then deposited into Alma’s new canister, which efficiently filters out blood and tumescent. Subsequently, the fat is easily and immediately able to be used for injection. While the surgery is perfectly suited to be done alone, it is advised to be done in conjunction with abdominoplasty, breast reduction or breast mastopexy; each would work in a complimentary manner on the other, enhancing the individual procedure for overall better results. Step 3, if wanted, involves injecting the newly harvested fat.

past; that way one can easily surmise where any lost volume has occurred and how to most naturally place the new fat. Typically, this will be in the temporal, buccal and lower eye area but can even extend to the lower face. What is most important is the initial analysis and from that, marking the patient exactly prior to the procedure. When it comes to harvesting fat, I prefer to opt for the high quality, soft-fat regions of the body. The fat there is always good quality and it is easy to harvest a high percentage of live cells – LipoLife3G recommends a fat vitality rate of greater than 95%. This usually includes the tummy, flanks, knees and thighs, but can even extend to the lower arms. In all of these regions, the thermal energy and a unique radial emission fibre allows for effective harvesting as well as homogenous skin tightening – often a concern of patients..

“As laser energy is delivered to the tissue, the laser cauterises blood vessels rather than causing them to rupture, as with mechanical liposuction”

THE PATIENT The primary candidate for the procedure is one suffering from volume loss across the face, hands, breasts and buttocks. These are normally visible through loss of audibles – or deep indentations – within the area. Using fat, you are not only able to volumise but also provide the subdermis with active live stem cells, increasing circulation, collagen production and texture in the treated area. In my past as a trauma surgeon we also harnessed fat injections to treat burn victims and saw incredible results with scar improvement, so any acne-scarring or trauma scarring can also benefit in the same way. Something else to be considered is the procedure timing and longevity. To accomplish the same results, I would normally have to deposit 40-60ml of filler for the same results; with laser-assisted liposuction (LAL), this is far less, and therefore much more efficient. The body is able to recognise the natural fat reintroduced to the area and begin self-depositing, meaning the results will only get better and better. THE PLANNING I often ask patients to bring along pictures of their face in the

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THE PAYOFF For me, BeautiFill is a real technological advancement in LAL. It is a complete, all-in-one solution in a compact, portable and well-organised unit. The system allows the surgeon to access high fat vitality for immediate grafting, removing the need for fillers and prioritising safety and quality – the two most precarious things in surgery – over everything else. Patients see volume loss and gain where desired, but also incredible results on the skin. The procedure creates effective skin tightening through collagen and elastin contraction and neogenisis. BeautiFill has also designed the LipoTight Cannula specifically for this procedure, which is intended for skin tightening on the face and neck. By shortening procedure times, ensuring high-quality harvesting and providing transdermal benefits during aspiration, BeautiFill feels like the right step in 21st century LAL. AM

Dr Yannis Alexandrides is an American and British board-certified plastic surgeon specialising in facial reconstructive and rejuvenation surgery. Since 2001 he has been the founder, director and head of surgical practice at 111 Harley St in London, which also has a clinical skincare brand, 111SKIN. Dr Alexandrides is a member of The American Society for Aesthetic Plastic Surgery and a former fellow of the Department of Plastic Surgery at the University of Pittsburgh Medical Centre.

Aesthetic Medicine • May 2020

EBINAR

Hosted by John Tanqueray

Introduction to ZO Skin Health

WIGM

W RE

E Z O S KIN H

Monday 11th May, 1pm

Wigmore Medical invites you to come and watch Dr John Tanquerary discuss ZO Skin Health, as part of the Aesthetic Medicine Live Virtual Week, on Monday 11th May 2020. For more details or to register your interest, please email training@wigmoremedical.com

C O M M E R C I A L F E AT U R E

THE NATIONAL MEDICAL WEIGHTLOSS PROGRAMME

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Obesity is on the rise for Brits

ata shows that almost 29% of adults are overweight (BMI 2529.9), and a further 36% are obese (BMI over 30) – that’s a total of 64% (almost two-thirds) of the UK adult population who are carrying more weight than is considered healthy. This current trend means that experts are predicting that without any action, 90% of adults in the UK will be overweight or obese by 2050.

PRIMARY CARE CAN NO LONGER HELP…

Liraglutide is a glucagonlike peptide-1 (GLP-1) agonist, which is manufactured by Danish pharmaceutical company Novo Nordisk. It is a daily, self-injected medication which was first licensed for the treatment of type-2 diabetes under the brand name Victoza and later approved for the treatment of obesity under the brand name Saxenda. Saxenda has been available in the UK since 2017. Sadly, the NHS is under significant strain, and reduced funding led to the decommissioning of weight loss services across the country, leaving people living with obesity with nowhere to go for help, support and treatment; particularly as the NHS is no

Aesthetic Medicine • May 2020

longer able to prescribe Saxenda. Novo Nordisk also make a new longer-acting GLP-1, semaglutide, which is licensed for the treatment of type-2 diabetes under the brand name Ozempic. Clinical trials are underway, with results indicating that it may be three times more effective at reducing weight than liraglutide. Licensing for this indication is expected to follow, however, given the challenges Saxenda has faced from NHS commissioners, it may well be that semaglutide faces similar obstacles in the NHS, and can only be used in the private sector.

BUT YOU CAN…

By becoming a certified partner of The National Medical Weight Loss Programme (NMWLP), registered healthcare professionals can set up a practice to provide private weight management services, to help those people living with obesity who want to achieve a healthier weight. The NMWLP was founded by nurse consultant Sandy Green, who wanted to increase accessibility of medical weight loss programmes where national health services are no longer available.

NMWLP MAKES IT EASY…

Quality training NMWLP training on the medical management of the overweight and obese was written

C O M M E R C I A L F E AT U R E

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THE NATIONAL MEDICAL WEIGHTLOSS PROGRAMME

and is delivered by Dr Matt Capehorn. He is an expert adviser to the National Institute for Clinical Excellence (NICE) on obesity, a professional adviser to the Obesity Empowerment Network (OEN) and part of the author group for RCGP-accredited obesity educational courses. The CPD-certified training course is also accredited by the Royal College of Nurses (RCN) and the World Obesity Federation, through the Strategic Centre for Obesity Professional Education (SCOPE). Delegates can expect to cover the epidemiology and physiology of obesity, understanding the fat cell, metabolism and appetite regulation, as well as a variety of weight loss interventions. The pharmacotherapy of various prescription medicines used for medically supervised weight loss are covered within the remit of setting up a private medical weight loss service. A recently added module also looks at best practice for offering remote consultation and prescribing services for patients in line with the high-level principles for remote prescribing, as co-authored and agreed by 13 of the UK’s healthcare regulators. The trend for safe, remote consultation services and prescribing in healthcare is on the rise, with many benefits to accessing healthcare services for both patients and practitioners. At-home learning During the covid-19 public health emergency, many businesses have had to evolve their operations, and NMWLP has risen to the challenge. Training, normally delivered in a face-to-face classroom environment, is now available with Dr Matt Capehorn via two four-hour face-to-face webinars. Remote learning (as with remote prescribing) brings added benefits, as training is much more conveniently accessed by all; and done in the comfort of your own home, with no travel or hotel expenses. As practitioners have closed their practices due to rules on non-essential businesses, what better time to invest in training to offer a new service? With the benefit of remote consultations and prescriptions clinicians can establish a viable business during an otherwise challenging time for the aesthetics industry. Even better, with just a £155 + VAT deposit, then five additional deferred payments, there’s never been a better time to become a Certified Partner of NMWLP.

Guaranteed Insurance with Cosmetic Insure Registered healthcare professionals who complete the NMWLP training will enjoy significant discounts through Cosmetic Insure, with immediate and guaranteed cover. New policies to cover the prescribing of both liraglutide and semaglutide, start from just £485 per annum with the NMWLP discount applied, (depending on annual business turn over). Existing policy holders who add these treatments following NMWLP training will see no increase in their premiums (subject to any increase in annual turnover). Regulatory compliance In England, only GMC-registered doctors need to register with the Care Quality Commission (CQC) to offer this weight loss service. All other healthcare practitioners, including independent prescribing nurses and pharmacists fall “out of scope”, (providing they do not work with a doctor). NMWLP works with Inspire to Outstand to assist those requiring CQC registration. Medicines supply NMWLP certified partners enjoy preferential rates on both liraglutide and semaglutide from our partner dispenser, PriMed Aesthetic Pharmacy, who can also send treatment packages direct to your patients.

JOIN US…

Becoming a Certified Partner of the NMWLP is available exclusively to registered healthcare professionals including doctors, dentists, prescribing pharmacists, nurse prescribers and nurses (who must work with a prescriber who attends the training). Find out more: nmwlp.co.uk. AM

Aesthetic Medicine • May 2020

CLINICAL

MYOMODULATION

Aesthetic Medicine â&#x20AC;¢ May 2020

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CLINICAL

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MYOMODULATION

EXPLORING MYOMODULATION Dr Steven Harris explains the main proposals that seek to understand myomodulation and discusses his own Mechanoreceptor Filler Hypothesis

here can be little doubt that myomodulation as a phenomenon exists. As practitioners, we regularly observe the change in muscle activity when a filler is placed next to it. There are many examples: a filler placed under frontalis to reshape the forehead reduces the contractility of that muscle with a reduction in the relevant horizontal lines. A filler used to reshape the lateral cheek can simultaneously raise the lateral brow by inhibiting the activity of orbicularis oculi while lifting the corner of the mouth by stimulating the contraction of zygomaticus major. In the lower face, a filler injected under mentalis not only reshapes the chin but appears to relax the activity of the pouting muscle to smooth the overlying skin and reduce the outward projection of the lower lip. There are many more examples of how fillers affect muscle activity. There has been much speculation and debate about the underlying mechanism of myomodulation. A number of proposals have been put forward by de Maio, Kane, Belhaouari, et al. and the author of the present article; all have their merits and shortcomings. A brief explanation of each will follow before the author’s revised hypothesis (Mechanoreceptor-Filler Hypothesis, originally published in 2019) will be proposed based on the latest scientific information.

DE MAIO

The first proposal given by de Maio is that over time muscles stretch and elongate to alter their ideal resting length for effective contraction. Filler placed under a stretched muscle, especially involving one of the mid-face elevators, acts as a pulley to modify the muscle’s length-

tension relationship, and in line with the Frank-Starling law of mechanics, will contract more effectively; filler placed above the muscle mechanically compresses it to reduce its contractile functioning.1 In a review of de Maio’s article, Kane suggests there is some merit to this explanation in that fillers placed under one of the mid-face elevator muscles (at their point of origin) would function more effectively from its new supported and raised position, but he points out this does not account for the behaviour of the elevator frontalis, nor does it explain the behaviour of the depressor muscles. Also, filler injected superficially exerts pressure in all three dimensions rather than just downward onto the muscle. According to Kane, a more plausible explanation is that the superficially-placed filler reduces the ability of the dermis to deform, thereby indirectly reducing the ability of the underlying muscle to contract. Moreover, there is no evidence to support the idea that muscles elongate over time and that the elevators weaken more than the depressors. If anything, it is more likely that both the elevators and depressor muscles shorten and weaken during the ageing process along with the contracting skull and soft tissues. 2 While the author agrees with Kane’s criticisms, it is very unlikely that filler, essentially a soft gel, would have the ability to raise, support and sustain a new contracting position of any of the mid-face elevators when placed directly under it (no matter the cohesivity of the gel). A large amount of filler would be required to achieve this and if anything, a significant amount of the filler would end up in the muscle itself, which would more likely reduce its ability to contract, as described in detail below.

Aesthetic Medicine • May 2020

CLINICAL

MYOMODULATION

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of the zygomaticus major. While the focus is on deep fat placement with a high G-prime, high viscosity filler for a volumetric advantage, this does not necessarily translate into a net upward lift, as the filler exerts forces in three dimensions. Perhaps the biggest mistake they make is in reference to the myotatic reflex. The myotatic, or stretch reflex, is dependent on spindle cells (stretch receptors) that detect changes in the length of the muscle. While spindle cells have been found in the muscles of mastication (masseter, temporalis and pterygoid), we also know there is a distinct lack of these cells in the facial mimetic muscles5,11; without spindle cells there can be no myotatic reflex. In explaining myomodulation by means of muscle relaxation the authors describe the filler entering the muscle to spread between the muscle fibres for a “calming” effect. Although they do not explain the underlying physiology in any great detail, the phenomenon certainly can be observed in areas such as the forehead and chin and may be explained in terms of sliding filament theory. According to the sliding filament theory, Figure 1: The elevator muscles (left) and depressor muscles (right) of the face. when a muscle contracts, the myosin Although the frontalis muscle is highlighted as an elevator, it is regarded as a depressor by the autonomic nervous system (printed with permission from 3D4 filaments of the muscle fibers slide past the Medical Complete Anatomy (3D4medical.com). actin filaments while the two groups remain at relatively constant length.6 Disrupting BELHAOURI, ET AL. this relationship as in the placement of filler in the muscle The recent proposal by Belhaouri, et al. suggests two would upset the length balance between the two active explanations for myomodulation: one by muscle stimulation proteins, reducing the ability of the muscle to contract, the and the other by muscle relaxation. According to the extent of which is likely to be dose dependent. There is no authors, myomodulation by muscle stimulation essentially consideration of superficially-placed fillers and very little takes part in the midface at the level of injections into the reference to the relationship between the elevator and deep malar fat. They present three pieces of evidence; the depressor muscles, and how changing the activity of one first is a mechanical volumetric shift which “fills and rounds” affects the others. to shorten and elevate the midface. The second involves the Finally, in both the articles by de Maio and Belhaouri, et rheological properties of the filler, in particular one with a al., there is no satisfactory explanation of the changes in high G-prime and high cohesivity for greater “lift”. emotional appearance that we observe during the process The third involves the orbicularis oculi muscle, which of myomodulation. they describe as the “principle motor element” of the midface. Injections into the deep malar fat would elongate the muscle fibres to cause a kind of dose-dependent, prolonged stretch or “myotatic” reflex. The authors then discuss myomodulation by muscle relaxation involving areas such as the chin, jawline, forehead, lips, lateral ocular orbit and the upper part of the nasolabial folds. Here, the product spreads between the muscle fibres to decrease their ability to contract in a “calming manner”. 3 There are a number of serious shortcomings with this recent proposal. The authors refer to the orbicularis oculi as the principle motor element of the midface, but they ignore the lateral cheek and in particular the effects of placing filler under the origin

Aesthetic Medicine • May 2020

CLINICAL

MYOMODULATION

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Figure 2: Dermal fillers (3 ml) placed deep to the elevators, zygomaticus major and mentalis and the depressor muscle, DAO resulting in a net elevator effect with a parasympathetic shift in emotional appearance.

Figure 3: Dermal Filler (1ml) placed under the origin of zygomaticus major for an improvement in physical and emotional appearance (lips were treated with 0.5ml).

MECHANORECEPTOR-FILLER HYPOTHESIS

stimulation of these mechanoreceptors leads to a cascade of events involving the CNS (central nervous system) and ANS (autonomic nervous system) to create a disinhibition of the inhibitory sympathetic nervous system in favour of a parasympathetic one. 4, 5, 8, 9, 12, 13, 14 Thus, filler placed deeply near the insertion of the elevator zygomaticus major activates the muscle’s mechanoreceptors, which leads to inhibition of the sympathetic nervous system. This in turn not only increases the activity of the muscle itself to raise the corner of the mouth, but more holistically it shifts activity in favour of all the elevator muscles (with the exception of frontalis) over activity of the depressors, along with a reduction in emotional arousal. As a result, the mid-face and lowerface demonstrate a net-elevator effect, as does the lateral brow, with an overall improvement in definition, closer to the patient’s ideal facial shape (figures 2, 3, 4). The same series of events takes place when the filler is placed deep to one of the depressor muscles, for example, DAO (depressor anguli oris); the depressor activity is inhibited to cause the same shift in favour of the elevator muscles to create not only a local improvement, raising the corner of the mouth, but improving the facial shape as a whole. As mentioned, the contractility of frontalis is associated more with a sympathetic response and therefore injecting a filler deep to it will reduce its functionality. In these examples and injections involving all the other elevator and depressor muscles, the filler placed deep to the muscle will not only lead to a physical change, but the patient will also appear more emotionally relaxed, a result of increased parasympathetic flow. Fillers placed superficially to any of these muscles will merely inhibit the activity of the particular muscle, therefore exerting a more local effect rather than one involving the CNS.

The present author’s Mechanoreceptor-Filler Hypothesis (MFH) is based on the discovery of Ruffini-like corpuscles in the facial mimetic muscles. Cutaneous mechanoreceptors are very well known and their effect on the facial mimetic muscles has been studied. A random controlled trial by Harris, et al. found that when facial cutaneous slow-acting mechanoreceptors were stimulated with small silicone projections on an eye-mask, the glabella lines (caused by depressor muscle activity) were reduced significantly by 64% after a period of 15 minutes. The subjects also reported an improvement in mood.7 While the sensory receptors of skin are well documented, less is known about the underlying intrinsic sensory system of the facial muscles. The receptor organs for striated muscle proprioception, muscle spindles, operate essentially as stretch receptors, but it is widely accepted that these are either very scarce or absent in the muscles of facial expression.5 10,11 Cobo, et al. investigated whether other kinds of sensory structures were present in human facial muscles. The muscles removed from cadavers were processed for immunohistochemical detection of nerve fibres and two mechano-proteins associated with mechano-sensing. Nerves of different calibers were found in the connective septa and within the muscle itself. In all the muscles analysed, capsular corpuscle-like structures resembling elongated or round Ruffini-like corpuscles were observed, and the axon profiles within these structures displayed immunoreactivity for both mechanoproteins.5 The finding of Ruffini-like corpuscles acting as mechanoreceptors in the facial mimetic muscles forms the basis of the original MFH; it explains how fillers placed in the soft tissue of the face cause a deformity to stimulate not only cutaneous mechanoreceptors, but ones in the mimetic muscles themselves. As explained above,

“Filler placed deeply near the insertion of the elevator zygomaticus major activates the muscle’s mechanoreceptors, which leads to inhibition of the sympathetic nervous system”

Aesthetic Medicine • May 2020

CLINICAL

MYOMODULATION

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muscle’s mechanoreceptors to decrease the activity of all the depressor muscles by the same autonomic shift as above. With larger amounts of filler injected directly under the muscle, more of the product will enter the muscle to reduce its ability to contract. Fillers placed above the muscle (in the dermis or fat) will reduce the ability of the dermis to deform – also in a dosedependent manner – and again decrease the ability of the particular muscle below to contract. Based on observation, it is the author’s opinion that at these larger doses any beneficial effects of myomodulation would be negated; yet another argument for the “less is more” approach. AM REFERENCES 1. De Maio, M (2018) Myomodulation with Injectable Fillers: An Innovative Approach to Addressing Facial Muscle Movement. Aes Plas Surg 42(3): 798-814 2. Kane MAC (2018) Commentary on Myomodulation with Injectable Fillers: An Innovative Approach to Addressing Facial Muscle Movement. Aesth Plast Surg 42:1360–1363

Figure 4: Dermal fillers (3 ml) placed deep to the elevator muscle, mentalis resulting in a net elevator effect and a parasympathetic change in emotional appearance.

3. L akhdar B, Lopez-Tomasety M, Quinodoz P, De Boulle K (2020) Myomodulation and Hyaluronic Acid. Prime Journal Jan Online Ed. 4. Harris S (2019) The Mechanoreceptor Filler Hypothesis. Prime Journal May/June Ed. (9): 34-39 5. Cobo JL, Francesco A, de Vicente JC, Cobo J, Vega JA (2017) Searching for Proprioceptors in Human Facial Muscles. Neurosci Lett (640) 1-5

SHORTCOMINGS OF THE MFH

The main shortcoming of the MFH is that it does not take account of how the amount of filler injected can affect the activity of the relevant muscle. It makes sense that the more filler injected into the dermis, the stiffer it becomes and the less able the muscle below is to contract. Similarly, in line with the suggestion of Belhaouri, et al., filler placed inside a muscle will limit its contractility and again, this is likely to be dose dependent. So, in the case of mentalis, for example, injecting a small amount of filler under the muscle will stimulate its activity, but the ability of the muscle to contract will diminish with the amount of filler that ends up in the muscle itself. Injecting a small amount of filler under the zygomaticus major near its point of origin will increase its contractility, but this is likely to be decreased, with larger amounts entering the muscle; the exact amount (or range) requires investigation. In other words, myomodulation is affected by four key factors: the type of muscle (elevator or depressor), the level of injection (superficial or deep), the rheology of the filler (especially cohesivity) and the amount of filler injected. Taking into account all these factors, the modified MFH (considering the amount of filler injected) offers a complete explanation to myomodulation and may be summarised as follows: when a filler is placed directly under an elevator muscle, it stimulates that muscle’s mechanoreceptors to increase the activity of all the elevator muscles by a shift in the autonomic nervous system towards a more parasympathetic flow. This results in a change in emotional appearance to a more relaxed (parasympathetic) look. When a filler is placed directly under a depressor muscle, it stimulates that

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6. Hanson J, Huxley HE (1953) Structural Basis of the Cross-Striations in Muscle. Nature. 172 (4377): 530–532 7. Harris S (2016) Reduction of glabellar lines using a silicone eye mask. Prime journal Nov Ed. 36-39 8. Johnson KO, Hsiao SS (1992) Neural Mechanisms of Tactual Form and Texture Perception”. Annual Review of Neuroscience. 15: 227–50 9. A braira V, Ginty D (2013) The Sensory Neurons of Touch. Journal Neuron 79(4): 618-639 10. Cobo JL (2017) Neuroanatomy of the face. Topographic-surgical, radiological and microscopic anatomy of the innervation of the face. University of Oviedo. Thesis 11. Cobo JL, Solé-Magdalena A, Junquera S, Cobo T, Vega JA (2019) Selected Topics in Facial Nerve Disorders. IntechOpen online chapter 1-14 12. G ellhorn E (1967) Principles of Autonomic–Somatic Integration: Physiological Basis and Psychological and Clinical Implications. University of Minnesota Press 13. P atestas M, Gartner L, Ascending sensory pathways (2016) A textbook of neuroanatomy, second edition. Wiley-Blackwell (12) 137-170 14. B aumel JJ (1974) Trigeminal-Facial Nerve Communications. Their Function in Facial Muscle Innervation and Reinnervation. Arch Otolaryngol. 99(1):34-44.

Dr Steven Harris MB BCh, MBCAM, MSc completed his medical studies in Johannesburg in 1997. He has been practicing aesthetic medicine at his clinic in North London since 2004. His original approach and techniques include facial reshaping with myomodulation and the nonsurgical lip lift (NLL). His regular educational posts can be viewed on Instagram: @drharrisclinic

Aesthetic Medicine • May 2020

THE ORIGINAL BUSINESS-TO-BUSINESS MAGAZINE FOR DISCERNING AESTHETIC PROFESSIONALS TICE INSPIRING BEST PRAC IN MEDICAL AESTHETICS

FEAUTURE

DERMATOLOGY FOR HANDS

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DERMATOLOGY FOR HANDS

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edical practitioners don’t need to be told that oils, creating cuts and sores and leaving us susceptible to regularly and thoroughly washing your hands infection. is one of the most important things you can Skin healing expert Hanna Sillitoe comments, “I advise do to prevent the spread of infection and that people avoid hand washes that contain ingredients protect yourself and others in the midst of such as sodium lauryl sulphate (SLS) and triclosan. There the current coronavirus pandemic. are many brands of soap that have fantastic anti-bacterial However, with people now becoming more and more properties but are less harsh on skin. Look for a hand soap vigilant and washing and sanitising their hands multiple free from synthetic detergents and preservatives. Most times a day, many are starting to suffer from dry, cracked, natural washes come fortified with nourishing ingredients red and sore skin as a result. This is also a huge such as organic essential oils, aloe vera, chamomile problem for key workers and NHS staff, with and calendula, all of which replenish our hands to the added irritation to their skin from PPE. keep skin feeling soothed and soft.” Dr Amiee Vyas, aesthetic practitioner Dr Ravi Brar, who practices at MK “The most and founder of Doctor Amiee, says, “As Smiles in Milton Keynes and holds important humectants trigger avoidance is not possible at a postgraduate diploma in clinical the moment, the focus of treatment dermatology, says, “Repeated are glycerine and should be on barrier building and exposure to water, soap and alcoholhyaluronic acid. There are repair with gentle active ingredients, based hand sanitiser causes dry skin. antioxidants and humectants. Using This can lead to the skin becoming also some very good lipids soap substitutes is also key to break itchy, sore and red, with some and ceramides on the the cycle of dryness and dermatitis. The developing blisters and painful cracks market” NeoStrata Restore Facial Cleanser works (fissures). People who have pre-existing very well as a non-drying hand wash, for dry skin, either due to medical conditions example.” or medication, are particularly susceptible Dr Brar also recommends re-washing with an to this. Understandably, this can make emollient. He says, “After using soap and water, re-wash following handwashing guidance difficult, but with an emollient. Dermol lotion is a good option. It has not it is important that we continue to follow the advice as much specifically been tested against covid-19 but is often used in as it is practical.” Dr Nick Lowe, consultant dermatologist at The Cranley surgical theatres for scrubbing sensitive hands.” Clinic in London, adds, “What causes the dryness is the damage to the delicate skin barrier. The skin barrier is very 2. PAT, DON’T RUB important it’s a very thin membrane on the outer part Rigorously rubbing the hands dry when the skin barrier of the skin which maintains the quality of the skin and its is already compromised can cause more damage and ability to keep itself moisturised. When that’s damaged it irritation, so recommend patients pat their hands dry with a soft cotton towel after washing. can lose water and the skin becomes dry and cracked. “Around 25% of people in the population have a tendency towards dry hands and hand dermatitis. Contact dermatitis is either a result of contact with an allergen which can cause a reaction, redness, scaling and itching; or there’s primary dermatitis which is due to irritants, such as soaps and detergents and the alcohol-based antimicrobial cleansers, which we are now using routinely. If someone also has skin diseases such as eczema and psoriasis, that can lead to increased pain and soreness of the hands.” With these hand health safety measures likely to be in place for months to come, avoiding soaps and hand gels is simply not an option. So, as skin specialists, what advice can you give to patients who are suffering with their hands at this time, to minimise the impact on their skin while maintaining high levels of hygiene, particularly, if they suffer from contact dermatitis, eczema or psoriasis?

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