AM November Issue by Aesthetic Medicine

INSPIRING BEST PRACTICE IN MEDICAL AESTHETICS

NO NEEDLE, NO RISK? NEEDLE-FREE INJECTORS MANAGING COMPLICATIONS VASCULAR OCCLUSION

DIGITAL AIDS TELEDERMATOLOGY

November 2019 | aestheticmed.co.uk

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

Dr Martin Kinsella, aesthetic practitioner, explains how Restylane’s OBT range is Refyning and Defyning natural expression “ Restylane Volyme™ is great in areas like the cheeks which often have a large deficit of volume to be filled, Restylane Defyne™ is my product of choice for nasolabial folds and marionette lines, while I like Restylane Refyne™ for small areas around the mouth ” DR MARTIN KINSELLA

Why do you like Restylane®?

A patient treated with the Restylane® OBT™ range

Restylane® has the broadest range of hyaluronic acid dermal fillers on the market which means that you can mix and match to suit tissue quality, treatment area and the results you want to achieve. I love the OBT™ range because it’s so versatile. I use Restylane Lyft™ from the Non-Animal Stabilised HA (NASHA)™ technology when I’m looking for a more pronounced lifting on areas like the jaw.

How are the different results created? By adjusting the size of the particles and the connections or ‘cross-links’ between the hyaluronic acid molecules you can get subtly different results. Fewer cross-links create a softer gel which integrates well into the skin and products with larger particles have more lift and projection.

Where do you usually use products from the OBT™ range?

BEFORE

AFTER

A patient treated with the Restylane® OBT™ and NASHA™ range

BEFORE

AFTER

Restylane Volyme™ has the biggest particle size so it’s great in areas like the cheeks which often have a large deficit of volume to be filled Restylane Defyne™ also has a large particle size to provide volume and smooth dynamic areas of the face so it’s my product of choice for nasolabial folds and the marionette lines Restylane Refyne™ has a smaller particle size and less lifting capacity so I like it for superficial fine lines around the mouth

Which patients would you use the OBT™ range for? I like the OBT™ range for everyone, but they are very well suited to patients with poor tissue quality, such as older patients, where a softer product integrates more easily into the skin.

Why do you trust Restylane®? I like the fact that Restylane® has a wealth of clinical data behind it. It’s a tried and tested product and it gives me reliable results time after time.

Restylane Refyne™

Restylane Defyne™

Restylane Volyme™

About Dr Kinsella Dually qualified doctor and dentist, Dr Martin Kinsella, has an expertise and passion for aesthetic medicine. Dr Kinsella has run international training courses teaching doctors and nurses in Turkey, Italy and Cyprus, but now focuses on his own patients and practices in Cheshire, West Yorkshire, Knightsbridge and Majorca. Dr Kinsella is passionate about Bio Identical hormones and has established a state of the art blood testing facility where he develops bespoke Bio Identical hormones.

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THE WORLD’S MOST

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November 2019

November 2019 | aestheticmed.co.uk

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RES19-10-0716c DOP October 2019 References 1.Data on file (MA-33939) 2. Öhrlund A. Poster presented at AMWC 2019

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THE FUTURE OF THE AESTHETICS INDUSTRY AWAITS YOU Register your interest and be the first to receive the 2020 education line up

www.aestheticmed.co.uk/interest

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.

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U S E F U L I N F O R M AT I O N

aestheticmed.co.uk

Contents NOVEMBER

EDITORIAL Vicky Eldridge, Editor

NEWS AND ANALYSIS

BUSINESS

10 NEWS The latest news from the industry

22 TELEDERMATOLOGY Georgia Seago explores the rise of teledermatology

18 AESTHETIC MEDICINE LIVE 2020 Get a first look at what will be happening

26 START-UPS Dr Jemma Gewargis on starting out in aesthetics

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

29 LEGAL Tina Chander discusses covert recording in the workplace

E: georgia@aestheticmed.co.uk T: +44 (0) 20 3728 9063

32 DIGITAL MARKETING Laura Moxham explores the question, how much is Google Ads going to cost my clinic?

ADVERTISING Jack Diamond

36 EMPLOYMENT Victoria Vilas on promoting a vacancy at your clinic

Georgia Seago, Deputy Editor

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

38 ASK THE EXPERT Aesthetic Medicine’s social media editor Chris Halpin answers your questions

MARKETING Chloe Monina E: chloe@aestheticmed.co.uk T: +44 (0)207 349 4799

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

DESIGN AND PRODUCTION ICD imagecreativedesign.co.uk

PRINTING Walstead United Kingdom walstead-uk.com

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 Allington House High Street Wimbledon Village SW19 5DX

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CONTENTS

IN THIS ISSUE...

aestheticmed.co.uk

SKIN 42 ACNE PIGMENTATION Post-acne scarring and pigmentation 48 PRODUCT FOCUS We discover the Medicalia range of clinical grade peels and post-operative skincare

52 EDITOR’S CHOICE Vicky Eldridge finds out about the new Eudelo Exoglow™ treatment from Dr Stefanie Williams 54 SKIN NEWS The latest skin product launches

50 SKINCARE JOURNEY Nurse Julie Scott shares her love of skin

INJECTABLES

DEVICES

OUT AND ABOUT

56 CAUSE AND EFFECT Claire Berry on managing patient expectations

72 BODY CONTOURING Dr Sotirios Foutsizoglou discusses the evolution of lipoplasty

86 OUT AND ABOUT Out and about in the industry this month

59 MANAGING COMPLICATIONS The Aesthetics Complications Expert Group shares its latest guidance on vascular occlusion

82 TREATMENT SPOTLIGHT Dr Vincent Wong shares a case study using the UltraCool treatment

68 NEEDLE-FREE INJECTORS Georgia Seago asks, what are the risks of injecting with needle-free devices?

Welcome to the November edition of Aesthetic Medicine

It’s hard to believe that this is our last issue of 2019. Where has the year gone? I love the autumn, it’s a time of transition and change, and we have some exciting changes here that I’m delighted to share with you. Georgia Seago has now joined our team as the new deputy editor of Aesthetic Medicine. Formally features editor on our sister magazine Professional Beauty, Georgia is bringing some fresh ideas and a new perspective to the publication, so I’m really looking forward to working with her. This month she has not only explored the emerging trend for teledermatology (p22-25) but has also written about the issue of dermal fillers being administered through needle-free injector pens (p68-70). I hope you will join me in welcoming her into our industry and to the Aesthetic Medicine family when you see her out and about at events. As always, please do get in touch with any news, launches and ideas for articles you may have. Both of our contact details can be found in the “useful information” panel to the left of this page. Vicky Eldridge – Editor

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

INDUSTRY NEWS

aestheticmed.co.uk

BAAPS announces formal review of buttock fat grafting procedures The British Association of Aesthetic Plastic Surgeons (BAAPS) announced last month its decision to launch a formal review of emerging new evidence into the safety and techniques used for fat-grafting buttock augmentation. This comes after a debate and series of votes among participating member surgeons at the BAAPS Annual Scientific Meeting. At last year’s conference, BAAPS recommended its members did not perform fat grafting to the buttocks until more data could be collated. The formal review will include a survey of BAAPS members and will examine emerging, peer-reviewed published evidence. The association’s current position remains that members do not undertake buttock fat grafting procedures until the formal review is completed. Paul Harris, BAAPS president, commented, “As an organisation dedicated to advancing safety, innovation and excellence in aesthetic plastic surgery, we have a commitment to our patients to deliver the most up to date knowledge and research which safeguards not only our patient’s safety. Around the world there are still patient deaths as a result of this procedure and patient safety should not be compromised.”

Speaking on behalf of the British College of Aesthetic Medicine (BCAM), Dr Uliana Gout said, “BCAM advises practitioners and patients to note the BAAPS cautionary statement regarding the Brazilian Bum Lift (BBL) treatments which have had a lot of recent international publicity and interest. “Patient safety is paramount to BCAM and we are aligned with BAAPS that all treatments should be backed by evidence-base to ensure safety and efficacy are optimised.”

Save Face and VICE campaign highlights dangers of aesthetic treatments to public Save Face recently joined forces with consumer media site VICE in a bid to help create awareness of the potential dangers of injectable treatments with members of the public. The campaign called “Fill Me In” involved a series of editorial articles on the site over the course of September. Topics included the risks of so-called “botox parties”, the dangers of purchasing dermal fillers online and the impact that social media and reality TV shows is having on demand for treatments, particularly lip fillers. Ashton Collins, director of Save Face commented, “Nearly 50% of the complaints we receive are from patients between the ages of 18-25, which is hugely concerning. VICE is the largest media outlet for people under 35 in the UK and we were thrilled to join forces.”

New TV show lets people win free cosmetic surgery A new Channel 4 series where a “jury” of the public decide if people get to undertake cosmetic surgery for free is being billed as “controversial” and “exploitative”. The Surjury is due to air in 2020 and is described by Channel 4 as a “factual entertainment series” whereby people seeking cosmetic surgery will stand before 12 members of the public to explain their reasons for wanting the procedure. The jury will give “measured advice” and share their own opinions and experiences if they themselves have had a cosmetic procedure in the past. The candidate must get a majority vote in order to win the free surgery. Love Island presenter Caroline Flack will host the series, introducing those wanting surgery to the jury while explaining and sharing facts about the procedure in question. Following Flack’s announcement that she’s set to take part in the series, The Surjury is facing serious backlash from some media outlets, with The Times calling it “a distressing idea for an entertainment show” and iNews branding it “a new low for television”. However, Channel 4’s factual entertainment commissioning editor Becky Cadman said the show would “neither glamorise nor condemn” participants’ choices.

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

INDUSTRY NEWS

aestheticmed.co.uk

ASA warns against using celebrities in social media treatment marketing The Advertising Standards Authority (ASA) is cracking down on the use of celebrities to market aesthetic treatments. Two recent rulings involve Instagram posts using the Kardashian/Jenner family. The first was against the Queen of Aesthetics salon in Parbold, Lancashire, which posted an advertisement for a “Kylie Jenner Package” of treatments on its Instagram page. The ASA challenged the misleading nature of the post in its suggestion that clients’ faces would closely resemble that of reality TV celebrity Kylie Jenner after the procedures. Queen of Aesthetics responded to the investigation by telling the ASA that it would be almost “impossible for a customer to look like anyone other than themselves after a non-surgical cosmetic procedure.” However, the ASA upheld the ruling on the grounds that the post included a picture of Jenner with the text “Kylie Jenner Package”.

The second ruling involved Beauty Boutique Aesthetics after a complaint regarding misleading advertising and the advertisement of a prescription-only medicine. The advert included a photo of Kim Kardashian with text that stated, “When someone is listing the reasons they don’t need Botox & all you can think about is how many units they need [sic]...” It also included the hashtag “botox”. The ASA upheld both complaints and said the ads must not appear again in their current form. The matter was handed over to the Committees of Advertising Practice (CAP) compliance team, which ensures advertisers comply with ASA rulings.

Public Health England launches mental health initiative Public Health England (PHE) has launched a new mental health initiative to help people look after their own mental health. The Every Mind Matters initiative is designed to give people simple tools to look after their mental wellbeing and support others. The platform, available to the public and for GPs to advise patients to use, will enable users to create a personalised plan of self-care actions to deal with stress, boost mood, improve sleep and feel in control. It will also be promoted to NHS workers within the service. The platform has been developed with the help of clinical and academic experts, national mental health charities and input from people with experience of poor mental health. Advice from the service includes showing users how to reframe unhelpful thoughts, increasing physical activity and practising breathing exercises.

Nine in 10 dermatologists agree not enough importance is placed on the psychological effects of skin conditions Nine out of 10 dermatologists agree that not enough importance is placed on the psychological effects resulting from skin conditions, according to a recent survey undertaken by the British Skin Foundation. Dr Andrew Thompson, reader in clinical psychology and practitioner clinical psychologist at the University of Sheffield and Sheffield Health and Social Care NHS Foundation Trust, commented, “This survey demonstrates that dermatologists recognise some patients experience psychological distress associated with their skin condition. It also indicates that while dermatology is making great advances in treating the medical aspects of skin disease, perhaps not enough is being done to address the accompanying psychological

effects. Clearly, we need more research that looks to develop effective psychological treatments or support for both children and adults living with skin conditions.” Additionally, 87% of dermatologists agree that people with skin conditions in the UK do not have sufficient access to psychological support. Dr Alexandra Mizara, consultant psychologist and British Skin Foundation spokesperson, said, “Skin patients often experience that they are not listened to or understood by their healthcare providers. The occasions that they are are rare and extraordinary. If you suffer with a skin condition that has impacted adversely on your life, talk openly about it to your doctor and ask them to refer you to see a psychologist.”

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

INDUSTRY NEWS

aestheticmed.co.uk

Methotrexate successful in treating resistant granulomatous foreign body reactions (GFBR) to dermal fillers Methotrexate has been found to offer a low-risk therapeutic alternative in resistant and severe granulomatous foreign body reactions to non-biodegradable fillers. A study undertaken in the Department of Dermatology of Bordeaux University Hospital and published in the Journal of The European Academy of Dermatology and Venereology treated four women with severe, treatment-resistant GFBR for up to six months. The cases were treated with 10-15mg of either oral or subcutaneous methotrexate weekly. Adverse effects were monitored once weekly in the first month and then monthly in the remaining five months. The delay after injection of the filler material was from 17 to 30 years. Histological findings were consistent with GFBR to liquid injectable silicone in two cases, polymethylmethacrylate in 1 case and

hydroxyethylmethacrylate in the last case. Three patients developed a mild hepatic cytolysis (grade 1 or 2). Methotrexate could be maintained in those cases and was discontinued after six months in all cases. Two patients developed recurrence of lesions, at 28 months and nine months respectively after treatment stopped, requiring reintroduction of treatment. The two other patients remained cleared after six months of follow-up.

Allergan launches consumer-facing podcasts Botox and Juvéderm manufacturer Allergan has launched a podcast series aimed at consumers considering medical aesthetic treatments. The Beauty Decoded Podcast has been created to help educate consumers about which aesthetic procedures are suitable for them and how they should access safe and ethical practitioners. Episodes will feature celebrity hosts including television presenter Rylan ClarkNeal and musician Sinitta. Featured practitioners include Dr Vincent Wong. In the first episode Clark-Neal talks to journalist and author of The Tweakments Guide, Alice Hart-Davis about the “tweakment” attitude to cosmetic work and how to approach it safely. Other episodes will cover topics such as treatment journeys for different procedures, the “less is more” approach and developing inner confidence. The first two episodes of the Beauty Decoded Podcast is out now on all major platforms including Apple, Spotify and Audioboom.

BAD responds to study linking psoriasis with cancer risk The British Association of Dermatologists (BAD) has released a response to a study called Association of Psoriasis With the Risk of Developing or Dying of Cancer published in JAMA Dermatology in October 2019. Speaking in behalf of the BAD, consultant dermatologist professor Brian Kirby, said, “This study reports that the risk of certain cancers and of dying from cancer are increased in psoriasis patients compared to controls. Patients with more severe disease are at a higher risk. It is important to recognise that this study shows that psoriasis is associated with certain cancers and that studies such as this do not suggest that psoriasis causes cancer. This would require significantly larger and differently designed studies to assess causation. “As stated by the authors, certain factors associated with psoriasis and in particular more severe psoriasis such as obesity, cigarette smoking and excessive alcoholic intake are all strongly associated with certain cancers. The findings of this study therefore probably reflect an excess of risk factors in the psoriasis population rather than the disease itself. If these factors were controlled, then the risk from psoriasis alone would be probably very small.”

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

INDUSTRY NEWS

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NEWS IN BRIEF THE HYDRAFACIAL COMPANY AND CONSULTING ROOM FORM DEAL

Aesthetic device manufacturer The HydraFacial Company has purchased assets of The Consulting Room, which has exclusively distributed the HydraFacial device in the UK since 2011. The acquisition has formed HydraFacial UK, a new direct market model that will allow HydraFacial to increase its presence around the world by adding northern Europe to its portfolio. The brand already has corporate offices and direct sales in China, Japan, Spain, Canada and the US.

NURSES NO LONGER CHEAPEST CAR USERS TO INSURE

Nursing professionals are no longer being offered the cheapest car insurance quotes, according to new research by Quotezone.co.uk. In the past, drivers in the nursing profession benefited from the lowest average car insurance premiums. Police professionals have now clinched the top spot with a median insurance premium of £499, followed by driving instructors and examiners. The median quote for nurses is now £717. Other medical professionals come mid-table with dentists and GPs receiving average quotes of £787 and £806 respectively.

UNIVERSITY OF SALFORD RECRUITS DYNAMIC TEAM TO DELIVER LEVEL 7

Manchester Postgraduate Dental Institute and ICE Hospital has appointed several leading clinicians as lecturers on its new level 7 programme in Non-Surgical Facial Aesthetics in partnership with the University of Salford. Joining Dr Tracey Bell, as programme lead are Cheryl Barton, Victoria Holden, Christian Lucas and Euan McKinnon, all of whom have extensive experience in both the dental and facial aesthetic fields. The 14-day programme will ensure students obtain a Level 7 standard of academic and practical skills in botulinum toxin and dermal fillers.

SKINCEUTICALS OPENS FIRST ADVANCED CLINICAL CENTRE

SkinCeuticals has opened its first UK advanced clinical centre in Kensington, London, in collaboration with The Cavendish Clinic. The treatment menu includes peels at the express peel bar and SkinScope skin anaylsis, and the product selection will feature SkinCeuticals’ custom D.O.S.E innovation for personalised corrective serums made in-clinic.

Glycolic and TCA peel blend more efficacious than TCA alone Layering glycolic acid under TCA “significantly” enhances improvement in photoageing parameters compared to TCA alone, says new research. A study published in the Journal of Cosmetic Dermatology set out to test whether signs of extrinsic ageing – such as wrinkles, hyperpigmentation, dryness and erythema – could be improved with better efficacy and tolerability using combined 70% glycolic acid and 15% TCA compared to a 35% TCA peel. A total of 40 female patients with signs of ageing at types II and III on the Glogau photoageing scale were divided into two groups of 20. One group was treated with the glycolic and trichloroaceticacid combination, while the other was treated with monopeeling of TCA. Each patient had five sessions with 14 days in between. Hydration, elasticity, melanin index, erythema index, and depth and volume of wrinkles were analysed before each treatment and after three months. While both methods showed good improvement in all parameters, the glycolic/ TCA group achieved significant differences in hydration and melanin index compared with the monopeeling group. The 35% TCA peel was found to be more effective in reducing wrinkles despite a lower tolerability. Subject-perceived improvements did not differ significantly between the groups.

Helium plasma gives skin contraction results superior to nitrogen Helium plasma has been found to give greater skin tissue contraction when compared with nitrogen plasma. A study published in Lasers in Surgery and Medicine compared both types of plasma for skin rejuvenation to measure differences in acute and chronic skin tissue changes in a porcine animal model. High-energy nitrogen plasma treatment exhibited greatest mean depth of acute tissue injury four hours post-treatment, whereas helium plasma treatment exhibited greater acute skin tissue contraction. Results for 20% and 40% power helium plasma treatment were very similar for both depths of acute tissue injury and acute skin tissue contraction. 30-day mean skin tissue contraction was greater for helium plasma treatment; however, the data varied significantly between animals in all paradigms.

NEWS IN PICTURES Harpar Grace has been named iS Clinical’s second most successful distributor in the world at its global conference in Warsaw, Poland. The company has been the exclusive distributor for iS Clinical for six years. Alana Chalmers, director of Harpar Grace International, said, “We are delighted to secure recognition as the second largest iS Clinical distributor in the world. We have achieved this success with not only being one of their youngest distributors but also with the most refined number of accounts.”

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

INDUSTRY NEWS

NEWS IN BRIEF ACE GROUP ANNOUNCES INAUGURAL CONFERENCE FOR 2020 The Aesthetics Complications Expert Group has announced it will be holding its inaugural conference next year in Birmingham. The event will take place on Wednesday March 11, 2020 at the Birmingham Repertory Theatre. The meeting will focus on how to avoid complications, their recognition and management. Tickets are only available to ACE Group members at a cost of £125 and will be on sale via acegroup.online from November 1, 2019.

CYNOSURE UK ANNOUNCES THIRD AESTHETIC EXCHANGE EDUCATIONAL SYMPOSIUM CynoSure UK has announced an upcoming symposium as part of the Aesthetic Exchange educational platform, in collaboration with cosmeceutical brand iS Clinical. Taking place on November 22-23, 2019, Topicals and Lasers: Maximising outcome and income will provide practitioners with the opportunity to attend several in depth seminars, discussions and live demonstrations spanning both face and body indications, led by a panel of industry authorities, internationally-renowned expert speakers and clinical trainers at the King’s Fund, London.

www.aestheticmed.co.uk

Pioneering NHS melanoma test to be available within two years The British Skin Foundation has partially funded research to develop a “pioneering” new melanoma test that predicts whether an early melanoma is likely to spread, or return in people who have previously been diagnosed with the skin cancer. The prognostic AMBLor test, set to be available within two years, was developed by Professor Penny Lovat and Dr Robert Ellis of Newcastle University and is currently seeking approvals. It uses the presence or loss of two biomarkers in the upper layer of the skin to identify a patient’s true risk of melanoma disease progression in the early stages, with the developers predicting that over 70% of new stage 1 melanoma patients will have a more accurate indication of the risk of the disease spreading. Lovat, professor of Cellular Dermatology and Oncology at Newcastle University and chief scientific officer at AMLo Biosciences, the University spin-out company behind the testing kit, commented: “As a patient, the AMBLor test tells you if you’re in the low risk category – and can offer you reassurance. It could also save the NHS up to £38 million a year by reducing the number of follow-up appointments for those identified as low risk.”

WORLD’S FIRST VIRTUAL AESTHETIC CONFERENCE LAUNCHES THIS MONTH The first Global Virtual Aesthetic Summit (GVAS) will take place on November 10 and 11. Held over 48 continuous hours, the conference will allow participants to select their own time zone and language, virtually visit exhibition halls, attend lectures and demonstrations in the auditorium and engage in discussions in the networking lounge, all on their computer or handheld device. The event is organised by Stephen Handisides, founder of MyFaceMyBody.

DR MUNIR SOMJI BECOMES KOL FOR GALDERMA Board certified surgeon Dr Munir Somji has been announced as a Key Opinion Leader (KOL) for global pharmaceutical giant Galderma. Dr Somji is the owner of DrMediSpa cosmetic surgery clinics. He said, “I’m excited to showcase Galderma’s products with new techniques and indications. Having worked with their portfolio for a number of years, I’ve discovered a novel approach to combining the vast Galderma range for optimal patient results.”

Study finds PRP improves melasma A study to assess the effectiveness of platelet-rich plasma (PRP) as a treatment for melasma found that PRP injections can have significant results within six weeks of treatment. The study, published in the Journal of Cosmetic Dermatology in September 2019, is the first randomised, placebo-controlled trial study using PRP for treatment of melasma. Ten female patients with bilateral mixed-type melasma took part in the split-face, single-blinded prospective trial. The participants had PRP injected intra-dermally on one side of the face and normal saline on the other over four treatment sessions that took place every two weeks. Melasma Area and Severity Index (mMASI) scores and Antera3D-assessed melanin levels showed significant improvement in the PRP condition than control condition between baseline and week six, while patient satisfaction significantly increased over time. However, Mexameter-assessed erythema and melanin indices did not significantly differ between the control and PRP conditions, though there was a trend toward reduced pigmentation in the latter. The study concluded that intradermal PRP injection could be used as an alternative or adjuvant therapy for melasma, though additional trials are needed for evaluation of long-term efficacy and safety.

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Step into your future Aesthetic Medicine Live 2020 is the first major industry meeting of the new year, so why not enter the next decade inspired and invigorated by knoweldge, ideas and new treatments for your clinic

020 will see the start of a new decade and, as we move in to the future, Aesthetic Medicine Live is here to help your clinic stay at the cutting edge with more education, exhibitors and launches than ever. Taking place at Olympia London on February 29-March 1, Aesthetic Medicine Live is the first major UK meeting of the year. Encompassing a two-day, two-agenda CPDaccredited clinical conference, a two-day business workshop programme, Live Stage and an ever-growing exhibition displaying market-leading brands, Aesthetic Medicine Live is a must-attend for aesthetic practitioners and business owners. MEET WITH KEY UK MANUFACTURERS AND SUPPLIERS A visit to Aesthetic Medicine Live will give you a chance to meet face-to-face with market-leading manufacturers and suppliers. From injectable products and threads to skincare, body shaping devices and lasers, our exhibitors will be showcasing their latest innovations with many giving free demonstrations on the Live Stage.

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Attending the exhibition will also give you a chance to take advantage of exclusive show offers and deals, which are only available to visitors at the show. Confirmed exhibitors include ABC Lasers, ACUMAG, Advanced Esthetics Solutions, Alliance Pharma, AQ Skin Solutions, Archidemia, Baldan Group, Belle, BestBrothers, BioActiveAesthetics / SkinPen UK, BioID, BTL, Candela, Celluma, Clinic Photopro, Cocoon Medical UK, Cosmetic Insure, Cutera, Cynosure, Dermalux, Enoura Aesthetics, Erchonia Lasers, Fusion GT, Hydrafacial UK, InBody UK, Inmode, Lumenis, Lynton Lasers, Med Aesthetics, mesoestetic (Gold Sponsors), Natura Studios, Observ, Opatra, Pabau, Perfecte’Me, PRP Lab, REVIV, Sky Medic, Sterimedix, Venus Concept, VIVACY and Wisepress. Entry is free if you book in advance at aestheticmed.co.uk/ booktickets or £20 on the door on the day. GOLD SPONSOR

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www.aestheticmed.co.uk BUILD YOUR BUSINESS SKILLS

Our Business Workshop programme gives you access to successful clinic owners and leading business consultants to inspire you to grow and develop your clinic. Topics will include creating a positive business mindset, identifying your key clients and tailoring your marketing to attract them; financial strategies for success and social media and digital marketing.

ENTER THE 2020 VIDEO AWARDS

Following last year’s success, the Aesthetic Medicine Video Awards are back for 2020. Recognising those who have excelled in using the medium of video for training, education, marketing and social media. See page 20 for details.

ACCESS SPECIALIST EDUCATION

Aesthetic Medicine Live will once again be hosting the UK Association of Aesthetic Plastic Surgeons (UKAAPS) SURGEON’S DAY as well as the British Association of Hair Restoration Surgeons (BAHRS) conference. We will also once again be running the Aesthetic Regenerative Medicine Conference in collaboration with Mr Ali Ghanem and Queen Mary University London.

GET CPD-ACCREDITED EDUCATION

Aesthetic Medicine North’s CPD-accredited clinical conference features a comprehensive two-day programme covering the latest trends in clinical practice.

WATCH FREE DEMONSTRATIONS

Watch free demonstrations and hear about the latest innovations and launches from our exhibitors and their key opinion leaders on the Live Stage located on the show floor and accessible to all visitors without booking.

CHAT TO EXHIBITORS

Meet face-to-face with market-leading manufacturers and suppliers. By registering for Aesthetic Medicine Live in advance you can save £20 on the on-the-day entry fee.

DON’T FORGET TO DOWNLOAD THE SHOW APP

To get the most out of the show download our app search exhibitors, products and offers. Stay up to date with the wide range of seminars and other features of the show. Don’t forget to turn on notifications for instant updates. Download the show app at aestheticmed.co.uk/showapp

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AM LIVE 2020

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Stars of the screen Following last year’s success, the Aesthetic Medicine Video Awards are back for 2020. Here’s how you can enter

ideo is one of the most powerful ways to communicate and engage with your audience and its popularity as a marketing medium is continuing to grow. In recognition of this, in 2019 we launched the Aesthetic Medicine Video Awards to acknowledge those who have created the most informative, engaging and well-produced videos to positively promote our sector. Once again there will be five categories for both clinics and brands covering social media, promotional and educational videos.

BEST TRAINING OR EDUCATIONAL VIDEO

Open to clinics, practitioners and brands. Videos must be no longer than five minutes and be for the purposes of training and education for aesthetic practitioners.

BEST SOCIAL MEDIA VIDEO BY A BRAND

Open to manufacturers, suppliers and product distributors. Videos must be no longer than one minute and have been created for social media for the purpose of educating or informing consumers or practitioners.

BEST SOCIAL MEDIA VIDEO BY A CLINIC OR PRACTITIONER

Open to clinics or individual practitioners. Videos must be no longer than one minute and have been created for social

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media for the purpose of educating or informing consumers or peers about the clinic or practitioner.

BEST B2C VIDEO BY A BRAND

Open to manufacturers, suppliers and product distributors. Videos must be no longer than three minutes and and have been created for the purposes of marketing, TV advertising, for use on a website or to be played in clinic receptions to educate consumers about the product or treatment.

BEST B2C VIDEO BY A CLINIC OR PRACTITIONER

Open to clinics or individual practitioners. Videos must be no longer than three minutes and have been created for the purposes of marketing, TV advertising, for use on a website or to be played in a clinic reception to educate the consumer about the clinic or practitioner. To enter, send a We Transfer or dropbox link to your video to entries@aestheticmed.co.uk including your full name and video credits, category you are entering and a short description of who your video is aimed at and what you were aiming to achieve with it. Or you can visit aestheticmed. co.uk and enter online. Entries are now open and will close on December 20, 2019. You can enter any video created and distributed in 2019. AM

Enter at www.aestheticmed.co.uk/videoawards FOLLOW US:

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A world of education Education is at the heart of Aesthetic Medicine Live and this year’s clinical CPD-accredited conference will follow the theme of diversity One of the things that makes aesthetics such an exciting sector to work in is the diverse range of patients the treatments, techniques and procedures can help. This SATURDAY FEBRUARY 29

year’s clinical conference will follow the theme of diversity, examining the different types of patients seeking aesthetic enhancement and how we can help them. SUNDAY MARCH 1

08.30 - 09.30

COFFEE AND REGISTRATION

09.30 – 10.30

SESSION 1 FULL FACIAL REJUVENATION FOR OUR 10.00 – 11.00 CORE MARKET: THE AGEING FEMALE FACE Women aged 35-55 are the core market of most aesthetic clinics, but how do we evolve our treatments and enhance outcomes with the latest techniques?

09.00 - 10.00

Speakers include: Dr Anna Hemming, Dr Arturo Almeida, Dr Sophie Shotter 10.30 – 11.30

SESSION 2 CONSIDERATIONS WHEN TREATING 11.00-12.00 THE MALE FACE The main focus of this session will be creating a natural look and avoiding overfilling to addressing volume loss in the male face without feminising features. Speakers include: Dr Lee Walker and Dr Raul Cetto

COFFEE AND REGISTRATION SESSION 1 TREATING PATIENTS WITH SKIN CONDITIONS The psychological impact of skin disease cannot be underestimated and aesthetic clinics are often on the front line. This session will explore managing skin conditions in clinic. Speakers include: Prof Nick Lowe, Cheryl Barton, Dr Raj Thethi, Anna Baker SESSION 2 TREATING THE FULL SPECTRUM OF SKIN TYPES From how to attract and keep a more diverse clientele by offering skin-type-specific treatments to what not to do to avoid complications when treating different skin types. Invited speakers: Dija Ayodele, Dr Ifeoma Ejikeme

11.30-12.30

12.00-13.00 SESSION 3 THE NEXT GEN: THE ETHICS OF TREATING YOUNGER PATIENTS WITH INJECTABLES Injectable treatments, in particular lip fillers, are becoming more and more popular with younger patients, but what are the ethics of elective treatments in Millennials and Gen Zers? Invited speakers: Sharon Bennett

SESSION 3 TREATING MENOPAUSAL PATIENTS The menopause has an effect on many factors from skin to hormones to intimate regeneration. We look at the role aesthetic clinics have to play. Speakers include: Dr Shirin Lakhani, Dr Martin Kinsella , Dr Sophie Shotter

12.30-14.30

LUNCH BREAK

14.30-15.30

14.30-15.30 SESSION 4 TREATING TRANSGENDER PATIENTS The needs of the transgender community can be very different from the more “traditional” target audience for aesthetics procedures with the approach being to match the outer appearance to their inner identity. Speakers include: Dr Vincent Wong

SESSION 4 HOW CAN WE HELP CLIENTS WITH WEIGHT ISSUES? Effective in-clinic weight loss and body contouring can be enhanced by taking a 360-degree approach. Here we look at the role of diet and nutrition in aesthetics.

15.30-16.30

SESSION 5 THE DIVERSITY OF HUMAN ANATOMY When it comes to avoiding complications, in depth knowledge of anatomy is key. We explore how VR is bringing the world of clinical anatomy into the future and how a one size fits all approach does not work. Speakers include: Mr Dalvi Humzah, Anna Baker

SESSION 5 MENTAL HEALTH MATTERS How do we recognise mental health disorders or underlying problems that may be a contraindication to treatment, and how do we help our patients for whom mental health is an issue? Speakers include: Dr Steve Harris, Mr Max Malik

16.30-17.30

SESSION 6 MANAGING COMPLICATIONS In this final session of the day a panel of speakers will discuss a diverse range of complications and how to manage them. Speakers include: Dr Martyn King, Dr Lee Walker, Dr Raul Cetto, Cheryl Barton, Dr Steve Harris

13.00-14.30

15.03-16.30

Speakers include: Dr Ash Dutta

Conference delegate passes cost £139+VAT for one day and £195+VAT for two days. Price includes entry to the Business Workshops.

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BUSINESS

CLINIC SOFTWARE

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CLINIC SOFTWARE

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Click of a button Teledermatology is leading patient consultations and diagnoses towards the future. We find out how patient and practice management systems are taking inspiration

s the aesthetics industry grows the NHS is struggling more and more to cope with patient demand for assessment and treatment of skin conditions. Enter teledermatology – the latest focus of the developing telemedicine market designed to ease the burden on NHS doctors – who spend three million hours a year assessing skin conditions – that also has potential to be extremely beneficial to aesthetic practitioners. The global teledermatology market is predicted to reach $8.6 billion (approx. £7.5bn) by the end of 2024, expected to expand at a CAGR of 8.7% from 2016. Dedicated teledermatology apps such as Consultant Connect allow practitioners to send high quality patient images or videos securely to specialists for diagnosis, treatment recommendation and patient monitoring. These can also be invaluable learning tools for NHS physicians, providing image quality and supporting notes of a high standard. Meanwhile, skincare sales platform Harley was created specifically to help aesthetic practitioners to develop and maintain a strong relationship with patients through technology, allowing them not only to source products outside of their stock and increase retail sales, but also to create bespoke and detailed skincare regimes remotely. Harley users can set up remote video consultations, either with regular or new patients, prescribe skincare based on their needs with full, tailored usage instructions; and monitor their progress through messaging functionality and repeat orders. Users can also accept consultation charges through the app. We take a look at some of the best new and established clinic management programmes to see how they’re using teledermatology-inspired tech to close the gap between patient and practitioner. >

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BUSINESS

CLINIC SOFTWARE

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CLEVER CLINIC

Newly launched in October, Clever Clinic was developed as a complete, forward-thinking solution to practice management, with a focus on helping practitioners ensure they comply with regulatory requirements. Free to Healthxchange customers and downloadable from the iOS App Store, the platform is custom-built to each user’s requirements with the three principles of patient management at its core – consultation, patient consent and regulatory compliance. Key features include a consultation platform where clinical plans can be fully documented using bespoke visuals, smart consenting with captured signatures and time and date stamps to ensure best practice; automated Healthxchange e-pharmacy orders to almost eliminate admin work, and a booking system with live notifications.

DIGITRX

DigitRx from Church Pharmacy is built to connect prescribers with non-prescribing healthcare practitioners, providing a fast, efficient and secure e-prescribing tool. Partner prescribing on the platform means that payment and delivery is arranged online with secure encryption, eliminating the need to scan, fax or post paperwork. After a face-to-face consultation, the prescriber creates a prescription or stock order and sends it to their HCP partner, who then accesses it from their own account to input payment and delivery details and submit the order. The software is free for both partners and additional helpful features include a 7pm extended cut-off time for evening order processing, amendment tracking between partners, a patient detail import tool and an analytics function to gain insight into the business through automated order pattern charts.

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CLINIC SOFTWARE

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Être Vous is a new platform focused on creating a seamless and aesthetically slick online experience for patients and practitioners alike. It aims to connect consumers with aesthetic procedures and clinical skincare products and convert them into customers, allowing clinics to create a “shop window” for their business free of charge, with access to a library of high-quality images. The EV search engine lets consumers easily find the treatments, experts or clinics they are seeking, landing on editorial content bespoke to each clinic created by the practice’s own experts to educate customers and raise the business’s profile. Member users also have access to EV’s video consultation capability, helping practitioners fill free time by letting them meet a new customer over video. Consultation deposits are paid in advance and bookings can be accrued 24/7. EV also has integrated widget functionality that can link a user’s practice website to collate appointments into one system, linking in with the platform’s business management tools.

PABAU

Used by thousands of practitioners in more than 50 countries, this clinical software system helps with every element of practice management, from electronic invoicing, appointments and online bookings to patient management, marketing and inventory. The platform aims to helps clinics go almost completely paperless to eliminate time spent dealing with paperwork and collate all patient consultation forms in the same place, making them legible and allowing them to be easily updated. Pabau offers to convert new users’ blank medical paper forms into electronic versions to be used on the iPad or iPhone software. Another key feature is the lead management functionality. All website enquiries are captured and the client’s data transferred into the CRM system, making it easier to track and convert potential customers and eliminating the possibility of leads falling through the cracks. AM

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BUSINESS

STARTING OUT

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At the start line Dr Jemma Gewargis gives a dentist’s perspective on starting a career in aesthetics and how to navigate the minefield of training

he aesthetic medicine market is growing exponentially and so it’s an exceptionally exciting time for the industry, with revolutionary products and enhanced techniques being introduced. As such, there is no better time to get involved and diversify your skills in the world of aesthetics, if this is a career path that appeals to you.

WHERE TO START

With so many options of where and how to train, it can feel like navigating a minefield. There are hundreds of introductory courses to choose from and deciding which one is best for you can be difficult. First of all, it is essential to research the industry, what it involves and the different treatments that can be offered. From here, decide what level you’d like to practice at. Are you looking to do a basic course and offer a few treatments, or do you wish to offer a range of treatments at a more advanced level? At this point, there’s understandably still uncertainty and you may be asking yourself questions such as, “Am I ready to commit thousands of pounds towards training if I don’t see this being something I truly enjoy?”; “What if it doesn’t suit my working style or personality?”; “Is there a demand for it in the area I’m working in?” and, “Is the market saturated with competition already?” Attending an aesthetics conference will allow a better insight into what is involved before investing in a course. Here you’ll meet organisers of training courses and get a better idea of what they can offer. You can also look at the different injectable products available and their uses, and there are often lectures given at an introductory level that can give you a better understanding of what starting out in the field involves. I did exactly this – I attended a conference and went to an introductory lecture by Dr Tapan Patel. This sparked my interest, assured me I’d love the profession and provided many excellent tips for starting in the industry.

TRAINING

It is important to consider a range of factors prior to choosing a training course, which I have outlined below. 1. Type of course • Firstly, consider the level the course is aimed at and ensure it is for medical professionals • Consider the duration of training – is the training over a day, weekend or multiple course dates? • How much theory and practical is involved and is prior learning provided? • Is the level of training a basic introductory course, advanced training, comprehensive Level 7 training or a University Masters degree? • What specific treatment areas are covered – upper/mid/ lower face. 2. Course support • Is pre- and post-course support provided? • What is the course delegate to trainer ratio? • What is the trainer’s level of expertise and years training? 3. Learning • What treatment areas covered? • What techniques are used e.g. cannula and needle? • Are indications, contraindications, consent and photography covered? • Does it cover different brands and densities of filler? • Does it cover different types of botulinum toxin and dilution protocols? • Does it cover management of complications such as vascular occlusion, including the dilution and use of hyaluronidase? • Will you learn about patient expectation management and post-care advice? • Does it include learning on marketing and advertising?

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BUSINESS

STARTING OUT

aestheticmed.co.uk

CONFERENCES & NETWORKING

There are multiple opportunities throughout the year to get involved in conferences and exhibitions which are a great opportunity to learn and network with like-minded professionals. Aesthetic Medicine Live is a brilliant annual aesthetic show at Olympia London which brings together a huge range of exhibitors and products under one roof. This is a fantastic chance to educate yourself, meet other professionals in the field and explore what new products are on the market. You can also listen to world-class speakers give lectures and demonstrations, which are invaluable to improving your own knowledge and techniques. Through networking, I have received invites to attend the Merz Expert Summit UK and Allergan Spark Conferences. These events were fantastic for developing my knowledge further and networking with world-class practitioners. Get in touch with your local representatives in your area for the products you are using too, as they can provide promotional materials and help with training opportunities.

SOCIAL MEDIA

There are more than three billion active monthly users on Facebook and Instagram. They have become powerful ways to engage with current and new clients as well as to network with other professional and product representatives. Using social media works both ways. Firstly, you can use it to keep up to date with different approaches to treatments and learn about new products on the market. Secondly, it can be used as an effective advertising tool to target your local customer base and is a very useful way to inform both current and potential clientele about the procedures you offer and to demonstrate your knowledge, which builds trust. As an effective means of showing your work, it does require time and effort to be put in – I suggest allocating a few hours per week to preparing content and brainstorming ideas for the following week. As with anything, consistency is key here.

sector to help support career development in aesthetics, with lots of member discounts and an aesthetics sector jobs board with some exclusive roles only visible to members. It’s free to register and very accessible for those early in their aesthetic careers.

ONGOING LEARNING

Ongoing CPD and learning is critical in the healthcare industry, and this doesn’t exclude the aesthetics field. Subscription to a reputable and educational magazine, such as Aesthetic Medicine, allows you to keep at the forefront of the latest developments in products and techniques. It also gives you information on upcoming events to sign up early for.

DENTISTRY AND FACIAL AESTHETICS

From a personal perspective, the fusion of cosmetic dentistry and facial aesthetics has been a seamless experience. The skillset of injecting and using fine instruments is built into the muscle memory of a dentist and is applicable to the techniques used in aesthetics. A foundation of in-depth anatomical knowledge studied at university for five years with cadaveric dissection of the head and neck supported the knowledge needed in treating the face. Dentists have strong clinical knowledge of the layers of the soft tissues and

With so many options of where and how to train, it can feel like navigating a minefield

JOB OPPORTUNITIES

As a dentist I already had a patient base, so, depending on your current working environment, once you have trained and become confident in your skills, you can begin to advertise your services to existing patients too. If you don’t already have an existing database, you will have to work on building a client list. Either way, I believe it is important to establish rapport with an experienced practitioner you can trust to mentor you through your career. I have found Total Aesthetics to be incredibly invaluable to kick-starting my aesthetics career. It is one of the available options in the

skeletal bony structures as well as the positioning of teeth and jaw as the face ages. Consideration of the aesthetic proportions as well as exceptional attention to detail is fundamental to the skill of a dentist and is highly applicable to facial aesthetic treatments. Together, enhancing a smile and an aesthetic treatment of the face can work in harmony to massively impact a patient’s confidence, with life-changing results, which is what excites me the most about combining the two. AM

Dr Jemma Gewargis is a cosmetic dentist and aesthetic practitioner, splitting her time between two private dental practices and an aesthetic skin clinic in West London. She is passionate about learning and developing her skills in the field of aesthetic medicine. She can be reached on Instagram: @dr.jemma.g and by email: info@drjemma.com

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BUSINESS

LEGAL

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Under cover It’s not only patient confidentiality that could be at stake by employees making covert recordings, says employment law expert Tina Chander

n the past decade, the issue of covert recording within the workplace has become a serious problem, especially within the aesthetics industry where strict patient confidentiality rules are in place. While using underhand methods to record conversations would usually be considered a serious breach of privacy, a recent judgement handed down by the Employment Appeal Tribunal (EAT) has clarified that it may be acceptable in the most pressing of circumstances. Although discouraged by businesses, the availability of voice recording technology makes it very difficult to prevent entirely, so it is crucial that steps are taken to protect the company and its employees should an incident come to light.

This judgment was held in relation to the case Phoenix House v Stockman, whereby the claimant disclosed, during her successful unfair dismissal claim, a covert recording she had made during her employment. However, in this case, the nature of the recording was deemed too important to ignore and was accepted, despite the employer contending that her compensation should be reduced to reflect her pre-dismissal conduct in making the recording. This shows that despite the practice being discouraged, businesses could still be put at risk if the issue is serious.

If an individual intends to record a conversation, then they should inform all parties that communications are on the record

DOES COVERT RECORDING EQUAL IMMEDIATE MISCONDUCT?

Within the EAT’s judgement, it was agreed that making a covert recording at work would normally be classed as misconduct.

CONTEXT IS KEY

If an individual intends to record a conversation, then they should inform all parties first, making them aware that communications are on the record. There are two common scenarios that most employers would be faced with. The first is an individual using covert recording to prove misconduct by others, where an employee will secretly record a conversation to try and catch the culprit red-handed by obtaining a recording >

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of the offending behaviour, whether it be a distasteful joke or unkind comment, for example. Such evidence will often be used to prove accusations of discrimination or inappropriate behaviour, and although the employer may not condone the covert nature of the recording, its substance cannot be overlooked, particularly if the allegations are serious. In this case, it is the responsibility of the employer to investigate the matter, with a view to taking disciplinary action if necessary. The other scenario is where an individual has secretly recorded internal management processes, such as appraisals or grievance hearings, with a view to using evidence gathered this way during an employment tribunal or appeal. Although covertly recording a formal meeting may be viewed as less intrusive than normal work interactions, it is still considered misconduct if participants have not consented beforehand.

WHAT THE LEGISLATION SAYS

Of course, this acknowledgment of contractual agreements is balanced against any special circumstances, which could potentially overrule an accusation of misconduct.

PROTECTING YOUR BUSINESS

It’s important to make staff aware that covert recordings will seriously undermine trust between individuals. Take the time to create clear policies prohibiting such actions and make it clear that dismissal could be the ultimate consequence. While implementing such a policy will improve transparency throughout the business, it should be worded carefully, bearing in mind the practicality of gaining consent during informal social settings with colleagues. It’s also advisable to remind managers of their responsibilities, encouraging them to avoid saying anything that may suggest bad faith, even if it was taken out of context. If a serious accusation does come to light act quickly and efficiently, taking the necessary steps to resolve the issue without prolonging the dispute. If you’re unsure about the best course of action to take regarding covert recordings, contact an experienced team of lawyers for advice. AM

Covert recording in the workplace is an issue covered by data protection laws and internal contracts

Covert recording in the workplace is an issue covered by data protection laws and internal contracts. Recording a conversation would likely constitute the collection of ‘personal data’ under the new General Data Protection Regulation 2018 (GDPR), meaning the person who made the recording must comply with rules in relation to storage of the data. However, it remains unclear whether an individual would face strict penalties for a breach, whereas an employer could expect substantial fines for not handling data appropriately. Meanwhile, the subject of the recording may claim that their right to a private life under the Human Rights Act has been infringed, which could be applied to the workplace. Despite these legislative implications, employment tribunals have the discretion to decide whether a covert recording should be admitted as evidence, so it is important that employers and employees are aware of the potential risks.

CONTRACTUAL POINTS

From a contractual perspective, making a covert recording can have serious implications if it’s in direct violation of preestablished principles. Within most workplaces there is an obligation of trust and confidence between employees and employers, and secretly recording colleagues could qualify as a serious breach of contract. The underhand nature of secret recordings is likely to cause friction internally, straining relationships throughout the business and damaging them indefinitely. For this reason, most employers openly express prohibition on such practices, creating policies and principles that warn staff and make such actions a disciplinary offence.

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Tina Chander is a partner and head of the employment team at Midlands-based law firm Wright Hassall. She deals with contentious and non-contentious employment law issues, acting for employers of all sizes and advising in connection with all aspects of employment tribunal proceedings and appeals.

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BUSINESS

DIGITAL MARKETING

aestheticmed.co.uk

Count the cost Laura Moxham explores the question, how much is Google Ads going to cost my clinic?

n the September edition of Aesthetic Medicine I explained the principles of Google Ads, so do have a read if you haven’t already. In that article, we looked at what Google Ads is and how it could work to be a ‘sales machine’ for your clinic – potentially attracting new patient enquiries on tap every day. However, Google Ads is not for everyone. Having spoken to hundreds of businesses, a typical question is: “How much should I spend on Google Ads?”

KNOW THE NUMBERS

Just imagine that for every £1 you invested in Google you received £2 to your clinic. That would be the holy grail – you’d be paying that all day every day, right? According to Google’s Economic Impact Report, that’s exactly what Google Ads can do for a business. Surely then, the question of how much it’s going to cost is simple? Well, unfortunately, it’s not. The secret to

being successful with Google Ads (or any other marketing for that matter) is knowing your numbers. So my advice is to do this first, before you embark on any marketing activity. Knowing the numbers makes your marketing, whether that be Google Ads or not, highly accountable. So rather than thinking: “I’ve heard Google Ads is great for getting new customers; let’s give it a go”, we’re now thinking, “How much do I need to invest to achieve my goal?” This will enter you into goal-based marketing with transparency. These figures will enable you to have more control over what ‘good’ looks like with your marketing. You just need to work out how much you would need to invest to achieve the outcome or goal for your clinic over a given period of testing time. So many marketing activities, and in particular Google Ads campaigns, fail because there are no clear goals. The

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BUSINESS

DIGITAL MARKETING

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most successful campaigns we’ve seen are those with clear goals to aim to achieve. With regards to the numbers, at my marketing agency YBA PPC when have our first strategy session with a new client, we ask two key questions: 1. How many new patients or customers do you want? 2. How much are you willing to pay per new patient enquiry? There are no magical figures here. No right or wrong. It will depend where you want to take your clinic – how fast or how slow the growth – and should ideally come from your business goals. It’s about knowing your numbers and making a conscious thought process in relation to your marketing. Let’s say you want 10 new patients per month and you’re prepared to spend £200 per patient as you know they’ll spend £1,000 over their lifetime with you, then your goal would be to spend £2,000 per month to achieve the 10 new patient enquiries. Knowing these numbers from the outset will allow you to review the return on investment, not the ‘cost’ to your clinic. There’s a big difference. For example the ‘cost’ is £2,000 spend but your ‘return’ is £10,000 revenue to the clinic. It can be the case that for some clinics they don’t make a profit on the first appointment. It’s really important to consider the spend over a period of time with this patient.

Before you embark on any marketing activity, my advice is to know the numbers

NOW FOR THE FUN PART

Once you know these numbers, then the fun can start. You’ve decided how much budget you want to spend and what you want to achieve with it, now we need to assess if it is possible to achieve with Google Ads. But here’s the kicker – every clinic advertising on Google is going to be slightly different. From the geographical area they cover, to the treatments they offer and how effective (or not) their website is. The list goes on. Sadly there’s no one-size-fits-all answer to whether your ad spend budget will achieve your goal. It depends on so many factors. Here’s my top three success factors to consider before embarking on your Google Ads campaign:

But don’t fall into the trap of widening out the area your ads are shown, as this can often cause wastage in your account. What we found is people will click on your ads, but are unlikely to become customers as they won’t travel outside their home town for the treatment. If you offer specialist treatments, or if your clinic is particularly sought after, you will find that people are happy to travel further afield and therefore you can confidently show your ads to a wider geographical area. I recommend playing around with Google’s Keyword Planner Tool to assess how many people are searching for the treatments you offer in the areas you cover. >

1. Are there enough people searching online for the treatments you offer? Sounds obvious, but if you only offer a few treatments then you have limitations in the number of people searching on Google. And Google in some situations won’t show your ads if there’s too few people searching. If you have a wide range of treatments, this will of course help as it will increase the number of people searching, and the number of new enquiries you could attract. Geography is another consideration here – if you have one clinic in a small local town, you will be restricted by the number of people searching for the treatments you offer and again your ads may not run because there’s simply not enough people searching for Google to show them.

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BUSINESS

DIGITAL MARKETING

2. How well does your website convert? You could have the best Google Ads campaign setup in history. It would be driving the perfect potential clients to your website for exactly what you offer, but if your website doesn’t inspire that person to call and take the next step it’s very much wasted effort and expense. Don’t get me wrong, the purpose of Google Ads is not to make the sale, but to take the prospect to the next step of the buying process. Its objective is to get them to take action – either to call the clinic to enquire, fill out a form for a call-back or to engage on Live Chat, whatever is appropriate for your clinic. Make sure your website and inner landing pages have a strong call to action that encourages the prospect to take the next step.

they aren’t working. The best advice is to do a search – type in the treatment you offer plus the town you are offering it in and see what your competitor’s ads say. It might be an introductory offer, or that they have free parking, or that their clinic is award-winning. You don’t have to be cheaper than your competition, just more appealing to click on. As you can tell, there’s a lot of different factors to consider before embarking on Google Ads. It is important not to forget that this is marketing and absolutely nothing is guaranteed but everything is to play for. When you first start out with your Google Ads campaign, it is possible for it to be immediately profitable, but don’t expect this to be the case. Instead, you should review your goals, have an agreed test period, and sit tight to tweak and improve it through to its success. After all, if it was that easy everyone would be doing it. You’re investing in the long term – to create a sales machine that repeatably and reliably brings you leads on tap.

3. Why chose your clinic? Again, you could have the best ad campaigns set up, but unless the ads you show are more appealing than your competitors, you’re likely to become frustrated that

YBA PPC is offering a free 20-minute strategy session for Aesthetics Medicine readers with Laura Moxham. . Simply email team@ybappc.co.uk quoting ‘Aesthetic Medicine Magazine November 19.’ AM

If you’d like to know more about how this works, email laura@yourbusinessangels.co.uk. I’m very happy to help guide you through this.

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aestheticmed.co.uk

Laura Moxham is an expert in internet marketing for Google Ads and PPC. She is the managing director of boutique agency YBA PPC, which is recognised as being in the top 3% of agencies within Europe and has been shortlisted in the ‘Best for Growing Businesses Online’ category in the Google Premier Partner awards, due to its high-calibre results from Google Ads.

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introducing

the neXT generation of HydraFacial™ MD Elite™

THE ELITE™ IS THE brand new HYDRFACIAL SYSTEM WITH unique ADVANCEMENTS TO ENSURE YOUR SUCCESS. With an enhanced user interface, LED light therapy, mechanical lymphatic drainage and a Perk delivery switch as standard... Personalised skin health has never been easier.

for more information on the brand new elite: Tel: 01788 572 007 email: info@hydrateyourbusiness.co.uk HydraFacial UK is now a direct business and part of the global HydraFacial Company bringing you the same high level of customer service, combined with the benefits of greater brand visibility, more investment and the increased support that comes from being part of world wide business.

BUSINESS

EMPLOYMENT

aestheticmed.co.uk

Position vacant

Victoria Vilas on promoting a vacancy at your clinic

hen a position becomes vacant at your clinic, you may have already identified a member of your team who is ready for promotion and is a perfect fit for the role. But do you have a legal obligation to advertise the role? Must your vacancies be advertised internally, circulated within your team, and also advertised externally, so they are displayed publicly? What guidelines should you follow to ensure that your hiring process is fair and in line with employment law?

Q: I HAVE A VACANCY AT MY CLINIC, WHAT LEGAL REQUIREMENTS ARE THERE FOR ADVERTISING THE ROLE?

A job advert should be carefully drafted so it does not appear discriminatory

When you are hiring, it is your legal obligation to ensure that you do not use advertising content or methods that could be seen to exclude certain groups of people due to their age, gender, sexual orientation, belief, race, or disability, as you could be accused of discrimination. The content of a job advert should be carefully drafted so it does not appear discriminatory. You should not specify a

preferred age or gender, for example. But, it is not just the content of a job advert that could be seen as discriminatory. If you choose to advertise your role in a way that makes it accessible to only a certain group of people, and excludes others, your method could be seen as discriminatory, not just your choice of language. For example, if you are looking for a doctor for your clinic, and only spread the word to male doctors you know, it may look as if you are excluding female doctors from your hiring process.

Q: DO I NEED TO ADVERTISE IF I ALREADY HAVE SOMEONE IN MIND?

There is no legal requirement to advertise a vacancy at your clinic, so the decision to advertise can be based on your recruitment needs. You do have an obligation to ensure that your hiring process is fair, and that you are choosing the best person for the job after adhering to your selection criteria. It is fine to promote an employee instead of advertising and considering external applicants, but your decision should be based on merit and suitability and not on familiarity or favouritism.

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EMPLOYMENT

aestheticmed.co.uk

Though you are not obliged to advertise, there may be some advantages if you do. If you receive external applications, you may have a greater number of candidates to consider for your role and these may be talented workers you were previously unaware of. Even if you already have someone capable in mind, it may be useful to compare their skills and abilities to those of other candidates, so you can feel assured that you are making an informed decision.

Q: IT IS ESSENTIAL TO ADVERTISE A VACANCY BOTH INTERNALLY AND EXTERNALLY?

If you are advertising the vacancy at your clinic, you can choose whether to advertise internally or externally, or opt for both, there is no legal requirement to advertise a vacancy to both external and internal applicants. There are advantages and disadvantages to both methods. If you advertise internally first and find a suitable candidate from your employees, you could avoid the costs associated with a recruitment campaign. You may miss out on excellent external candidates though. If you advertise externally, you may be promoting your vacancy to a wider audience, but you will have to pay a fee to advertise online, and you may have to spend time sifting through a number of poor applications.

Q: WHERE IS IT BEST FOR ME TO PROMOTE MY VACANCY?

Job board websites that feature a high number of jobs from a wide range of industries, such as Reed, Indeed, and Totaljobs, attract a high number of job seekers. Advertising a vacancy on such platforms is likely to generate a good

response from applicants, but you may have to sift through many emails from candidates who aren’t a good match for your role. Advertising on your own clinic website may be more targeted, but you are likely to receive a lower number of applications as many job seekers may not be aware of your ‘careers’ page. Job board websites that list thousands of vacancies rank highly in search engine results when job seekers search online, and you may simply not be able to compete on SEO with the one careers page on your own clinic website. If you wish to alert your employees to your vacancy, you may not need an advert as such, as you could announce the opportunity at a team meeting. You could also circulate the full job specification, so your employees are fully informed on whether their skills and experience are a good match for the requirements of the role, and can decide whether the job is of interest to them. As you are likely to already hold a copy of employee CVs, you could instead ask your internal applicants to apply by answering some preliminary screening questions, to give you information on why they would like to apply for such a role and why they feel they would be the best candidate. Wherever you choose to advertise internally or externally, or both, just make sure that you have planned your selection criteria in advance, so when you receive your applications, you can be fair and efficient when processing them and deciding on your final candidate shortlist.

FURTHER READING

ACAS: https://beta.acas.org.uk/hiring-someone/

Victoria Vilas is marketing and operations manager at ARC, an aesthetics recruitment consultancy. The ARC team helps organisations in the industry grow their businesses by hiring the most talented aesthetic professionals.

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BUSINESS

ASK THE EXPERT

aestheticmed.co.uk

Ask the expert How do I keep my costs down when advertising my Facebook page?

o matter how much you plan your content, you’ll never be able to reach your Facebook page’s entire audience in one go. Reports show the “organic reach” of posts on Facebook is usually 7%, meaning non-paid-for content only appears in the newsfeed of 7% of the people who “like” your page. To reach a wider audience, you’ll need to consider using Facebook Ads. The good news is that ads aren’t as scary or costly as you might think, especially if you know the tips and tricks going in. As with anything on social media, you need to have a clear goal in mind before you start a Facebook Ads campaign. While there are plenty of campaign options to choose from, here are three types that are simple to use and often are the most effective. 1. Brand Awareness: This campaign is designed to make users more generally aware of your Facebook page. Facebook’s algorithm places your adverts strategically across the website, increasing the likelihood that customers will take notice of your page. 2. Engagement: There are a number of options when you choose an engagement campaign. This can be great if you’re just starting your page, as you’re given an option for “page likes”. Increasing the number of people who like your page will mean that while the percentage for organic reach of content remains low, you’re still reaching more people. 3. Traffic: If you’ve got a great website, then this is what you want to use. Traffic adverts help direct people from

your Facebook page through to your site. Make sure the advert matches with your website experience to ensure a smooth customer journey.

KEY TIPS FOR YOUR FIRST ADVERT

Once you’ve chosen which type of campaign you want to use, you’re then able to choose your audience, based on a number of demographics – use your Facebook Insights to help guide you. Once you’ve chosen your target audience, it’s time to make the advert. Here are some quick wins that will help your first ad be a success. • Use high-quality images, unique to your business. Facebook Ads allow you to use more than one single image, either as multiple images in one post or as a slideshow. Take your customers on a journey through your clinic, or show off your treatment results. • The first 90 characters in your advert are key. Mobile is the highest source of traffic on Facebook, but adverts tend to be cut down to the first 90 characters on these devices. Be concise and lead with your key selling point or message to ensure the best response. • Choose your placements. Facebook suggests automatic placements as “recommended” but in reality, this just means Facebook puts your ads in places people tend not to look. Always choose to “edit placements” and restrict it just to Facebook (and possibly Instagram, if you’ve got some really great images). AM

Chris Halpin is social media editor for Aesthetic Medicine and Professional Beauty Group. He is experienced in digital marketing marketing and specialises in pay-per-click, SEO and social media management.

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A PARTNERSHIP YOU CAN COUNT ON CELEBRATING OUR 10TH ANNIVERSARY IN AESTHETIC TREATMENTS As your trusted partner in aesthetics, Azzalure is a truly global toxin approved in 72 countries with 40 million glabellar line treatments in Europe and the United States alone.1,2 Here’s to another decade of natural-looking results and high patient satisfaction.3

Azzalure Prescribing Information (UK & IRE) Presentation: Botulinum toxin type A (Clostridium botulinum toxin A haemagglutinin complex) 125 Speywood units of reconstituted solution (powder for solution for injection) Indications: Temporary improvement in appearance of moderate to severe: • Glabellar lines seen at maximum frown, and/or • lateral canthal lines (crow’s feet lines) seen at maximum smile in adult patients under 65 years, when severity of these lines has an important psychological impact on the patient. Dosage & Administration: Azzalure should only be administered by physicians with appropriate qualifications and expertise in this treatment and having the required equipment. Botulinum toxin units are different depending on the medicinal products. Speywood units are specific to this preparation and are not interchangeable with other botulinum toxins. Reconstitute prior to injection. Intramuscular injections should be performed using a sterile suitable gauge needle. Glabellar lines: recommended dose is 50 Speywood units divided equally into 5 injection sites, 10 Speywood units to be administered intramuscularly, at right angles to the skin; 2 injections into each corrugator muscle and one into the procerus muscle near the nasofrontal angle. Lateral canthal lines: recommended dose per side is 30 Speywood units divided into 3 injection sites; 10 Speywood units to be administered intramuscularly into each injection point, injected lateral (20 - 30° angle) to the skin and very superficial. All injection points should be at the external part of the orbicularis oculi muscle and sufficiently far from the orbital rim (approximately 1 - 2 cm); (See summary of product characteristics for full technique). Treatment interval should not be more frequent than every three months. The efficacy and safety of repeat injections of Azzalure has been evaluated in Glabellar lines up to 24 months and up to 8 repeat treatment cycles and for Lateral Canthal lines up to 12 months and up to 5 repeat treatment cycles. Not recommended for use in individuals under 18 years of age. Contraindications: In individuals with hypersensitivity to botulinum toxin A or to any of the excipients. In the presence of infection at the proposed injection sites, myasthenia gravis, Eaton Lambert Syndrome or amyotrophic lateral sclerosis. Special warnings and precautions for use: Care should be taken to ensure that Azzalure is not injected into a blood vessel. Use with caution in patients with a risk of, or clinical evidence of, marked defective neuro-muscular transmission, in the presence of inflammation at the proposed injection site(s) or when the targeted muscle shows excessive weakness or atrophy. Patients treated with therapeutic doses may experience exaggerated muscle weakness. Not recommended in patients with history of dysphagia, aspiration or with prolonged bleeding time. Seek immediate medical care if swallowing, speech or respiratory difficulties arise. Facial asymmetry, ptosis, excessive dermatochalasis, scarring and any alterations to facial anatomy, as a result of previous surgical interventions should be taken into consideration prior to injection. Injections at more frequent intervals/higher doses can increase the risk of antibody formation. Avoid administering different botulinum neurotoxins during the course of treatment with Azzalure. To be used for one single patient treatment only during a single session. There is a potential risk of localised muscle weakness or visual disturbances linked with the use of this medicinal product which may temporarily impair the ability to drive or operate machinery. Interactions: Concomitant treatment with aminoglycosides or

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other agents interfering with neuromuscular transmission (e.g. curare-like agents) may potentiate effect of botulinum toxin. Pregnancy, Lactation & Fertility: Not to be used during pregnancy or lactation. There are no clinical data from the use of Azzalure on fertility. There is no evidence of direct effect of Azzalure on fertility in animal studies. Side Effects: Most frequently occurring related reactions are headache and injection site reactions for glabellar lines and; headache, injection site reactions and eyelid oedema for lateral canthal lines. Generally treatment/injection technique related reactions occur within first week following injection and are transient. Undesirable effects may be related to the active substance, the injection procedure, or a combination of both. For glabellar lines: Very Common (≥ 1/10): Headache, Injection site reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, pain, discomfort, stinging and haematoma). Common (≥ 1/100 to < 1/10): Temporary facial paresis (due to temporary paresis of facial muscles proximal to injection sites, predominantly describes brow paresis), Asthenopia, Eyelid ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching (twitching of muscles around the eyes). Uncommon (≥ 1/1,000 to <1/100): Dizziness, Visual impairment, Vision blurred, Diplopia, Pruritus, Rash, Hypersensitivity, Eye movement disorder. Rare (≥ 1/10,000 to < 1/1,000): Urticaria. For lateral canthal lines: Common (≥ 1/100 to < 1/10): Headache, Temporary facial paresis (due to temporary paresis of facial muscles proximal to injection sites), Eyelid ptosis, Eyelid oedema and Injection site disorders (e.g. haematoma, pruritus and oedema). Uncommon (≥ 1/1,000 to <1/100): Dry eye. Adverse reactions resulting from distribution of the effects of the toxin to sites remote from the site of injection have been very rarely reported with botulinum toxin (excessive muscle weakness, dysphagia, aspiration pneumonia with fatal outcome in some cases). Prescribers should consult the summary of product characteristics in relation to other side effects. Packaging Quantities & Cost: UK 1 Vial Pack (1 x 125u) £64.00 (RRP), 2 Vial Pack (2 x 125u) £128.00 (RRP), IRE 1 Vial Pack (1 x 125u) €93.50, 2 Vial Pack (2 x 125u) €187.05 (RRP) Marketing Authorisation Number: PL 06958/0031 (UK), PA 1613/001/001 (IRE) Legal Category: POM Further Information is Available From: Galderma (UK) Limited, Meridien House, 69-71 Clarendon Road, Watford, Herts. WD17 1DS, UK. Tel: +44 (0) 1923 208950 Fax: +44 (0) 1923 208998 Date of Revision: September 2018 Adverse events should be reported. For the UK, Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. For Ireland, Suspected adverse events can be reported via HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517. Website: www.hpra.ie; E-mail: medsafety@hpra.ie. Adverse events should also be reported to Galderma (UK) Ltd. References: 1. Azzalure SPC 2018. 2. Data on File MA-39613. 3. Molina B et al. J Eur Acad Dermatol Venereol 2015;29(7):1382–8. Date of Preparation: April 2019 Job code: AZZ19-03-0018a

25/10/2019 12:46

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

AlumierMD

Ever after AlumierMDs’ EverActiveTM + Peptide serum conquers the challenges of vitamin C efficacy in aesthetic skincare

itamin C in the form of L-ascorbic acid (LAA) has long been a staple ingredient in cosmetic dermatology, due to its widely proven ability to defend the skin against free radical damage while targeting the pathology behind common conditions. There are many reasons why LAA might not reach the skin in an active state. Delivering fresh and active LAA is one of the greatest challenges for cosmetic scientists, as it is only possible when a number of components are in alignment. The physicians and biochemists at AlumierMD have more than 100 years combined experience in cosmetic science and, despite the high number of vitamin C serums available on the market, were not satisfied that patients were receiving the best possible outcomes from current formulations. Imagine offering active, pharmaceutical grade LAA at its therapeutic dose of 15% in a formula which maintains its stability throughout the entire period of use by your patient, protecting the DNA of fibroblasts and upregulating collagen I and III synthesis, all while down-regulating melanogenesis and inflammation. One of the reasons LAA serums are not currently reaching their potential is related to the large long-term use bottles they are stored in. The extended periods in which the LAA is in contact with its water-based solution and repeated exposure to air and light with every application allows the LAA to oxidize and lose efficacy. What if those challenges could be overcome by combining scientific knowledge, state-of-the-art technology and an unwavering commitment to patient outcomes? Enter EverActive C&ETM + Peptide serum by AlumierMD, the product of tireless research and development by the AlumierMD scientific committee. Determined to triumph over the challenge of formulating with the notoriously fragile LAA, they have moved the medical aesthetics industry forward with their pioneering technology in vitamin C activation. Precisely 2.7 grams of powdered LAA is suspended in an airtight cap above each of the three 15ml serum bottles until the patient activates the LAA by mixing it with the serum at home.

Sandford Lane, VP of engineering at AlumierMD, says, “None of the packaging in existence provides a large enough chamber for the amount of L-ascorbic acid crystals needed to achieve the 15% dose that we were not willing to compromise on. “The EverActive C&ETM + Peptide Serum development took over two and a half years. After facing the challenge of finding an eco-friendly material for the cap, we had further phases including design, compatibility testing and troubleshooting across five prototypes.” For the benefits of your patients, AlumierMD’s efforts were worth it. EverActive C&ETM + Peptide serum has conquered vitamin C formulation challenges and has been described as nothing short of a scientific break-through for our industry. For more information and stockists, please visit www.alumiermd.co.uk AlumierMD’s EverActive C&E launched UK wide in September 2018 RRP: £149.00

uk.enquiries@alumierlabs.com | alumiermd.co.uk | @alumiermduk

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S K I N / D E R M AT O L O G Y

ACNE PIGMENTATION

aestheticmed.co.uk

Fade away Post-acne scarring can be just as difficult to tackle as acne itself. Amanda Pauley and Georgia Seago get advice on the ultimate treatment plan.

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S K I N / D E R M AT O L O G Y

ACNE PIGMENTATION

aestheticmed.co.uk

ecent research from the British Skin Foundation found that nine out of 10 dermatologists agree that not enough importance is placed on the psychological impact skin conditions can have. In particular, the physical and mental marks left by acne are a big concern. Separate findings collated from sources including the Happiness Research Institute and the British Journal of Dermatology has shown the impact acne can have on an adult’s quality of life, with 44% of people with the condition now suffering with at least one mental health condition. It’s easy to understand patients’ frustrations when they think they’ve reached the end of their skin health marathon, finally getting acne under control, to then be presented with the long-lasting after effects – stubborn red marks, discolouration and scars. “The number of clients I’ve seen who tell me they’ve been everywhere and tried everything, and that doctors and skin therapists have told them they might just have to live with it, is astonishing,” says Pamela Marshall, clinical aesthetician and co-founder of Mortar & Milk in Fulham, London. “[The industry] needs to be doing more.” Patients need to be educated on the causes and differences between postinflammatory hyperpigmentation and acne scars, and how these conditions can be managed with different treatment approaches from a trusted professional.

“In clinic, we often start with a lower pH peel and give clients products to use at home to increase skin hydration and barrier function, then we move on to microneedling, which is excellent for forcing skin to remodel itself by building new collagen and elastin,” says Marshall. “I also tell clients not to use AHAs more than once or twice a week because used too often they can interfere with a healthy skin barrier function, causing inflammation.” In terms of the best ingredients to recommend patients use topically, actives such as vitamin C, alpha-arbutin and kojic, mandelic and azelaic acids all have beneficial effects, says Dr David Jack, aesthetic doctor and ambassador of devices brand InMode UK. He adds: “Prescription grade ingredients, such as hydroquinone and stronger retinols, can decrease production of melanin so are probably the most commonly prescribed ingredients for post-acne hyperpigmentation.” It’s a good idea to take photos of your patient at every step of their treatment journey, so you can show them their progress if they’re feeling disheartened with the speed of the results. “Clients look at themselves in the mirror every day so they don’t always take into account the changes that are occurring,” adds Ayodele. “Having these photos in your arsenal means you can show them exactly how much they’ve progressed, while explaining that if the condition took X amount of time to form then it will take time to clear. It’s about managing expectations. Don’t promise flawlessness, promise to improve the appearance of their condition.”

People with bad acne scars can feel very selfconscious and often end up going to great lengths to hide them

POST-ACNE HYPERPIGMENTATION – CAUSES

Patients are likely to think hyperpigmentation is the same as a scar. “Post-inflammatory hyperpigmentation (PIH) comes from inflammation in the skin,” says Marshall. “When the skin is wounded, with an acne spot for example, it inflames and triggers melanocyte production, which can lead to excessive melanin coming to the surface, causing those dark or red marks.” Because melanin can also spread to the surrounding area near the injury, it doesn’t matter how small or inconsequential the spot is, it has the potential to leave behind a larger mark after the infection has cleared, which could linger for weeks, months or even years. It’s also important to know that darker Fitzpatrick skin types have a higher propensity for increased melanin production when wounded, which means post-acne hyperpigmentation is much more common in clients of colour. “We all have a similar amount of melanin but in darker skin tones the melanocyte cells are bigger and more active, which is why these clients will hyperpigment more as a result,” says Dija Ayodele, founder of Black Skin Directory, an online resource connecting patients of colour to expert skincare professionals in the UK.

ACNE SCARRING – CAUSES

Adult acne can also leave scars, which most commonly occur when nodules and cysts burst and damage the nearby skin, or when patients exasperate the problem by picking. Marshall explains, “Atrophic or indented scarring happens when acne spots are picked at and the skin doesn’t produce enough fibroblasts to heal properly. Meanwhile postinflammatory hyper-pigmentation scarring is not indented but comes from increased melanin production in the skin. >

TREATMENT OPTIONS

While post-acne hyperpigmentation can naturally fade over time, how quickly varies from person to person. A treatment and homecare routine that helps patients achieve skin health will aid the process, using the right ingredients to boost cell turnover without causing excessive inflammation or damage to the skin’s barrier function.

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S K I N / D E R M AT O L O G Y

ACNE PIGMENTATION

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“Both come down to how our skin heals postinflammation. When our skin is inflamed, we release arachidonic acid, which is the ‘director’ of our healing mechanism. When the skin is compromised (i.e. not hydrated well) its healing mechanism will be compromised and can cause both atrophic scarring and PIH.” The most common types of acne scar are ice picks, which appear as small, deep holes that look like the skin has been punctured with a sharp object; boxcar, round or oval depressions or craters; and rolling, caused by bands of scar tissue that form under the skin, giving it an uneven, ‘rolling’ appearance. “People with bad acne scars can feel very self-conscious and often end up going to great lengths to hide them. The situation can be made worse if that person feels like they are being stared at,” says Esther Fieldgrass, founder of clinic chain EF Medispa. “Therefore, you need to communicate a realistic outcome, which you always aim to, but can never promise to exceed.”

to rebuild the dermal scaffolding and plump out the skin, being mindful of the patient’s skin type and medical history, including contraindications like keloid scarring. Marshall agrees a cautious approach is best. “For boxcar scarring, for example, I use microneedling infused with hyaluronic acid and then let it heal for at least six weeks, putting the long-term health of the skin above anything else,” she says. However, if the scar is particularly deep or textural, more advanced treatment options may be required. Dr Sophie Shotter, founder of Illuminate Skin Clinic, says her personal preference is a technique called chemo abrasion: “This involves using a medical grade sand paper on affected areas followed by applying TCA. Superficial peels, even as a course, won’t significantly improve deep acne scars,” she says. Shotter also recommends fractional or ablative laser, – though with moderate to severe downtime – microneedling, radiofrequency treatments like Intracel or Venus Viva and Tixel, which uses thermal energy to provide gradual resurfacing. In some cases dermal fillers can also be used to treat deeper acne scars such as boxcar or ice pick scars. “Dermal fillers in combination can be extremely effective. This technique physically breaks down scar tissue at the deep adherent margin of the scar then buttresses the area with filler to reduce the risk of reformation of the deep part of the scar,” says Dr Jack, adding: “I would normally do this technique as an initial treatment then finish with a resurfacing technique such as Fractora or Morpheus8 to refine the skin surface.”

When the skin is compromised its healing mechanism will be compromised and can cause both atrophic scarring and PIH.

TREATMENT OPTIONS

Fieldgrass recommends microneedling, derma stamp, laser and specialised peels as effective scar treatments to help

LIFESTYLE ADVICE

It’s important to remind patients that how they look after their skin outside of the clinic is a key factor in the success of their treatment programme. During the hour-long pre-treatment consultation for new clients at Mortar & Milk, Marshall and her team talk about lifestyle elements too. “We will also talk to them about their diet,” says Marshall. “Nutrition is everything when it comes to skin. It’s important that clients understand that hydration is a trifecta, and hydrated skin functions well. Topical hydration through clinical formulations, water intake and essential fatty acids in the diet are critical for skin functionality. When the skin functions well, it heals well.” AM

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S K I N / D E R M AT O L O G Y

ACNE PIGMENTATION

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NOON AESTHETICS SKINCARE

Noon Aesthetics Paraceutical Skincare range, which is exclusively distributed in the UK by Advanced Esthetics Solutions, has been designed to effectively target hyperpigmentation and sun damage. Using the brand’s DermShield Technology, the formulas provide a high concentration of active ingredients with low irritation, helping to fade stubborn marks while preventing unwanted side effects such as irritation and redness.

Scar revision Four of the best topical products for treating scars and post-acne hyperpigmentation ALPHASCIENCE ALPHA BRIGHT SERUM

Alpha Bright Serum is an ideal addition to acne-prone clients’ skincare arsenal, packed with natural active ingredients and advanced antioxidant stabilisation techniques designed to fade stubborn red marks. The product’s molecular combination works to neutralise the pollutants and free radicals that help cause pigmentation, reducing brown spots and evening out skin tone. The product is stocked exclusively at EF Medispa clinics and online.

NEOSTRATA ENLIGHTEN PIGMENT CONTROLLER

Pigment Controller is formulated to control pigmentation with a synergistic combination of actives to increase cell turnover. Key ingredients include neoglucosamine to gently exfoliate surface cells to fade skin discolouration, 0.1% retinol to help rebuild skin’s natural support structure, stabilised vitamin C to help fade post-acne marks; and alpine plant extracts and sabi white, which the brand says are a proven alternative to prescription strength hydroquinone.

MESOESTETIC C.PROF 223 SKINMARK SOLUTION

Designed for use with microneedling treatments specifically for acne scarring, this trade-only product stimulates cell repair and restructures the protein network of the dermis, providing hydration and enhancing elasticity and firmness in the skin. Active ingredients in the formulation include darutoside for tissue regeneration; chlorella vulgaris extract to increase collagen synthesis; and organic silicon for a restructuring action.

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S K I N / D E R M AT O L O G Y

PRODUCT FOCUS

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Doctor’s orders Medicalia is a comprehensive range of clinical grade peels and post-operative skincare designed to give clinics a complete solution

ew to the UK and Ireland, Medicalia is a doctor-led, US-founded skincare brand with a comprehensive range of pre and post-operative products to form a clinical strength skincare system. The products use biomimetic technology with two advanced emulsion formulas – water-oil-water microemulsions and oil-water-oil microemulsions – to help improve, restore, repair and boost the skin’s healing recovery process. Each product has a specific function in a patient’s treatment plan; either to expedite traumatised skin recovery before or after surgical procedures, decrease downtime,

provide a solution for a chronic skin condition such as acne or rosacea, have an anti-ageing effect or, for the body; tackle indications such as bruising or stretch marks. There is also a line of four medi-peels to address varying skin concerns: Retinol & Hexylresorcinol for advanced signs of ageing; Collagen & Vitamin C for mature skin; Phytic Acid & Acto-Zyme for oily, acneic skins; and Zinc & Peptides for acne lesions, scarring, mild eczema and psoriasis. The peels can be used as a single treatment or as part of a course. To support the peels, the Medicalia range also includes Peel Prep Solution, Neutralising Gel and Post-Operative CCH Mask Treatment. Aesthetic skin specialist Karen Sargeant, who trialled the peels in clinic ahead of the brand’s UK launch, commented: “Each of the Medicalia peels is different from the others and addresses varying concerns. For the client, the downtime is brief and the results are very good.” Medicalia offers stockists product and treatment training, marketing and PR materials and support, and ongoing technical support. The Medicalia homecare range:

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MEDI-REPAIR

MEDI-SOOTHE

MEDI-CLEAR

MEDI-HEAL FACE

MEDI-REFINE

Eye line – Pre and post-operative • Eye Make-up Remover • Eye Gel Oxy - ‘C’ • Eye Cream Gentle line – Dry, sensitive, rosacea skins • Gentle Cleanser • Gentle Toner • Gentle Cream Pre and post-operative • Post-operative care cream • Silico-Lipid Serum

Retinol line • Retinol & ‘C’ Care Cream • ‘C’ Serum with Oxyzomes • Retinol Concentrate Purifying line • Exfoliating Cleanser • Clarifying Cleanser • Clarifying Cream • Spot Treatment Perfecting line • L-Retinol Smoothing Cream • Lightening Cream AM

Aesthetic Medicine • November 2019

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S K I N / D E R M AT O L O G Y

SKINCARE JOURNEY

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Journey of discovery Aesthetic nurse Julie Scott shares her skincare journey and her love affair with skin

o begin sharing my journey in skin health, I must first mention my background and my discovery of my passion for skincare. My growing interest in the topic originated when I qualified as a plastic surgery nurse and nurse prescriber, after which I started my work as a plastic and reconstructive nurse in several NHS hospitals, going on to become the clinical nurse specialist for a renowned group of London plastic surgeons. Employed in such a field as plastic and reconstructive surgery, I frequently found myself working with skin cancer

sufferers and various forms of skin damage. As a result, I became hugely aware of the importance of skin health. Since then, I have worked hard to build my clinic, Facial Aesthetics, to what it is today – treating and preventing dermatological skin conditions with optimum skin health at its core. Skin health is my passion; it’s fundamental to my job. Aesthetic procedures are wonderful, but even more wonderful on a fabulous canvas. Therefore, I view skin health as the absolute foundation of what I do. After all, you wouldn’t put a beautiful painting in a shabby, old frame.

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S K I N / D E R M AT O L O G Y

SKINCARE JOURNEY

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A HOLISTIC APPROACH

I believe a more holistic approach to skincare is the way to ensure that my patients receive the best treatment and, consequently, the best results they can. Our skin is our outermost line of defence and so it is natural that it should bear the scars of life’s battles, whether it be stress, time or exposure. We should also be aware that skin evolves and changes and that what it needs at one time may be very different to what it needs at another, or even just at a different time of year. That is why, at Facial Aesthetics, we pride ourselves on developing a steady and long-lasting relationship with our patients, to get to know them and their skin so that we can be confident that we are optimising their routine every step of the way. Everyone who comes to our clinic has a computerised skin analysis during one of their first consultations. This allows us to look closely at the skin and assess its needs and any areas of concern, by taking photos and evaluating the skin in a number of categories such as texture, wrinkles, pores, porphyrins and UV spots. This analysis is repeated throughout treatment so that patients can see the progress, even the invisible progress, that their skin is making, and so that we can best advise them on the next step of their skin journey. Education is also a key part of my job – using my knowledge and experience to teach the importance of maintaining healthy skin. I aim to educate my clients on the restorative benefits of good skincare to help spread the message of learning to protect your skin to best help it in the long term, since prevention is always preferable to cure.

PRODUCT CHOICES

When it comes to the ‘how’ with skin health and achieving that fresh canvas for all other skin treatments, I find it helpful to go back to basics. To do this, I help my patients build a strong daily skincare routine, using products that I know and trust, and for this I use ZO Medical and ZO Skin Health. As far as reliability and suitability go, ZO really is the all-round package. With such a wide range of products it is incredibly versatile, you can create a routine unique to each patient’s needs and, see consistent, positive results. I have been a personal user of the ZO brand for a number of years and am a total advocate of the therapeutic restorative action of the programme. I am excited by the results that I achieve and the changes that I make to my patients’ self-esteem. In terms of my hero products, I look to the essentials of any solid skincare routine, the cleansing and the oil control, to get the skin fresh and ready for the day. For this, I love the Exfoliating Cleanser, to rid surface oil and help unclog pores to leave the skin feeling clean. Next up is the prevention and protection, where you can’t go wrong with Daily Power Defense. I liken this to a “brick wall” to my patients, it is a powerful antioxidant and the master at restoring barrier function. It also helps support the skin’s natural DNA and repair process, defending against future damage. Finally, I love the Growth Factor Serum, a lightweight gel which works to reduce the appearance of fine lines and wrinkles, and to improve skin’s elasticity and firmness by restoring hydration to boost skin rejuvenation. ZO has products for a wide number of conditions such as acne, rosacea, or ageing skin, which is vital for me, working with each of my patients with their individual needs and concerns. The journey to skin health is not always an easy one and I genuinely appreciate and value the trust and confidence my patients have in knowing that I will help them look the best they possibly can. After 25 years in the field what I do know for certain is that it’s never too late to start your journey. AM

I believe that a more holistic approach to skincare is the way to ensure that my patients receive the best treatment

Julie Scott has more than 25 years’ experience in the fields of plastic surgery and skin rejuvenation. She is a member of the BACN and RGN having qualified as a plastic surgery nurse and nurse prescriber. Since 2003, Scott has been the clinical director of Facial Aesthetics, providing wide ranging therapeutic techniques for skin aging and dermatological skin conditions for clients across Essex. Having worked with a number of leading surgeons she is excited to have been trained and chosen to be an ambassador for the ZO Skin Health brand, as she has a passion for promoting skin health for her patients. She believes in prevention and maintenance to achieve maximum skin health. Registered General Nurse (RGN), Independent Nurse Prescriber (NIP), Member of BACN, Member of the ZO Skin Faculty, Advanced Botox and Fillers

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S K I N / D E R M AT O L O G Y

EDITOR’S CHOICE

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Eudelo ™ Exoglow Vicky Eldridge discovers Dr Stefanie Williams’s new treatment that is ideal for autumn skin, Eudelo Exoglow™

ike many people the autumn and winter months can make my skin feel a bit dry, dull and lacklustre and, after enjoying some summer sun (despite being careful with my SPF), I have some irregular patches of pigmentation too. These concerns, combined with the loss of elasticity that comes with ageing, have been the inspiration for a new treatment package developed by dermatologist Dr Stefanie Williams – Eudelo Exoglow™. During the change of season when skin becomes dry, it can be tempting to keep applying more and more moisturiser, but Dr Williams believes that the current trend of over moisturising and using overly-rich skincare, such as facial oils and cleansing balms, can contribute to the ‘epidemic’ of dull skin. This plus declining levels of collagen and elastin leads to impaired texture and skin quality and an increase in irregular pigmentation. The Eudelo ExoGlow™ protocol combines the regenerative power of autologous growth factors, using the powerful Exo solution, alongside a targeted in-clinic peel and specialist homecare to revitalise, brighten and transform the skin from the deepest levels upwards. The treatment has three stages.

STEP 1

An initial assessment and digital skin scan is carried out as well as objective measurement of the skin’s radiance at baseline, to evaluate the degree of sun damage, pigmentation, texture changes and pore size, among other parameters. Bloods are taken for the generation of the Exo essence. At the end of the six-hour incubation period, the final growth factor solution will be frozen for future use. The patient is supplied with pre-peel skincare to be used for the first four weeks.

Unlike traditional PRP, Eudelo’s Exo solution benefits from incubating the blood for six hours prior to extract the growth factors (instead of being used straight away) as well as including a much wider variety of growth factors by not only harvesting from platelets, but from all the different types of cells in the patient’s blood

STEP 2

The patient comes in for their first treatment at a convenient time. A numbing cream is applied to ensure maximum comfort, then tiny portions of the patient’s bespoke Exo essence are injected superficially into the skin. For maximum skin benefits, Exo therapy can be combined with medical needling – Eudelo Exo Needling™ – the favoured delivery method at Eudelo. The second Exo treatment session takes place after six weeks, using the prepared, fresh-frozen Exo essence, so there is no need for additional blood samples. The final Exo treatment session takes place after another six weeks.

STEP 3

About four weeks after the first Exo treatment, the patient comes to the clinic for a one-off, specialist in-clinic peel and is provided with post-treatment homecare for the next four weeks. Four weeks after this peel, patients come back for a nourishing and calming Dermatology Grade Facial™ and post-treatment scans to assess the results at this stage. The homecare regime is once again adjusted to the patient’s individual needs at this stage of the process. After the first month, patients can expect to see a dramatic boost in skin radiance and reduction in pigmentation, with up to 80% improvement after completing the full protocol. Downtime is one to two weeks (redness and puffiness for a few days, then flaking) for the in-clinic peel. Downtime after each Exo session is a few days of redness and in some people there can be minor swelling. Eudelo ExoGlow™ is the perfect solution for a multitude of skin concerns for that wonderful autumn glow. AM

Aesthetic Medicine • November 2019

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INTRODUCING

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S K I N / D E R M AT O L O G Y

SKIN NEWS

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Swisscode adds two new products to line-up Pure Swiss Aesthetics has announced the addition of Hydro Facial Spray and Hydro Facial Lotion to the Swisscode line. Hydro Facial Spray is an instant moisturising spray with toning, plumping, replenishing and immune-boosting properties, as well as a natural sun protection filter. It is designed to be applied throughout the day for a replenishing boost. Hydro Facial Lotion is a protecting lotion with a soft texture that can be used for the face, neck and décolleté. Providing long-lasting cellular protection and detoxifying actions, its light plant-based cosmetic ingredients rejuvenate, nourish and protect the skin from environmental stressors while restoring the natural protective barrier.

Teoxane launches 3D Lip iS Clinical unveils Teoxane has announced the launch of 3D Lip, a product which has been formulated to plump, nourish and hydrate the lips in between clinic treatments. 3D Lip contains microspheres of collagen and hyaluronic acid for instant hydration and long-lasting plumping. Concentrated levels of ceramide 2 and matrikine complex smooth lines and hydrate for a anti-ageing effect, while shea butter nourishes for long-lasting softness. 3D Lip creates an immediate, visible boost to lip volume by instantly increasing the hyaluronic acid levels in the area. The product is part of the LipUnique Collection being launched by the brand, which also includes the new Teosyal RHA KISS® which has been designed to offer the same premium composition and rheological properties of RHA®2, but with the added benefit of a smaller volume of 0.7ml for an even more natural look. This formulation can reshape the lip and provide subtle dynamic volume. AM

GeneXC Serum

iS Clinical has launched GeneXC Serum, a product it claims is “the most powerful antioxidant formula” it has ever tested. A synergistic formulation of antioxidants and DNA repair Extremozyme® technology, GeneXC Serum activates genes to enhance the skin cells’ ability to respond to stress and renew. It also helps to brighten and improve overall skin function. Further benefits include superior antioxidant protection, improvement in skin tone and elasticity, support in cellular regeneration and metabolism. One clinical study showed that, when skin was exposed to GeneXC Serum, there was increased antioxidant protection, improved hydration, enhanced skin barrier function, improved ECM integrity, enhanced cell renewal and repair; and enhanced immune response.

Protocol releases winter skin gift set Nutrition brand Protocol has unveiled a new seasonal Winter skin nutrition box in time for Christmas. The box features three full-size supplement products including No.16 Green Superfood, Skin Radiance and Collagen and Hyaluronic Acid. No.16 Green Superfood is a formulation of plant-based foods including chlorella, spirulina, lactose-free probiotics and a complex of nutrient-rich mushrooms. Skin Radiance is packed with natural antioxidants, which work to feed the skin so that redness is reduced, tone is more balanced and the complexion appears brighter. Collagen and Hyaluronic Acid is a formulation of type I and III collagen hydrolysate (VERISOL®) that has been clinically tested to support the maintenance of healthy

skin, hair and nails, while the addition of hyaluronic can boost skin hydration.

Aesthetic Medicine • November 2019

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I N J E C TA B L E S

CONSULTATION AND ASSESSMENT

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Cause and effect Claire Berry discusses managing patient expectations and treating both the cause and effect of indications for optimal outcomes

anaging patient expectations is one of the fundamental things we need to establish when performing facial aesthetics. It can make the difference between you being an excellent clinician in the eyes of the patient and a terrible one. Manage the expectation of the final outcome and you have mastered the art of ensuring you don’t get phone calls and messages in the days after a treatment. There are a couple of ways we can do this. It all starts with a thorough consultation and the idea that both you and the patient only go ahead when you are confident that you both have the same idea about the final result.

OPTIMAL RESULTS

Clinicians know that to get optimal results in some cases we need to use multiple mls of product. This comes at a cost for the patient, which may not be an option for some. By doing

the treatment based only on what they can afford and not explaining the following, you may be setting yourself up to fail. What you should explain is that there is an optimal result, a moderate result and a light result. This way we are placing the decision with the patient to decide which outcomes they want to achieve based on their budget. Some patients present with big expectations but a minimal budget and this needs to be discussed in detail before starting any treatment plan.

A 360 DEGREE APPROACH

Another thing I am passionate about is the idea of cause and effect. We have seen a shift in the way we approach some facial rejuvenation treatments, looking at the ageing process and using that to overcome our patients’ issues rather than directly treating the issue itself. This is of course not wrong. Dealing with the cause can improve longevity of results and further improve the final outcome. However,

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I N J E C TA B L E S

CONSULTATION AND ASSESSMENT

aestheticmed.co.uk

in the cases where a patient cannot afford all treatment options or modalities, the focus should be on the effect, the reason why the patient came to see you in the first place. However, emphasis should be placed on ensuring the patient understands this is a light to moderate treatment outcome and not dealing with the cause, as this will affect longevity. As an example, if a patient comes in and wants their deep nasolabial folds treating, an advanced clinician knows that the cause of this is the loss in volume of the mid and lateral face, fat pads and remodelling of underlying structures. So the cause is the volume loss and ageing process and the effect is the deep nasolabial folds. The first thing we may want to do is jump in with a cheek lift. At this point I need to point out that this is absolutely the way to think about treating this issue and this is the course of treatment that should take place – at some point. However, the lift achieved from performing dermal fillers on cheeks alone may not be enough to target the nasolabial area wholly, especially when we are looking at a lower end budget. If you solely treat the cheeks, the patient may leave unhappy because they can still see the nasolabial folds clearly and now they’ve ‘forked out’ for a treatment that hasn’t solved their issue and one that they didn’t think they needed in the first place. I have seen this happen a number of times with other clinicians and I have heard patients distressed about it when they have been seen elsewhere and this was the treatment plan. What I explain to the patient is that there is a cause and effect situation going on in these particular cases and I go on to teach them about the ageing process so that they understand the anatomy and process fully before we start. I firstly explain that there are three treatment options: 1. Treat the CAUSE but with the possible risk that this will not be adequate to fully treat the area that the patient has attended the clinic concerned about. Treat the EFFECT but with limited lasting results 2. because the cause of the issue will not have been treated and so will continue to progress. 3. Treat the CAUSE and EFFECT for optimal results so that results are longer lasting, targeting the area of concern for the patient and the cause of concern anatomically. Breaking this down further still, if we treat the cheeks alone we most probably won’t be filling them enough to lift the deep nasolabial fold. If this is the plan of action it should be explained to the patient that the nasolabial fold will still be evident to some extent so they know to expect this. This may be known as a light treatment. The patient will most probably want to return to you for further treatment (or they may possibly go elsewhere if they feel this wasn’t managed and it bothers them that they can still see the folds). If this is the case, then you risk being deemed a bad injector in the patient’s eyes.

We have seen a shift in the way we approach some facial rejuvenation treatments

If we treat the effect of the cause alone this may give temporary relief of the issue, however, the cause is still evident (the cause being the volume loss). This will continue to progress over time and so the effect will progressively worsen along with the other signs of ageing. You may think of this as a moderate result. The hope is that the patient loves the effects of the treatment and understanding your explanation of cause and effect, they will be back for more (especially as you’ve effectively managed expectation and treatment outcome). For best or optimal results the two treatment modalities should be treated simultaneously or at least in close proximity. If the two treatments are to be split over appointments (and still using our case with the nasolabial folds as an example) then I would recommend treating the nasolabial folds directly first to satisfy the need of the patient, treating the area with which they have attended your clinic. The understanding being that both sites need treatment for optimal results eventually. By explaining cause and effect it may help you to be able to get them to appreciate that to achieve these ‘miracle’ or optimal results it can take multiple mls of product and therefore comes at a cost. Allowing them to physically choose an option, be it light, moderate or optimal, they are in control of their outcome and then have no reason to complain. It also helps you to choose the site to treat in order to give them the results they want to achieve based on their budget. This all may come with experience, but once you achieve this you may have a much happier patient. AM

Claire Berry is the owner of Claire Louise Aesthetics. She carries out her work from dental clinics in Doncaster. She has been performing medical aesthetics alongside her dental career for five years and also mentors other clinicians so they can gain confidence and experience in their own practice.

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MANAGING COMPLICATIONS

The wrong occlusion The Aesthetics Complications Expert Group shares its latest guidance on the management of a vascular occlusion associated with cosmetic injections ABSTRACT

Vascular occlusion has been cited as the most severe and feared early complication in aesthetic treatment1 and the incidence appears to be on the increase. There are several steps practitioners can take to minimise this risk and early identification and treatment of this complication is paramount. This guideline undertakes to educate and inform practitioners on steps to minimise risk, diagnose and manage a vascular occlusion in order to prevent skin necrosis.

KEYWORDS

Dermal filler, complication, injectable, skin necrosis, vascular compromise, vascular occlusion, cosmetic medicine.

DEFINITION

A vascular occlusion occurs when blood is no longer able to pass through a blood vessel. It may be a complete occlusion or may be partial resulting in a diminished blood

supply. A vascular occlusion may be the result of an internal obstruction, such as a blood clot or a foreign body such as filler material, or a blood vessel may be occluded due to external compression. If left untreated, a vascular occlusion of a blood vessel supplying the skin may result in skin necrosis and tissue death. Necrosis can be defined as ”The death of most or all of the cells in an organ or tissue due to disease, injury, or failure of the blood supply.”2 Unlike normal cell death (apoptosis), which is a programmed and ordered phenomenon, necrosis is the accidental death of the cell caused by various mechanisms such as an insufficient supply of oxygen, thermal or mechanical trauma or irradiation. Cells that are undergoing necrosis swell and then burst (cytolysis), releasing their contents into the surrounding area. This results in a locally triggered inflammatory reaction characterised by swelling, pain, heat and redness. The necrotic cells are subsequently phagocytosed and removed by the immune system. >

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Although the exact mechanism for a delayed onset of presentation is not properly understood, there are several proposed mechanisms: 1. Due to the hydrophilic nature of hyaluronic acid fillers in attracting water molecules, this can lead to delayed swelling post-treatment and a subsequent external compression of a vessel. 2. An embolus may obstruct a vessel to an area of skin which has a poor collateral circulation and although immediate signs of occlusion fail to manifest, the poor collateral supply fails to deliver enough nutrition to the skin over the following hours when signs of vascular compromise then occur.1 3. Delayed vascular occlusion may be due an intra-arterial injection which does not initially occlude the vessel but creates a nidus for platelet aggregation which subsequently leads to a blockage.

INTRODUCTION

The three proposed mechanisms of vascular occlusion associated with cosmetic injection3 are: 1. Intravascular embolism 2. Extravascular compression 3. Vascular Spasm A study by Chang, 20164 failed to show that vascular compression was reproducible in an animal model, although a case report by Lima, 20195 showed that tissue hypoperfusion occurred following vascular compression identified using high frequency ultrasound. Vascular occlusion is possible via several mechanisms following cosmetic injections, however intravascular embolism is the pathophysiology best supported by the evidence.3 When a blood vessel is inadvertently injected with filler material, the normal circulation may be impaired leading to reduced tissue perfusion and compromise of the tissue relating to its angiosome.6 Most soft tissue fillers used in cosmetic practice consist of hyaluronic acid and although hyaluronic acid is well tolerated outside the vessel wall, it is highly inflammatory within blood vessels. One experimental study has shown that biphasic hyaluronic acid globules within an arterial vessel lumen produces intense vessel wall inflammation and spasm using histopathologic analysis of tissue obtained from rabbit ears.6 It is speculated that this inflammation and spasm aims to restrict blood flow and further dispersal of foreign material into the adjacent vascular territory. It is apparent that complications associated with hyaluronic acid injection into an artery involve not just embolus with inflammation of the vessel wall, but spasm of the surrounding anastomoses to limit further spread and protection against wider areas of necrosis.6 Many cases of vascular compromise occur immediately with injection1 and the practitioner needs to be aware of the signs of this. However, there are several published papers describing delayed onset of symptoms of vascular occlusion.1,7,8,9

4. An intra-arterial injection may initially occur in a larger vessel or at a bifurcation point where it initially remains but may later become dislodged leading to an occlusion in a terminal branch.

INCIDENCE

Although necrosis may occur as a result of many aesthetic treatments, it is most commonly associated with the injection of soft tissue fillers. The incidence of necrosis related to the injection of collagen has been reported at nine in 100,000 cases of which 50% of cases were in the glabellar region10 and for all dermal fillers an incidence of one in 100,000 cases.11 However, it is widely recognised that although the prevalence of vascular occlusions following injection of soft tissue filler is increasing due to the rising popularity for these treatments and procedures being performed by less experienced practitioners, incidence data is very poor due to under-reporting. An internet-based survey conducted on 52 experienced injectors worldwide concluded that 62% reported one or more intravascular event.12,13 Skin necrosis has occurred as a result of injection of all types of dermal filler including collagen, hyaluronic acid, PMMA (Polymethylmethacrylate beads), calcium hydroxylapatite and autologous fat.7

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SIGNS AND SYMPTOMS OF VASCULAR OCCLUSION (Adapted from De Lorenzi, 2017 3) SIGNS/SYMPTOMS

TIME OF ONSET

CONSIDERATIONS

Pain

Immediate or seconds

May be absent in the presence of local anaesthetics

Blanching

Immediate, may be transient Phenomenon of blanching may be fleeting in nature due to assistance in perfusion from collateral vessels. Adrenaline in local anaesthetics may mimic and even disguise blanching associated with intravascular injection of soft tissue filler.

Livedo pattern

Minutes to tens of minutes

Skin colour may be affected by ambient temperature, poor circulation or from preexisting medical conditions.

Delayed capillary refill time Minutes

Greater than three seconds suggestive of vascular compromise.

Blue/Grey appearance

Tens of minutes to hours

Due to the build-up of deoxygenated blood in the affected tissue.

Skin breakdown

Days

Opportunistic anaerobic bacteria predominate due to the lack of oxygen in the tissues and choice of antibiotic needs to be considered.

Repair

Days/weeks

After epithelial integrity has been lost, repair begins via the method of secondary intention.

1. Pain1,7,8,10,13,14,15 Severe pain is usually experienced by the patient at the time of injection. However, if local anaesthetic has been used (either topically, a nerve block or administered with the product) this symptom may be less reliable. Remember: Extraordinary pain is not a feature of soft tissue filler treatments and if a patient complains of sudden or escalating pain during treatment or in the subsequent hours after treatment, this should alert the practitioner to the possibility that a vascular occlusion has occurred and warrants an urgent review. Injectors should also be aware that pain distant from the area that has been injected may also be a warning sign of vascular occlusion. 2. Blanching1,7,10,13,14,15 When the vasculature is affected, the area will often initially look pale, white or dusky due to the reduction in blood supply to the affected tissue. This colour will remain after removal of the needle or cannula. The blanching may initially be transient and local, but if unresolved, the pattern of the blanching becomes reticulated or irregular, following the same path as the blood supply that has been restricted. This blanching may be masked initially, if adrenaline or certain topical anaesthetics have been used.8,15

AREAS OF CAUTION

It is essential to consider that there are no safe areas of the face and all areas should be treated with the same respect and anatomical knowledge. Special attention should be given when injecting into the midline as this area appears to be a more dangerous area to inject for vascular occlusion and cases of visual loss as documented in a world literature review.16,17 Evidence dictates that there are two main areas on the face that have a higher incidence of vascular occlusion following soft tissue augmentation with filler. 1. Glabellar region1,15 Supratrochlear artery, supraorbital artery and cutaneous branches of the ophthalmic artery. 50% of cases of vascular occlusion occur as a result of intravascular injection of dermal fillers into the glabellar region due to the poor collateral circulation in this watershed area.10,11,13,17 2. Nasolabial Fold1,15, nasal tip and alar triangle Facial artery15, angular artery15 and lateral nasal artery The nasal tip and alar are also commonly affected due to these being supplied by an end artery with limited collateral blood flow.1 The angular artery turns sharply within the alar triangle and is prone to external compression or inadvertent injection leading to vascular Occlusion.10,11,15

3. Dusky, purple discolouration1,7,15 This is more typical several hours later following treatment and is due to the accumulation of deoxygenated blood in the affected tissues. The appearance can mimic that of bruising, but bruises do not blanch as they are caused by blood leaking into the skin.

1. Having a detailed knowledge of the 3-dimensional anatomy of the area being treated.15,18 Practitioners need to understand the distribution and depth of vessels of the target area and possible variations of these.

4. Coolness15 When the blood supply has been affected, the tissues are not being perfused so the temperature will be reduced, this will not be apparent immediately following injection.

2. Aspiration prior to injection to try and ascertain that the injection is not intravascular. Although it is well known that aspiration may not always be possible, even if the needle tip is within a vessel.1,7,15,17,19 Practitioners should not >

MINIMISING THE RISK OF A VASCULAR OCCLUSION

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depend solely on aspiration as a stand-alone test for safety. Published evidence from Casabona, 2015 20 showed reliability of aspiration at 53%, Van Loghem, 201721 recorded reliability between 33%-63%, depending on various factors including needle size, pull back time and needle length. Torbeck, 201922 suggested that the rheology of the filler used is a major factor in gaining a true positive aspirate. Rheology determines amount of pull back and time of pull back, these parameters ranged from 0.5 to 30 seconds using either 0.2ml or 0.5ml. 22 Therefore, injectors should adjust amount of time to aspirate and adjust the volume pulled back on the syringe if this test is to have any reliance. 3. Slow injection technique under low pressure with the filler delivered at the appropriate depth and tissue plane.7,13 4. The smallest possible volume to achieve the desired effect should be used, avoid overfilling an area1 and if more product is required, a repeat treatment in seven to 14 days may be more appropriate and safe.13,15,17 5. Avoid areas of previous scarring as deep tissue scars may fix arteries in place and make them easier to penetrate.1,15 6. Avoid bolus injections in areas at risk of vascular occlusion. 25 7. Avoid using adrenaline, or products containing adrenaline, as this may mask the blanching produced by an occlusion.1,8 8. Injection of local anaesthetic or premixed with a soft tissue filler may mask any pain experienced by the patient in the event of a vascular occlusion and the practitioner should not rely on this warning sign alone. 9. Do not inject into the tip of the nose as this is a highly vascular area with restricted tissue space. 10. Use caution when injecting into the glabellar region.13 Injections should be placed superficially (intradermal) and medially.17 Practitioners should be encouraged to use botulinum toxin first in the glabella to reduce severity of wrinkle before injecting soft tissue filler. This area should only be injected by experienced injectors. 11. The use of blunt ended cannulas of 25G or larger bore diameters are less likely to penetrate vessels and lead to an inadvertent intravascular injection.1,15 The risk of penetration of a vessel wall with a blunt tipped cannular increases with the force used and the age of the patient. 12. Patient selection is paramount, be cautious when treating patients who have undergone rhinoplasty10 or other surgical procedures as the anatomy and vasculature may be altered. 13. Pay attention when injecting â&#x20AC;&#x201C; look for warning signs and listen to your patient! 14. The risk of vascular occlusion is higher when using fillers of a greater density (higher G prime) as these have the potential to create a greater extrinsic pressure on a vessel.

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15. Practitioners, particularly less experienced practitioners, should consider using only reversible hyaluronic acid fillers as this may make the management of a vascular occlusion easier due to its hydrolysis by hyaluronidase.1

TREATMENT OF VASCULAR OCCLUSION

A vascular occlusion may result from arterial occlusion by direct injection into an artery or embolisation of product, typically presenting immediately with acute pain and blanching. It may also occur due to venous occlusion from external compression of a vessel by soft tissue filler or subsequent oedema and compression, more often with hyaluronic acid fillers. Venous occlusion usually presents later with a less severe dull pain or no pain at all14 and dark discolouration of the skin.13 In some cases, it may be possible to resolve the occlusion with conservative measures, such as massage, tapping and or heat applied to the area. However, if conservative methods fail, hyaluronidase should be administered without delay when a hyaluronic acid dermal filler has been used. 1. Immediately stop treatment7,8,10,11,13,14,17,18 As soon as the practitioner suspects the blood supply has been compromised (typically pain and blanching in the injected area), the most important step is to immediately discontinue injecting any further product and if possible, aspirate any product when withdrawing the needle or cannula.23 Inform the patient of the problem. If the practitioner is not confident or is inexperienced in the management of a vascular occlusion, they should seek the immediate advice of a more experienced practitioner. However, a vascular occlusion needs prompt management as the risk of tissue damage and skin necrosis increases over time.

ASSESS CAPILLARY REFILL TIME (CRT)

The capillary refill time should be assessed on the affected and unaffected sides. Capillary refill time (CRT) is defined as the time needed by a distal body region, such as the fingertip, to regain the original colour after having been compressed. Sansone, 2017 24 considers a normal physiological capillary refill time of two and three seconds under 65 years of age, for males and females respectively, as well as four seconds in both genders for elderly persons. CRT greater than three seconds may be suggestive of a vascular compromise. A fast capillary refill time on a background of a bluish skin discolouration may indicate venous insufficiency.15 It is prudent to observe and assess skin colour and capillary refill prior to treatment as a benchmark for post treatment assessment. To test capillary refill time, moderate pressure with either a finger or small, firm, flat object should be applied to the area being assessed for five seconds and then released. The time for the skin to return to its normal colour should be observed and recorded. The test should be conducted over the entire area and on both the affected and unaffected sides for comparison. If capillary refill time is sluggish but not less than three seconds, an initial attempt using conservative measures, such as massage, tapping and heat, should be used. If capillary refill time is not improved by conservative measures or CRT is greater than three seconds,

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practitioners should employ the ACE Group high dose pulsed hyaluronidase protocol. 25 2. Firmly massage the area7,8,10,11,13,14,17,26 Firm and prolonged massage may help to encourage blood flow and may remove any obstruction caused by a foreign body occluding a vessel. Massage may be required for several minutes. 3. Apply heat7,8,10,11,13,14,17,18,19,23,26 Heat will encourage vasodilatation and increase blood flow to an area. 4. Tap the area14,19 Tapping over an area may dislodge intra-arterial emboli either at the site or further up in the vessel. 5. Inject with hyaluronidase1,7,10,11,13,14,18,19,23,26 Where hyaluronic acid fillers are the culprit, injecting with hyaluronidase may relieve the problem before complications even occur.25 Practitioners must remember that this is a time critical event and that test patching is not required if hyaluronidase is used for a vascular occlusion as the

MANAGING COMPLICATIONS

risk of tissue damage is generally greater than the risk of anaphylaxis. As with any aesthetic treatments, it is important to have appropriate resuscitation equipment available to deal with any potential complication.15 There is some evidence to suggest that using hyaluronidase when a non-hyaluronic acid soft tissue filler has been injected may lessen the subsequent tissue damage11 due to dissolving native hyaluronic acid and decreasing pressure on the blood supply.23 Practitioners should employ the ACE Group high dose pulsed hyaluronidase protocol. 25 Despite the simplicity of the intervention, it has prevented necrosis in virtually all cases since it has been implemented and even up to 48 hours after the initial treatment. The protocol involves repeated administration of relatively high doses of hyaluronidase into the whole area of compromised tissue and not just where the filler was injected 14, repeated hourly until clinical resolution (improvements in capillary refill, skin colour and pain). This technique has also led to successful and complete recovery without any adjunctive treatment required. 2 There is contradictory evidence to suggest that hyaluronidase diffuses into the lumen of blood vessels even when injected external to it. However, when treating a vascular occlusion, it is not necessarily essential to >

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inject directly into the vessel, but the surrounding area is also likely to result in dissolution of the product. Indeed, the injection of hyaluronidase into the subcutaneous plane rather than attempting intra-arterial injection has shown more favourable outcomes. 27 6. Aspirin1,15 Following the evidence for the use of aspirin in cardiovascular disease, in order to limit platelet aggregation, clot formation and further vascular compromise, a stat dose of 300mg should be given immediately, followed by 75mg a day28 until the vascular occlusion has resolved where there are no contraindications. Concomitant use of gastric protection medication may be recommended in some patients. If treatment of a vascular occlusion has failed, necrosis may ensue. The patient should be monitored regularly and if tissue breakdown occurs, a referral for specialist management and care may be appropriate (Refer to ACE Guidelines on Necrosis). 7. Antibiotics1,10,13,23 Necrosis consists of dead cells and dead tissue and is prone to secondary opportunistic infection. Depending on the extent of necrosis, topical and/or oral antibiotics may be required to promote healing and to prevent further complications developing. Anti-herpetic medication may be advised if necrosis occurs in a susceptible patient in a perioral distribution.1,11 In the case of a treated vascular occlusion without any signs of skin damage, antibiotics should not be given for prophylaxis. 8. Superficial debridement7,10,13,17,18 Referral to a plastic surgeon may be required for removal of dead tissue to promote healing. 9. Wound care management1,10,17 Appropriate dressings and wound care to encourage healing. 10. Pain management Pain management needs considering in cases of necrosis, as although over the counter medication may be all that is required, necrosis can cause severe pain requiring opioid analgesia. 11. Refer It is always sensible to involve other practitioners experienced in the management of vascular occlusion for further advice and/or treatment. 12. Speak to your medical defence organisation A vascular event can be a distressing ordeal for both patient and practitioner. Whether or not it is managed well and resolved, a claim may ensue.

OTHER TREATMENT OPTIONS

Hyperbaric oxygen therapy (HBOT) has been successfully used in nasal tip grafting following cases of cancer or trauma with positive results on revascularisation although there is limited evidence to recommend this for necrosis secondary to aesthetic procedures.10,13,29 Several case reports have described an improvement in aesthetic outcome using HBOT1 but some authors do not feel that the costs, risks and inconvenience is warranted.30 HBOT increases the supply of oxygen to the compromised tissue and helps to remove toxic free radicals. 23,29 The use of low molecular weight heparin1,11 has been used to prevent thrombosis and embolisation in one case report31 although there is not enough evidence to recommend this as a standard treatment. Oral vasodilators including PDE5 (cGMPspecific phosphodiesterase type 5) inhibitors or Prostaglandin E1 (PGE1) 1 have also been advised for the treatment of vascular occlusion but evidence is lacking for their wider use for this indication.11

NO LONGER RECOMMENDED: NITROGLYCERIN PASTE

2% Nitroglycerin (glyceryl trinitrate) paste induces vasodilatation and increases blood flow to the area. It has been recommended to be used topically in the event of a vascular occlusion to encourage reperfusion.1,7,8,10,11,13,17,19,26,32 Dayan et al32 reported a series of nine patients whose vascular occlusion was successfully healed with a protocol of hyaluronidase and nitroglycerine paste 2cm applied daily with massage in clinic plus a daily dose of aspirin 325mg with antacid until capillary refill was less than two seconds. Nitroglycerin paste (RectogesicÂŽ, used off label) is applied under an occlusive dressing and used for several days, >

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Ensure good documentation, photographic evidence, good patient support and follow up with emergency contact number

Symptoms and signs of vascular occlusion (pain, blanching, discolouration)

FOLLOW-UP

All patients presenting with a vascular occlusion need follow up until the problem has completely resolved, this may be on a day by day basis initially. Immediate follow up is required when a patient contacts the practitioner and a delayed onset of vascular occlusion is suspected. All practitioners carrying out soft tissue augmentation should provide patients with an emergency out of hours number and if a patient reports symptoms that may be consistent with a vascular occlusion, an immediate face to face review should be arranged. It is not acceptable to do this via electronic media. Good follow up, on-going support and full explanations to the patient is the best approach to stop a complication turning into a litigious medical malpractice claim. AM

Stop treatment Delayed presentation with symptoms and signs of impending necrosis (dull pain, discolouration, coolness, livedo reticularis)

Massage Assess and repeat process if CRT < 3 seconds

Apply heat

Tap the area

Resolved?

Advice and follow up

Yes s

Hyaluronidase pulsed protocol as per ACE Guidance

Asprin 300mg stat and then 75g daily until resolved Consider further hyaluronidase

Resolved?

Advice and follow up

it was recommend applying for 12 hours and then removing for 12 hours until clinical improvement was seen17 or until it was no longer tolerated. Nitroglycerin can lead to skin reactions, irritation and erythema as well as systemic effects including dizziness and hypotension. However, a study by Hwang et al, 201634 failed to show any improvement in outcome using topical nitroglycerin ointment 2% in induced arterial occlusion in an animal model using rabbit ears. In fact, it tended to cause a more congested appearance and worsen perfusion by allowing filler material to diffuse from capillaries into larger arterioles thereby further compromising the circulation. The authors do not recommend the use of topical nitroglycerin for vascular occlusion following soft tissue augmentation. >

Yes s

Discuss with colleague, local expert and medical defence organisation

Ongoing care, wound care, antibiotics, consider debridement

Advice and follow up

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REFERENCES 1. Souza Felix Bravo, B., Klotz De Almeida Balassiano, L., Roos Mariano Da Rocha, C., Barbosa De Sousa Padilha, C., Martinezt Torrado, C., Teixeira Da Silva, R. and Carlos Regazzi Avelleira, J. (2015) ‘Delayed-type Necrosis after Soft-tissue Augmentation with Hyaluronic Acid’, J Clin Aesthet Dermatol, Dec;8(12), pp 42-47. 2. Oxford Dictionary

18. N ettar, K. and Maas, C. (2012) ‘Facial Filler and Neurotoxin Complications’, Facial Plast Surg, 28, pp 288–293. 19. Cohen, J.L. (2008) ‘Understanding, Avoiding, and Managing Dermal Filler Complications’, Dermatol Surg, 34, S92–S99. 20. Casabona, G. (2015) ‘Blood aspiration test for cosmetic fillers to prevent accidental intravascular injection in the face’, Dermatol Surg, 41(7), pp 841-847.

3. De Lorenzi, C. (2017) ‘New High Dose Pulsed Hyaluronidase Protocol for Hyaluronic Acid Filler Vascular Adverse Events’, Aesthetic Surgery Journal, pp 1-12.

21. Van Loghem, J. (2018) ‘Sensitivity of aspiration as a safety test before injection of soft tissue fillers’, J Cosmet Dermatol, 17, pp 39–46. © Aesthetic Complications Expert Group, Management of a vascular occlusion, Page 12 of 14

4. Chang, S.H. (2016) ‘External Compression Versus Intravascular Injection: A Mechanistic Animal Model of Filler-Induced Tissue Ischemia’, Ophthalmic Plast Reconstr Surg, Jul-Aug;32(4), pp 261-266.

22. Torbeck, R. (2019) ‘In Vitro Evaluation of Preinjection Aspiration for Hyaluronic Fillers as Safety Checkpoint’, Dermatol Surg, 00, pp 1–5.

5. Lima, V.G.F. (2019) ‘External vascular compression by hyaluronic acid filler documented with high-frequency ultrasound’, J Cosmet Dermatol, Mar 5. 6. Ashton, M. (2018) ‘The Role of Anastomotic Vessels in Controlling Tissue Viability and Defining Tissue Necrosis with Special Reference to Complications following Injection of Hyaluronic Acid Fillers’, Plast. Reconstr. Surg, 141:818e. 7. Ozturk, C.N., Li, Y., Tung, R., Parker, L., Peck Piliang, M. and Zins, J.E. ‘Complications following injection of soft-tissue fillers’, Aesthetic Surgery Journal, 33(6), pp 862-877. 8. Narins, R.S., Jewell, M., Rubin, M., Cohen, J. and Strobos, J. (2006) ‘Clinical Conference: Management of Rare Events Following Dermal Fillers – Focal Necrosis and Angry Red Bumps’, Dermatol Surg, 32, pp 426-434. 9. Maruyama, S. (2017) ‘A Histopathologic Diagnosis of Vascular Occlusion After Injection of Hyaluronic Acid Filler: Findings of Intravascular Foreign Body and Skin Necrosis’, Aesth Surg Jour, Vol 37(9). 10. Grunebaum, L., Allemann, I., Dayan, S., Mandy, S. and Baumann, L. (2009) ‘The risk of alar necrosis associated with dermal filler injection’, Dermatol Surgery, 35, pp 1635-1640. 11. Tracy, L.,Ridgway, J.,Nelson, J.S., Lowe, N. and Wong, B. (2014) ‘Calcium hydroxylapatite associated soft tissue necrosis: A case report and treatment guideline’, Journal of Plastic, Reconstructive & Aesthetic Surgery, 67, pp 564-568. 12. G raiche, J. (2007) ‘Overview of complications of sclerotherapy’, Australian College of Phlebology, Scientific meetings and workshops. 13. Sclafani, A.P. and Fagien, S. (2009) ‘Treatment of injectable soft tissue filler complications’, Dermatol Surg, 35, pp 1672–1680. doi: 10.1111/j.15244725.2009.01346.x. 14. U rdiales-Gálvez, F., Delgado, N.E., Figueiredo, V. et al. (2018) ‘Treatment of Soft Tissue Filler Complications: Expert Consensus Recommendations’, Aesthetic Plast Surg, 42(2), pp 498–510. doi:10.1007/s00266-017-1063-0 15. DeLorenzi, C. (2014) ‘Complications of Injectable Fillers, Part 2: Vascular Complications’, Aesthetic Surgery Journal, 34, pp 584-600. 16. B elezany, K. and Carruthers, J.D.A. (2019) ‘Update on Avoiding and Treating Blindness From Fillers: A Recent Review of the World Literature’, Aesth surg Jour, May 16;39(6), pp 662-674. 17. Glaich, A.S., Cohen, J.L. and Goldberg, L.H. (2006) ‘Injection Necrosis of the Glabella: Protocol for Prevention and Treatment After Use of Dermal Fillers’, Dermatol Surg, 32, pp 276–281.

The ACE Group have produced a series of evidence based and peer reviewed guidelines to help practitioners prevent and manage complications that can occur in aesthetic practice. These guidelines are not intended to replace clinical judgement and it is important the practitioner makes the correct diagnosis and works within their scope of competency. Some complications may require prescription medicines to help in their management and if the practitioner is not familiar with the medication, the patient should be appropriately referred. Informing the patient’s General Practitioner is considered good medical practice and patient consent should be sought. It may be appropriate to involve the General Practitioner or other Specialist for shared care management when the treating practitioner is not able or lacks experience to manage the complication themselves. Practitioners have a duty of care and are accountable to their professional bodies and must act honestly, ethically and professionally.

23. H ong, J.Y., Seok, J., Ahn, G.R., Jang, Y-J, Li, K. and Kim, B.J. (2017) ‘Impending skin necrosis after dermal filler injection: A “golden time” for first-aid intervention’, Dermatologic Therapy, 30, e12440. https://doi. org/10.1111/dth.12440 24. S ansone, C. (2017) ‘Relationship between Capillary Refill Time at Triage and Abnormal Clinical Condition: A Prospective Study’, The Open Nursing Journal, 11, pp 84-90. 25. King, M., Convery, C. and Davies, E. (2018) ‘This month’s guideline: The Use of Hyaluronidase in Aesthetic Practice (v2.4)’, J Clin Aesthet Dermatol, 11(6), E61–E68. 26. Deok-Woo, K., Eul-Sik, Y., Yi-Hwa, J., Seuna-Ha, P., Byung-Il, L. and EunSang, D. (2011) ‘Vascular complications of hyaluronic acid fillers and the role of hyaluronidase in management’, Journal of Plastic, Reconstructive & Aesthetic Surgery, 64, pp 1590-1595. 27. Wang, M. (2017) ‘Comparison of Intra-arterial and Subcutaneous Testicular Hyaluronidase Injection Treatments and the Vascular Complications of Hyaluronic Acid Filler’, Dermatol Surg, 43, pp 246–254. 28. ‘Antithrombotic therapy: A National Clinical Guideline’, SIGN Guideline No. 36. Scottish Intercollegiate Guidelines Network. March 1999. 29. Darling, M. D., Peterson, J. D. and Fabi, S. G. (2014). ‘Impending necrosis after injection of hyaluronic acid and calcium hydroxylapatite fillers: report of 2 cases treated with hyperbaric oxygen therapy’, Dermatological Surgery, 40(9), pp 1049–1052. 30. DeLorenzi, C. (2013) ‘Complications of injectable fillers, part I’, Aesthetic Surg J, 33(4), pp 561–575. 31. S chanz, S., Schippert, W., Ulmer, A., Rassner, G. and Fierlbeck, G. (2002) ‘Arterial embolization caused by injection of hyaluronic acid (Restylanes)’, Br J Dermatol, 146, pp 928–929. 32. Kleydman, K., Cohen, J.L. and Marmur, E. (2012) ‘Nitroglycerin: A Review of Its Use in the Treatment of Vascular Occlusion After Soft Tissue Augmentation’, Dermatol Surg, 38, pp 1889–1897. 33. Dayan, S., Arkins, J.P. and Mathison, C.C. (2011) ‘Management of impending necrosis associated with soft tissue filler injections’, J Drugs Dermatol, 10, pp 1007–1012. 34. H wang C.J., Morgan, P.V., Pimentel, A., Sayre, J.W., Goldberg, R.A. and Duckwiler, G. (2016) ‘Rethinking the Role of Nitroglycerin Ointment in Ischemic Vascular Filler Complications: An Animal Model With ICG Imaging’, Ophthalmic Plast Reconstr Surg, Mar-Apr;32(2), pp 118-22. doi: 10.1097/IOP.0000000000000446.

Authors Dr Martyn King Dr Lee Walker Dr Cormac Convery Emma Davies RN NMP Expert Group Dr Martyn King (Chair) Emma Davies RN NIP (Vice Chair) Sharon King RN NIP Dr Cormac Convery Dr Lee Walker Linda Mather RN NIP

Consensus Group Helena Collier RN NIP Dr Ben Coyle Dr Ravi Jain Dr Sam Robson Mr Taimur Shoaib Lou Sommereux RN NIP Frances Turner-Traill RN NIP Gillian Murray

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NEEDLE FREE INJECTORS

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No needle,

no risk? Georgia Seago delves into the needle-free filler pen trend and finds out how patients could be at risk

o-needle “injector” devices are increasingly being used in the UK for aesthetic procedures, including mesotherapy and dermal fillers. The pen-like devices have become particularly popular among the non-medical community as an alternative to traditional methods using needles or cannulas because of the purported absence of pain, side effects or complications for the patient. However, without any clinical evidence to support these claims and gradually emerging indications to the contrary, it’s a murky area that needs unpacking to protect patient safety.

EMERGING TECHNOLOGY

Jet injection devices have long been used to deliver drugs into the body without the use of needles, most commonly with insulin for diabetics. But over the past year or so the technology has emerged in the aesthetics and beauty industries as an alternative to injectable product delivery, with applications including anti-wrinkle treatments, dermal fillers, mesotherapy, fat dissolving and PRP. Most of the unbranded pen devices on the market are composed of a disposable sterile cartridge inside a casing activated by a spring-push mechanism. Product is delivered into the skin mechanically using high air pressure, but the majority

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of devices don’t carry specifications in terms of depth or dimensions of the entry point created by the jet. Needle-free pens appear to be an attractive option to beauty therapists who acknowledge they don’t have the skills required to administer traditional injectables or who don’t want to inject, because they believe that needlefree options provide a safer alternative. Several training providers describe needle-free treatments for dermal filler as “pain and complication-free”, with one website stating: “The hyaluronic acid only reaches the papillary layer of the dermis making this a safe treatment with no risk of occlusion as well as no sharp tips to puncture blood vessels [sic].” Another, which offers one-day courses with certification to treat clients immediately on completion, describes the treatment as “largely pain-free and bruise-free”. However, increasing anecdotal evidence suggests otherwise. National accredited practitioner register Save Face had received 67 complaints relating to no-needle filler procedures so far this year. “Patients get told that if they’re scared of needles this is a pain-free option to get plumper lips. Actually, from the experiences of people we’ve heard from, it’s not. It’s very painful and the results are very unpredictable,” says Ashton Collins, co-director of Save Face.

GROWING CONCERNS

Meanwhile, Scotland-based Frances-Turner Traill, clinical director of FTT Skin Clinics and consultant cosmetic nurse for the Confidence Cosmetic team at the Nuffield Hospital in Glasgow, recently dealt with the first vascular occlusion as a result of a lip filler treatment using a needle-free device that Aesthetic Medicine is aware of. The severe case was referred into Turner-Traill’s clinic as an emergency 12 hours after a lip treatment caused by a needle-free injector pen. In her opinion, the devices bring their own new set of potential complications. “ The extrusion force is higher than that of a healthcare professional using a needle. There’s no skill, no artistry and no respect to anatomy using pens over needles or cannulas,” she says. Collins agrees: “The molecules [of HA filler] are really too large to penetrate the skin in that way, and what happens is the product gets distributed very unevenly. We’ve had patients come to us with product having dispersed with the air pressure so that it ends up sitting outside the lip border. With a needle or a cannula you can be very targeted with where you put the product, but with this it’s very unpredictable. “ Other potential issues stem from the type of filler being implanted. Many no-needle filler training providers advertise that students will work with highly viscous, crosslinked volumising HA fillers, with the product often placed superficially, potentially leading to complications such as granulomas. A case reported by The Sun Online in August

NEEDLE FREE INJECTORS

MANAGING COMPLICATIONS If a patient presents with a complication from needlefree lip filler, Turner-Traill shares the following advice: “You may be treating a vascular occlusion compromised with haematoma and a significant spread of product due to the high-pressure delivery. Check intra-orally too to assess area of compromise or occlusion and impending necrosis. “The vascular occlusion with compromise presenting may be more significant than you have dealt with previously and subsequent treatment therefore will be too. Check that although capillary refill time may be returning, it is useful to measure against an unaffected area before, during and after treatment. “Ensure you have clinical pathways in place such as hyperbaric oxygen therapy and plastic surgery support on standby.” Read the recently released ACE guidelines on managing vascular occlusions on pages 59-66.

of this year involved a patient left with severe lumps and bruising immediately after treatment using a needle-free pen with Dermalax Plus with Lidocaine, available from Filler World. Other training providers don’t give any details of the product students will be taught to use in their online blurb, or indicate that they will be given advice on how to choose a suitable product for the intended treatment area. “We’ve issued notices to our members to say that this isn’t as straightforward as hyalasing standard lip filler [in the case of a complication], and because the product used varies so much – in one case a girl had been ‘injected’ with topical hyaluronic face serum – you really just have no way of knowing what’s been used… there are no patient records and, with these fillers there are often no batch numbers or anything to trace back what people have been injected with, so for practitioners to be correcting these sorts of things can be quite high risk,” explains Collins.

BENEFICIAL APPLICATIONS

This all isn’t to say that needle-free injection devices are dangerous across the board or that they don’t have any place in the safe practice of medical aesthetics. Dr Martyn King, chair of the Aesthetic Complications Expert Group and owner of Cosmedic Skin Clinic in Staffordshire, trialled the Med Jet device from Smart Group in clinic. He says: “I found it very, very good for doing mesotherapy and PRP and, though I didn’t use it in this way, I think it would be very good at doing hyperhidrosis. >

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NEEDLE FREE INJECTORS

"Because of the pain you get with injecting hands and feet in particular, I think Med Jet would treat those areas quite well.” The Med Jet device uses a low-pressure delivery system and creates an aperture six times smaller than a 30-gauge needle. It can be used for intradermal, subcutaneous and intramuscular delivery. King continues: “I mostly used it for PRP on the scalp which is quite a painful procedure, but I didn’t get bruising or bleeding. Rather than injecting with a needle, which would mean injecting more volume in less places, more because of the pain than anything else, with Med Jet, you can do a lot more injections in quite a quick space of time and inject a little bit less, so you could actually cover quite a large area with just a little injection.” However, when it comes to filler, King advises to steer clear of volumising products and thinks more complications will begin to emerge. “I think what we’ll start to see is a lot of people with small lumps and papules below the skin. The trouble is that while fillers do get broken down naturally in the skin, if you inject too superficially they can last for years, because naturally produced hyaluronidase is in much lower quantities in the superficial layers of the skin.”

CALLS FOR MORE RESEARCH

Until more research is done into the performance and effects of needle-free filler delivery, it’s somewhat of a waiting game for enough anecdotal evidence to slow the uptake of patients accessing these treatments dangerously. “The JCCP is aware of the increasing use of injection-free filler pens and the anecdotal evidence of complications,” says Andrew Rankin, nurse prescriber and JCCP trustee.

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“Of course, there is a difference between no evidence of risk and evidence of no risk. In the absence of evidence, we would consider the use of these devices would be at Level 7.” He points to a safety alert from the Canadian government advising Canadians that “needle-free dermal filler devices that are promoted for cosmetic skin treatments – such as reducing wrinkles and increasing lip volume – may pose health risks.” It also states that none of the devices have been authorised for sale in Canada and that potential side effects include hematomas, abscesses from a bacterial infection, spreading of transmissible diseases due to crosscontamination if proper sterilisation isn’t observed, and damage to the blood vessels due to excessive pressure or operator error. BCAM board member Uliana Gout agrees that very little evidence exists on the topic in medical aesthetics, and that research needs expanding as a priority. “‘Transdermal delivery of actives is an exciting and pioneering arena in aesthetic medicine with regard to skin quality improvement and even stimulation of the underlying structure,” she says. “An example is the evolution of needle-free injector pens; which are proving an interesting new development for practitioners. As always it is essential to assess the evidence-base behind each innovation to ensure optimisation of safety and efficacy. “Namely, care should be taken with cross-linked fillers injected into the skin and below with regard to ensuring no intravascular risk is associated with a blind injection mode. Managing and assessing depth of injection is essential for patient satisfaction and safety.” AM

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Body of evidence Dr Sotirios Foutsizoglou, clinical governance director of the British Association of Body Sculpting (BABS) discusses the evolution of lipoplasty

he first known attempt to remove subcutaneous fat through a small incision was carried out in 1921 in Paris, France, by Charles Dujarrier, who operated on the calves of a Folies Bergère dancer using a uterine curette. Details of the procedure are not known but, unfortunately, it ultimately resulted in amputation of a leg. Following this, to the best of our knowledge, no other similar attempt was carried out for half a century. Joseph Schrudde of Germany first reported on curetting subcutaneous fat at the 1972 meeting of the International Society of Aesthetic Plastic Surgery (ISAPS) in Rio de Janeiro, Brazil. He termed the procedure “lipexheresis,” which he stated “he had performed occasionally since 1964.” In 1975, he provided a more detailed report on the procedure in Lagenbeck’s Archives of Surgery.1 The use of blind long scissors for undermining followed by the traumatic technique of using a sharp uterine curette, frequently resulted in prolonged drainage, lymphorrhea, hematoma and even skin necrosis. The first surgeons to add suction for the purposes of fat extraction, as opposed to just using curettage, were an Italian father and son team – Arpad and Giorgio Fischer. 2 They presented their work in 1977. The tip of the instrument

was still sharp and, as a result, it severed not only fat but also surrounding structures. The post-operative course was again marred by complications and side effects not unlike those resulting from lipexheresis. Therefore, the procedure was not enthusiastically received. llouz, a gynaecologist, is credited with popularising liposuction by using the Fischers’ technique with the Karman cannula – a widely available, reasonably priced, soft, flexible cannula that was developed for abortion procedures.3 Illouz is also responsible for the original ‘wet technique’ in which a hypotonic saline solution with hyaluronidase was injected into the fat. ‘Wet technique’ liposuction was popularised in Europe, however, prior to Klein’s introduction of tumescent anaesthesia the predominant form of liposuction practiced in the United States was the dry technique. Patients were put under general anaesthesia and minimal local anaesthesia was used, so significant blood loss was a common complication with the dry method.4 The introduction of tumescent anaesthesia by Klein revolutionised liposuction among dermatologic surgeons and cosmetic surgeons at large. Liposuction with local anaesthesia allows the removal of large volumes of fat with minimal blood loss, low post-operative morbidity, excellent cosmesis, and a remarkable safety profile.5 >

The first known attempt to remove subcutaneous fat through a small incision was carried out in 1921

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It is generally accepted that lidocaine up to 35 mg/ kg, injected in the subcutaneous fat in wetting solutions containing epinephrine, is safe. It is notable, however, that this dose is in direct contrast with the original recommendation of less than 7 mg/kg published in the Physicians’ Desk Reference. Absorption rates vary significantly, and measurements of peak plasma lidocaine levels are more meaningful than absolute amounts of injected lidocaine in assessing potential toxicity.15 Several different formulations of wetting solutions have been recommended. These formulations do not differ significantly from each other. For the most part, they are isotonic in nature and contain low concentrations of epinephrine and lidocaine. In general terms, 1cm3 of wetting solution for each 1–1.5 cm3 of estimated aspirate is infused. Sequential infusion, as opposed to infusing all areas to be suctioned at once, lessens acute fluid load by clysis and variability of tissue distortion by the wetting solutions. Uniform layering of infusion facilitates sculpting. While for small volumes, such as treatment of necks or inner knees, 60ml Toomey syringes with infusion cannulae can be used, infusion pumps are better suited for removal of larger volumes. The next advance worthy of mention was that of Ulrich Kesselring.6 Although he used sharp instrumentation attached to suction, he was the first to recommend working in the deep fat compartment just above the muscle fascia. His results were superior to previous ones presented, in no small measure due to his method of patient selection; he performed the procedure only on young women with small amounts of localised fat and elastic skin. Eventually, after a great deal of lively debate with Yves Gerard Illouz at a variety of plastic surgery meetings, Kesselring adopted Illouz’s technique.

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LIPOSUCTION

Bahman Teimourian was the first surgeon practicing in the United States to make a significant contribution to the evolution of lipoplasty.7 His work was independent from the European surgeons. In 1976 he was still using scissors for undermining, which he followed by curetting with a modified fascia lata stripper attached to suction. He boldly extended his procedure to many body regions. His complication rate was 30%, characteristic of all curette techniques. He first reported on his technique in 1979 and then later as he modified it. Teimourian recognised the importance of

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separate tunnels, as opposed to a “windshield wiper” type of approach to fat removal. He eventually adopted a cannula technique instead of curettage. Concurrently, Pierre Fournier and Francis Otteni of France were popularising the use of syringes as the suction source for lipoplasty.8 They also favoured non-cutting edge cannulae.

ULTRA-SOUND ASSISTED LIPOSUCTION

In 1987, Professor Nicolo Scuderi of Italy was the first to describe ultrasound-assisted lipoplasty (UAL), after which a plethora of publications endorsed the practice of UAL.9 In 1997, a meeting in St. Louis, hosted by Leroy Young, was organised with the objective of facilitating the exchange of ideas between leading biophysicists with interest in how ultrasound energy affects adipocytes. In addition to American board certified plastic surgeons, industry representatives were also asked to participate. William Cimino, a prominent biophysicist, presented his developing method of vibration amplification of sound energy at resonance (VASER).10 This third-generation ultrasound lipoplasty device, when compared to earlier devices, limited the power of ultrasound energy delivery to levels which, while sufficient to fragment adipocytes, were less harmful to surrounding lymphatics, blood vessels, and nerves. UAL delivers ultrasonic energy directly to deep fat deposits through very tiny incisions in the skin. This technique enhances the current procedure in liposuction by adding ultrasonic waves to break down the magnified and giant fat cells in the deep fat deposits, preserving normal size microscopic fat cells in the superficial subdermal fat layer, which enables smooth results with UAL. This technique shortens the total multi-area operation time to about one hour or less and avoids possible mechanical damage to surrounding tissues. The ultrasound liquefies fat thus the aspirate is less bloody and contained more fat than tradition liposuction aspirate. Skin tightening and weight loss cannot be compared to traditional liposuction that is more traumatic. Classic liposuction does not achieve metabolic benefits of weight loss. UAL is not a replacement for suction- assisted lipoplasty – SAL; it is an extension of this technique. The advantages of UAL are selective destruction of fat cells, the possibility of skin tightening of treated areas, and a reduction of physical strain on the surgeon. UAL uses highfrequency sound waves to liquefy fat beneath the skin surface before removing it with a gentle suction. Tumescent liposuction and traditional liposuction cannot liquefy fat cells, and this makes the fat more difficult to remove. There is less surgeon fatigue, allowing the surgeon to focus on true sculpting in body contouring and less tissue trauma. UAL is also successful in breast surgery and as a very superficial ultrasound-assisted lipoplasty for the treatment of axillary osmidrosis.11 UAL allows the trabecular system and elastic skin to retract, but the degree of skin tightening following UAL depends on the age and quality of skin. Ultrasound waves in the infiltrated tissue cause fat tissue destruction via: 1. Selective destruction of adipocytes

2. Micromechanical effect – Ultrasound displaces intracellular molecules, breakups up chromosome, and conglomeration of molecules caused by the breakup of intermolecular bridges, leading to cessation of DNA duplication, modification of the proteins spatial structure, formation of free radicals, denaturation of the cellular membrane components and electrochemical modifications of the cellular surface12 3. Cavitation phenomenon - strong cellular fragmentation and lipolytic effect13 4. Thermal effect14

PREOPERATIVE MARKINGS

Patient markings are carried out in a standing position and usually are done in a topographic manner. Using indelible marking pens of different colours is useful. Sights of maximum removal and depressions or valleys are appropriately noted. In addition to the localised fat deposits to be suctioned, the areas to be augmented with autologous fat transfer (AFT) are marked. Undesirable skin adhesions to underlying tissue (such as the folds between back rolls), and location of folds to be created (such as better definition of the gluteal folds or design of abdominal etching) are similarly marked. Access incisions needed to reach the areas to be suctioned are placed as close as possible. Shorter cannulas provide better control. When cannula (without suctioning) discontinuous undermining is planned to facilitate skin contraction beyond the borders of suctioning (as in larger cases of gynecomastia), this is also drawn. Photographs taken with the markings in place are used to confirm the surgical plans with the patient and serve as documentation of what was treated. Standardised circumferential multiple-view preoperative and post-operative photographs are also taken. Post-operative garment size is determined prior to surgery.

Patient markings are carried out in a standing position and usually are done in a topographic manner

PATIENT SELECTION

Patient evaluation is the most important step for the surgeon. Wrong choices in psychological, medical, physical, and aesthetic evaluation lead to unsatisfactory results, nagging patients, more difficult repeat surgical interventions, and litigation. The psychologically unfit patient, or an individual with low self-esteem, marked anxiety, fear, body dysmorphia, or unrealistic expectations can be difficult to diagnose preoperatively. Time spent with patients showing them representative photographs, encouraging patients to provide magazines or other pictures illustrating their expectations, and the prospective patient’s attitudes toward previous aesthetic surgical outcomes and surgeons, are all important. When in question, it is best to avoid surgery. A comprehensive medical evaluation should be carried out for lipoplasty patients, as it is for all other aesthetic procedures. Specifically, it should rule out a history of chronic lung disease, bleeding disorders, thromboembolic disease and acute or chronic systemic diseases. For example, use of oral contraceptives places the patient at higher risk for pulmonary embolus. Lifestyle and dietary habits can also lead to protein deficiency and fluid or electrolyte imbalance. >

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In addition to eating disorders, such as bulimia, many people have bizarre dietary habits; others exercise excessively without adequate nutritional support and are chronically malnourished, with low iron source, low albumin levels, low potassium levels, or all three. In addition to alcohol and recreational drug dependence, taking megadoses of certain vitamins and other over-the-counter remedies is common, for example, consumption of vitamin E, which can influence clotting. Testing for hepatitis B or C, or the human immunodeficiency virus, although prudent, does not remove all risks. Complete physical examination should evaluate patients for pre-existing orthopaedic and neurologic conditions that may be aggravated when the patient is put under anaesthesia on the operating table. From an aesthetic standpoint, the ideal patient (BMI less than 24.9) for lipoplasty is a relatively healthy, thin, young, person with highly localised subcutaneous fat excess: â&#x20AC;&#x153;figure faultsâ&#x20AC;? with taut skin. The average candidate (BMI 25-29.9) is over 40 years of age, weighs 7-9kg over ideal weight, has a history of weight fluctuations, and has some degree of skin relaxation and/or striae. Although such a patient will experience some improvement from lipoplasty, which may incorporate superficial suction, autologous fat transfer (AFT), and intraoperative and post-operative Endermologie, he or she should be informed that subsequent suctioning and dermolipectomy may be necessary for optimal result. The less than ideal patient (BMI over 30) is older, is more than 9kg overweight or generally obese, has a history of weight fluctuations, and has clearly loose skin. Striae, soft tissue ptosis with cascading folds of redundant skin, the beginning of abdominal ptosis, banana rolls (sometimes multiple), inner thigh ptosis, or a combination of these features are present on physical examination. In this group, patients older than 55 years seem more readily satisfied with the results of the procedure than their younger counterparts. The patient should repeatedly be informed before surgery of the limitations imposed by their anatomy. A more conservative approach followed by secondary suctioning, after interim skin contraction, and eventual dermolipectomy may be required. Regardless of age and how close to the ideal candidate a patient is, sufficient preoperative discussion(s) to bring post-operative expectations to a realistic level is essential. Visual inspection is not sufficient for adequate preoperative evaluation. Palpation for skin turgor, elasticity, and strength is important. If pinched skin does not return instantly to normal >

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position, lipoplasty by itself is a poor choice. The pinch test demonstrates the difference between body regions with excess localised fat deposits and the surrounding areas. For example, pinching the hypogastric area in a patient who is a good candidate should demonstrate thickness several folds over fat lateral to it.

COMPLICATIONS

Liposuction has become one of the most popular and commonly performed aesthetic procedures in plastic surgery. However it can be associated with life threatening complications such as fat or pulmonary embolism. That is why it is of paramount importance that those who perform liposuction and fat grafting procedures have a surgical background, are familiar with the various liposuction techniques ranging from traditional SAL to VASERassisted liposuction, are competent in the use of tumescent and wetting solutions in aspirative lipoplasty in order to minimise lidocaine and epinephrine related complications such as toxicity and arrhythmias respectively, and preferably have considerable experience in body contouring procedures including lipo-abdominoplasty and bodylift as with increased BMI it is more likely that some form of skin excision will also be required for optimal results. Complications usually occur in three different windows: the perioperative period (0-48h), the early post-operative period (one to seven days), and the late post-operative period (one week to three months). Perioperative complications can include anaesthesia and cardiac complications (e.g. lidocaine toxicity), hypothermia (i.e. core body temperature of < 35oC) due to excessive use of tumescence with unwarmed fluids and/or cool ambient theatre temperature, trauma to skin or internal organs (e.g. unrecognised hernia preoperatively), fluid shifts leading to hyper- or hypovolaemia. Early post-operative complications include venous thromboembolism or the most feared pulmonary embolism – be aware of any acute lower limb swelling and associated Homan’s signs, infection including necrotising fasciitis, and skin necrosis. Late post-operative complications are predominantly associated with contour irregularities, skin texture changes and pigment disorders such as hyperpigmentation. However, delayed seroma formation, persistent ecchymosis (probably to haemosiderin deposition) and paraesthesia/ dysaesthesia can also occur.

CONCLUSION

My preferred technique is the VASER-assisted liposuction that uses an UAL device that incorporates less energy with more efficient probes that emit acoustic energy from the sides rather than through the end of the cannula. The advantages of UAL are decreased bruising, reduced blood loss, overall faster healing, short downtime, and reduction

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in post-operative discomfort. We have often used UAL as a “fine-tuning” to treat liposuction irregularities in secondary cases, since it allows for more precision. Using the ultrasound selection of fat cells, we can affect only the irregular fat collections and the superficial subdermal fat layer will be preserved. UAL increases the safety and minimises risks because of the reduced trauma and minimised amount of blood removed through UAL. It is also associated with preservation of vascular and nervous structures. Ultrasonic assisted liposuction is intended to create improved body contouring and harmony. It is a safer technique for removing larger amounts of fat compared to other techniques or standard liposuction. Ultrasound action after surgery causes some weight loss all over the body with skin tightening that get noticed in the first six months, with remarkable tightening at the end of 18 months. Finally VASER-assisted liposuction by using less energy UAL can also be used in conjunction with fat grafting to breasts, buttocks or any other area of the body that may need augmentation. Please note that my preferred method of harvesting small amounts of small adipocytes for fat grafting to the face and dorsum of hands is by syringe aspiration using a multi-hole aspiration cannula followed by centrifugation to effectively remove oil, blood, impurities, and infiltrate fluid. AM REFERENCES 1. Schrudde J. Lipectomy and lipexheresis in the area of the lower extremities. Langenbecks Arch Chir. 1977;345:127–31. 2. Fischer G. First surgical treatment for modelling the body’s cellulite with three 5 mm incisions. Bull Int Acad Cosmet Surg. 1976;2:35–7. 3. Illouz YG. Body contouring by lipolysis: a 5-year experience with over 3000 cases. Plast Reconstr Surg. 1983;72(5):591–7. 4. Kelley L. Lipotoxic at low lidocaine levels. World Congress on Liposuction, Detroit, Michigan, 2000. 5. Klein JA. Tumescent technique: tumescent anesthesia and microcannular liposuction. St Louis: Mosby; 2000. 6. Kesselring UK, Meyer R. Suction curette for removal of excessive local deposits of subcutaneous fat. Plast Reconstr Surg. 1978;62(2):305–6. 7. Teimourian B, Gotkin RH. Contouring of midtrunk in overweight patients. Aesthet Plast Surg. 1989;13(3): 145–53. 8. Fournier PF, Otteni FM. Lipodissection in body sculpturing: the dry procedure. Plast Reconstr Surg. 1983;72(5):598–609. 9. Scuderi N, Paolini G, Grippaudo FR, Tenna S. Comparative evaluation of traditional, ultrasonic and pneumatic-assisted lipoplasty: analysis of local and systemic effects, efficacy and costs of these methods. Aesthetic Plast Surg. 2000;24(6):395–400. 10. Cimino WW. The physics of soft tissue fragmentation using ultrasonic frequency vibration of metal probes.Clin Plast Surg. 1999;26(3):447–63. 11. Tsai RY, Lin JY. Experience of tumescent liposuction in the treatment of osmidrosis. Dermatol Surg.2001;27(5):446–8. 12. Di Giuseppe A. Ultrasonically assisted liposculpturing: physical and technical principles and clinical applications. Am J Cosmet Surg. 1997;14(3):317–27 13. Z occhi ML. Ultrasonic assisted lipoplasty: technical refinements and clinical evaluations. Clin Plast Surg. 1996;23(4):575–98. 14. R ohrich RJ, Morales DE, Krueger JE, Ansari M, Ochoa O, Robinson Jr J, Beran SJ. Comparative lipoplastyanalysis of in vivo-treated adipose tissue. Plast Reconstr Surg. 2000;105(6):2152–8. 15. Fodor P. Moderator: Safety Considerations in Lipoplasty, Expert Exchange, Perspectives in Plastic Surgery 1999;13(2): 113–24.

Dr Sotirios Foutsizoglou developed a particular interest in anatomy during his time working in plastic and reconstructive surgery in the NHS. He became heavily involved in teaching anatomy and physiology to medical students and junior doctors and has worked as an anatomy demonstrator for Imperial College. He is currently completing his last year of training in plastic and reconstructive surgery at Evangelismos General Hospital of Athens. Since 2012, in his role as the lead trainer of KT Medical Aesthetics Group, he has been training practitioners in facial anatomy and advanced non-surgical treatments and procedures. He has written and lectured on facial anatomy and complications associated with injectables both nationally and internationally.

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

INMODE

Full facial rejuvenation Dr Dev Patel, medical director of Perfect Skin Solutions, shares his formula for combating the ageing effects of the sun using InMode’s Morpheus8 and Lumecca

hile sunlight is an abundant source of vitamin D, and a crucial ingredient for overall health, the UV radiation that comes along with it isn’t a matter to be taken lightly – and not just in relation to skin cancer. Although ageing is a natural process that affects the entire body, from bone density and muscle atrophy to neurological decline, sun damage remains one of the most overlooked signs of ageing with newcomers to my clinic. What many people remain unaware of is the accelerating impacts UV damage can have on ageing. UV radiation from the sun causes damage to skin cells, including their DNA. Excessive exposure can lead to signs of premature ageing, such as pigmentation, wrinkles, thinning of skin, and, in the most severe cases, skin cancer. Internally, UV radiation also speeds up collagen breakdown leading to skin laxity, which, combined with age-related loss of fat and bone, results in the loss of youthful projection. Patients will present various concerns such as droopy eyelids, jowls, and a sagging jawline or neck. Thanks to the cutting-edge radiofrequency technology of InMode’s Morpheus8 and Lumecca IPL, the fantasy of being able to globally treat every key component of ageing with one simple treatment protocol, from the skin’s surface down to the deeper zones, is now a reality. LUMECCA IPL Lumecca delivers intense pulsed light (IPL) like I’ve never encountered before and, along with Morpheus8 fractional radiofrequency treatment, is a breakthrough, thanks to InMode’s pioneering technology. In particular, it is highly effective against vascular and pigmented lesions, such as wrinkles and pigmentation as a result of ageing by UV damage from sun exposure. It promises complete photo-rejuvenation in one to two treatments, compared to four to six treatments with standard IPLs. After just one treatment to the hands, my first patient exclaimed it had “taken 20 years off”. The results are indeed phenomenal. MORPHEUS8 FRACTIONAL RF Morpheus8 is also one of the most impressive radiofrequency technologies I’ve seen in years. It’s a microneedling device that specifically targets not only the dermis for collagen production, resulting in tightness, but also deeper subdermal tissue, for remodelling and contouring. Large bursts of energy are delivered at a depth of 4,000 microns uniformly without any form of thermal damage to the skin. This kickstarts a natural anti-ageing process, where the dermal cells renew and rearrange, leading

to smoothing of wrinkles as the skin tightens, as well as the disappearance of hyperpigmentation scars when damaged skin cells are replaced with healthy ones. The lift, tightening and volume I can deliver to a patient’s face or any treatment area is astounding, especially when you consider that it’s a simple office procedure with negligible downtime. A POWERFUL COMBINATION Lumecca and Morpheus8 complement each other as an extraordinary powerhouse protocol that can reverse skin laxity, drooping and discolouration due to decades of sun damage, and even restore volume, which peaks six months to one year after the final treatment. By combining these two treatments in just a few visits to my clinic, I can deliver holistic and safe skin damage correction simply but very effectively, to give the skin a healthier and more youthful appearance.”

By combining these two treatments in just a few visits to my clinic, I can deliver holistic and safe skin damage correction simply but very effectively

Before

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For further information or to find a local clinic, contact InMode: T: 0208 9652594 E: info@inmodemd.co.uk W: inmodemd.co.uk Dr Dev patel is available at Perfect Skin Solutions, A: 121 Winter Rd, Portsmouth, South sea PO4 8DS E: info@perfectskinsolutions.co.uk T: 023 9275 4777 Consultants available in Harley Street, London.

Aesthetic Medicine • November 2019

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DEVICES

TREATMENT SPOTLIGHT

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Cool operator Dr Vincent Wong shares a case study using the UltraCool treatment

ombination treatments are known for enhancing results by allowing practitioners to blend together different technologies for increased efficacy and outcomes. Dr Vincent Wong use the UltraCool protocol in his clinic which he says, “gives patients a lifted appearance as well as a skin glow, making it an extremely popular non-invasive treatment with instantly visible results”. The treatment combines the UltraSkin II HIFU system (for lifting and tightening effects) with the Cool Laser (for skin quality improvement), both from Novus Medical. Promoted as a ‘non-surgical face-lift’, the UltraSkin II offers patients a pain-free way to reduce signs of ageing across the face without plastic surgery. Dr Wong says, “The UltraSkin HIFU has better precision and delivers focused ultrasound energy which heats up tissues safely at three different depths, namely the SMAS (at 4.5mm), deep dermis (at 3mm) and superficial dermis at 1.5mm.” The Cool Laser is a versatile Erbium laser. It’s short pulse duration allows the Cool Laser to deliver clinically significant results across a wide range of treatments without harming the surrounding skin conditions. It is also suitable for all skin types. Dr Wong likes combining the two treatments together. He says, “For this combination, the lowest fractional setting is used, where the laser beam is divided into 169 micro spots with a specific pattern of mutual distances. With this specific setting, the laser hits the skin at a depth of 13 microns. Because these spots are surrounded by untreated tissues, the healing process is distinctly more rapid and patients notice a healthy glow after the treatment.” AM

Patients notice a healthy glow after the treatment

CASE STUDY KL, a 57-year-old female patient of Chinese origin came into the clinic requesting treatments to achieve a lifted appearance, especially in the lower face and chin areas. KL was adamant that she did not want any injectable treatments, but wanted to look better for a family event taking place in 16 days time. She was in good health, with no significant past medical history and was not on any medications. On examination, KL pointed towards the areas that bothered her. There was some skin laxity around the jowl area and along the jawline, with a small amount of submental fat. Her skin was dull and dry, with evidence of chronological and photo-ageing. After explaining the procedure, downtime, pros and cons, KL was happy to proceed with the UltraCool treatment. Consent forms were signed and photos were taken. For the first part of the treatment, ultrasound gel was applied to her mid and lower face, before she was treated with the UltraSkin HIFU system. We progressed from 4.5mm, to 3mm and 1.5mm , with two passes each. The treatment was very well tolerated. This was then followed by a light peel with the Cool Laser. Topical recovery cream was applied after both procedures. KL was slightly red but there were no other signs of treatment otherwise. Photos were taken immediately post procedure and at the two-week follow up. There was a significant improvement to skin quality, jawline definition and a reduction in submental fat were clearly visible post procedure, and as expected, the results improved over the following two weeks.

Dr Vincent Wong has won a number of awards for his work and has been shortlisted as one of the Ultimate 100 Global Aesthetics Leaders. Dr Wong regularly runs training courses and workshops for other healthcare professionals and mentors junior doctors. He specialises in feminisation and masculinisation of faces within the LGBTQ+ community. He is actively involved in research and presents his work and research at national and international conferences.

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OUT AND ABOUT

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Out and about Out and about in the industry this month

Croma-Pharma press trip, Vienna, Austria New Aesthetic Medicine deputy editor Georgia Seago was among the group of journalists invited to Vienna by Croma-Pharma to mark the brand’s re-launch into the UK. On the first day of the trip, hosted by UK manager Julian Popple, the group enjoyed a walking tour of the city’s sights before a traditional Viennese dinner. The following day was spent at Croma’s HQ, where they were given a tour of the laboratory, offices and showroom spaces. The Croma team, including managing director Andreas Prinz, gave presentations on the company’s history and future plans for the UK market, starting with the re-launch of HA dermal filler brand Saypha, formally Princess Filler. Croma’s portfolio also includes PDO threads, a PRP system and personalised skincare brand, Universkin. A toxin is on the way too, set to launch in Europe around 2021. Prinz said the company wants to focus “completely on the healthcare practitioner”, supported by development of the Croma is More clinic management help and support programme. The final stop was Yuvell, Croma’s flagship clinic in the centre of Vienna, where managing director Valentina Prinz and Dr Daniel Müller talked through the clinic’s operation and approach to treatment delivery.

CCR, Olympia London CCR 2019 took place over two days at Olympia London with educational talks, a VIP lounge and new features including a programme on surgical and non-surgical aesthetic gynaecology, content from the BCDG and a live Vivacy symposium. Speakers included Mrs Sabrina Shah-Desai, Alice Hart-Davies and Dr Tristan Metha.

Aesthetic Medicine • November 2019

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OUT AND ABOUT

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Sinclair Pharma masterclass, Royal College of General Practitioners, London Sinclair Pharma held a masterclass for users of its product portfolio, which includes Ellansé, Silhoutte Soft and Perfectha, to update them on the latest techniques, recommendations and research for the use of dermal fillers and threads. The day was divided into three parts: the upper face, mid face and lower face, with live demonstrations and speakers including Dr Pierre Nicolau, who provided anatomy overviews throughout, Dr Tahera Bhojani-Lynch, Dr Victoria Manning, Dr Charlotte Woodward; Dr Tim Eldridge and Dr Martin Kinsella.

Endosphères aesthetic beauty trends breakfast, The AllBright Mayfair, London Compressive microvibration devices brand Endosphères held a press breakfast hosted by Safety in Beauty founder Antonia Mariconda to reveal aesthetic beauty trend predictions for the future. Mariconda talked through the trends while guests enjoyed breakfast snacks. Mariconda identified the overarching themes set to influence the industry as: next generation genetics, the all inclusive consumer, virtual reality, nature hacking and the informed consumer. She also talked through the top facial and body aesthetic trends for 2020, including body sculpting via electromagnetic technology, new Korean toxins and micro channelling treatments.

SkinPen afternoon tea, The Allbright Mayfair, London The BioActive Aesthetics team assembled a group of microneedling experts for a SkinPen presentation over afternoon tea. The event covered how the device can be used and what indications it can treat, plus new findings and research into future applications. Speakers included Dr Andy Williams, burns consultant and plastic surgeon, Dr Maryam Zamani, occuloplastic surgeon and aesthetic doctor; and Dr Benji Dhillon, cosmetic surgeon and founder of Define Clinic.

Aesthetic Medicine • November 2019

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