Aesthetics September 2019

S IC 19 IDE ET 20 S N TH DS I ES R S A A IST AW AL N

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VOLUME 6/ISSUE 10 - SEPTEMBER 2019

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Anatomy of the Jaw CPD Dr Tracey Bell details the anatomy and classifications of the jaw

Special Feature: Retaining your Reception Team Practitioners explain their top tips for a happy reception team

Toxin for Nasal Corrections Dr Ahmed El Houssieny explores botulinum toxin A for nasal concerns

Discussing Pay Increases

Victoria Vilas provides advice for employers and employees regarding pay rises

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Contents • September 2019 06 News The latest product and industry news 16 Advertorial: Galderma & Med-fx A Q&A with the representatives on the new distribution agreement 19 CCR Preview

A preview of the exciting agendas taking place at CCR 2019

20 News Special: Aesthetic Complications

Aesthetics looks at BCAM’s recent aesthetic complication statistics

21 Advertorial: Tor Generics Ltd

Introducing the single-dose bacteriostatic saline solution

Special Feature: Retaining your Reception Team Page 23

CLINICAL PRACTICE 23 Special Feature: Retaining your Reception Team

Practitioners provide their top tips for building a happy reception team

28 CPD: Jaw Classifications and Anatomy

Dr Tracey Bell explores jaw anatomy and classifications

33 Nasal Correction Using Toxin

Dr Ahmed El Houssieny advises how to treat the nose using botulinum toxin

36 Aesthetics Awards 2019 Finalists Announcing the long-awaited 2019 Aesthetics Awards finalists 42 Case Study: Treating Acne Scars

Nurse prescriber Adrian Baker presents a successful acne scar case study

46 Understanding Appearance Psychology

Dr Kathleen Long details how practitioners can use mirrors to improve patients’ perceptions of their appearance

48 Treating the Tear Trough

Ophthalmologist Miss Jennifer Doyle shares her top tips for successful tear trough treatments

50 Advertorial: Croma-Pharma

Aesthetics speaks to Croma-Pharma about its HA products and new affiliate office in the UK

53 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 55 Consent in Aesthetics

Dr Claudia Petillon discusses the importance of consent post-Montgomery

59 Discussing Pay Increases

Operations and marketing manager Victoria Vilas shares advice for handling requests for a salary increase

62 Understanding the Employee Lifecycle

HR advisor Tania Jarman outlines the five stages of employment

64 Working with Your Partner

Aesthetics speaks to several business owners about what it’s like to work with their spouse

In Practice: Discussing Pay Increases Page 59

Clinical Contributors Dr Tracey Bell is an aesthetic practitioner with 25 years’ experience as a qualified dentist. Dr Bell is the owner of four dental and aesthetic clinics in the Isle of Man and the UK and has a Master’s in Dental Law and Ethics and a General Diploma in Law. Dr Ahmed El Houssieny is a trained anaesthetist with a passion for aesthetics. He is an Honorary Lecturer at the University of Chester and an education provider on cosmetic procedures. Dr El Houssieny is a member of the British Society of Aesthetics.

Adrian Baker is a nurse prescriber and has worked in aesthetics for nine years. He is the director of Lumiere MediSpa based in Oxford. He is also the coauthor of the RCN accredited BACN Aesthetic Nursing Competency Framework from 2013-2016.

Dr Kathleen Long qualified in 1976 and currently works as a locum GP and aesthetic practitioner. She is the president of the British Medical and Dental Hypnosis Society (Scotland) and president elect of the European Hypnosis Society.

Miss Jennifer Doyle has a Bachelor in Medicine and a Bachelor of Surgery, as well as a Master’s in Medical Sciences from the University of Oxford. Miss Doyle currently works as an NHS registrar in Ophthalmology, as well as leading her clinic, Oxford Aesthetics.

67 In Profile

Consultant plastic surgeon Mr Taimur Shoaib reminisces about his career

69 The Last Word

Dr Hennah Bashir argues why she believes celebrities should be more transparent regarding their treatments

NEXT MONTH

AESTHETICS AWARDS 2019 FINALISTS PAGE 36!

• IN FOCUS: Energy • Tattoo Removal Technologies • Delayed Onset Nodules • Tips for CQC Registration

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Editor’s letter Congratulations to all our Aesthetics Awards Finalists, revealed on p.36! Almost 200 clinics, companies, products and professionals will be recognised at the most prestigious event in the aesthetics calendar on December 7. This will be my sixth Aesthetics Awards ceremony Chloé Gronow and I can honestly say, it gets better and better Editor & Content Manager each year. In 2014, we had 21 categories and 500 guests, this year we have 26 categories, ensuring we celebrate all areas of the specialty, and are expecting more than 800 guests! The evening is always a fantastic time to unwind and reflect on everyone’s achievements throughout the year, and we are always blown away by the efforts so many people and companies go to in order to maintain patient safety, as well as the extremely high standards everyone upholds.

This is also a busy month for events – the team and I will be attending the AestheticSource Symposium on September 6, Allergan Spark Exhibition on the 14th and 15th, the IAPCAM conference on the 20th, BCAM’s annual conference on the 21st and the Aesthetic Business

Conference by Hamilton Fraser on the 26th. It will be great to catch up with everyone after the summer and learn more about how your clinics have developed, so do keep an eye out for myself, our deputy editor, Shannon and journalist, Megan.

Now, onto our September issue! This month we have explored HR challenges and how to build a trustworthy and successful team.

After hearing reports from a number of practitioners about the challenges of retaining a reception team, we spoke to two clinic owners on p.23 about how they overcome these. HR consultant Tania Jarman also explores the employee lifecycle on p.62, while recruitment specialist Victoria Vilas advises on pay rises on p.59.

Finally, we have a heart-warming article on p.64 all about working with your partner. It seems to be a common occurrence in aesthetics that many couples run their clinic together, with one person leading on the clinical aspects, while the other manages the commercial side of things. If you’re thinking of going into business with your partner but aren’t sure how to strike a positive work-life balance, then do read our interviews with three successful couples who’ve managed to do just that!

Clinical Advisory Board

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

WE WANT TO HEAR FROM YOU!

Mr Dalvi Humzah is a consultant plastic, reconstructive and aesthetic surgeon with more than 20 years’ experience and is director of P&D Surgery. He is an international presenter, as well as the medical director and lead tutor of the multi-award-winning Dalvi Humzah Aesthetic Training courses. Mr Humzah is founding member of the Academy of Clinical Educators at the Royal College of Physicians and Surgeons of Glasgow.

Mr Dalvi Humzah, Clinical Lead

Do you have any techniques to share, case studies to showcase or knowledge to impart?

Sharon Bennett is chair of the British Association of Cosmetic Nurses (BACN) and the UK lead on the BSI committee for aesthetic nonsurgical medical standards. She is a registered university mentor in cosmetic medicine and has completed the Northumbria University Master’s course in non-surgical cosmetic interventions.

Dr Christopher Rowland Payne is a consultant dermatologist and internationally recognised expert in cosmetic dermatology.

As well as being a co-founder of the European Society for Cosmetic and Aesthetic Dermatology (ESCAD), he was also the founding editor of the Journal of Cosmetic Dermatology and has authored numerous scientific papers and studies.

Mr Adrian Richards is a plastic and cosmetic surgeon with 18 years’ experience. He is the clinical director of the aesthetic training provider Cosmetic Courses and surgeon at The Private Clinic. He is also member of the British Association of Plastic and Reconstructive and Aesthetic Surgeons and the British Association of Aesthetic Plastic Surgeons.

Dr Raj Acquilla is a cosmetic dermatologist with more than 12 years’ experience in facial aesthetic medicine. In 2015 he won the Aesthetics Award for Aesthetic Medical Practitioner of the Year and in 2012 he was named Speaker of the Year. Dr Acquilla is a UK ambassador, global KOL and masterclass trainer for botulinum toxin and dermal fillers.

Dr Stefanie Williams is a dermatologist with special interest in aesthetic medicine.

She is the founder and medical director of the multi-award winning EUDELO Dermatology & Skin Wellbeing in London. She lectures in the Division of Cosmetic Science and has published more than 100 scientific articles, book chapters and abstracts.

Jackie Partridge is an aesthetic nurse prescriber with a BSc in Professional Practice (Dermatology). She has recently completed her Master’s in Aesthetic Medicine, for which she is also a course mentor. Partridge is a founding board member of the British Association of Cosmetic Nurses and has represented the association for Health Improvement Scotland.

Dr Tapan Patel is the founder and medical director of PHI Clinic. He has more than 16 years’ clinical experience and has been performing aesthetic treatments for more than 14 years.

Recently, he was listed in Tatler’s Top 30 AntiAgeing Experts. Dr Patel is passionate about standards in aesthetic medicine.

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

She is the clinical director of Revivify London, an honorary clinical teacher at King’s College London and a visiting associate professor at Shanghai Jiao Tong University.

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EDITORIAL Chloé Gronow • Editor & Content Manager T: 0203 196 4350 | M: 07788 712 615 chloe@aestheticsjournal.com Shannon Kilgariff • Deputy Editor T: 0203 196 4351 M: 07557 359 257 shannon@aestheticsjournal.com Megan Close • Journalist T: 0203 196 4363 M: 07557 359 257 megan@aestheticsjournal.com MARKETING Aleiya Lonsdale • Head of Marketing T: 0203 196 4375 | aleiya.lonsdale@easyfairs.com Annabelle Arch • Marketing Manager T: 020 3196 4427 | annabelle.arch@easyfairs.com DESIGN Peter Johnson • Senior Designer T: 0203 196 4359 | peter@aestheticsjournal.com

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© Copyright 2019 Aesthetics. All rights reserved. Aesthetics is published by Aesthetics Media Ltd, which is registered as a limited company in England; No 9887184 ABC accredited publication DISCLAIMER: The editor and the publishers do not necessarily agree with the views expressed by contributors and advertisers nor do they accept responsibility for any errors in the transmission of the subject matter in this publication. In all matters the editor’s decision is final.

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Skincare

Talk #Aesthetics Follow us on Twitter @aestheticsgroup and Instagram @aestheticsjournaluk

#Celebration BAAPS @BAAPSMedia We’re 40 this year! We’re extremely grateful to those who have served the Association over the years to make #BAAPS what it is today

#Training Dr Ash Labib @ashlabib It’s the end of three successful visits to Dublin! 6 masterclasses, 33 delegates advanced Volux training and lots more! Thanks to the amazing team @kyram90 for their support, I thoroughly enjoyed it! #AllerganUK #ALMedicalAcademy #Teamwork Facial Aesthetics @facial.aesthetic.courses We hope everyone has had a fantastic summer. We pride ourselves on what an experienced, hard-working team we have at Facial Aesthetics and decided to celebrate that yesterday by having a day out at the Edinburgh Fringe! #Knowledge Dr Olha Vorodyukhina @dr_olha I love working with these professionals! Here’s us at the Cosmetic Courses experts meeting, the Nottingham team!

Sharing knowledge is the key to success. #Mentorship #Training #ExpertNurse Lou Sommereux @lousommereux BACN educational working party in London this afternoon.

Re-visiting and rewriting the BACN RCN-accredited competencies! #EducationalPathway

SkinCeuticals releases pigmentation serum Cosmeceutical company SkinCeuticals has released a new serum that aims to address visible discolouration in skin to deliver a brighter, more even tone.

The Discoloration Defense Serum is formulated to address pigmentation triggered by inflammatory processes in the skin such as melasma caused by hormonal changes and acne scarring, according to SkinCeuticals.

The product contains 1.8% tranexamic acid, 5% niacinamide, and 5% 4-(2-hydroxyethyl)-1piperazineethanesulfonic acid (HEPES).

A 12-week single-centre clinical study looked at 63 females, aged 26-60, with Fitzpatrick I-IV and mild to moderate facial pigmentation, including melasma, post-inflammatory hyperpigmentation and hyperpigmentation, who applied Discoloration Defense Serum to the face twice a day in conjunction with a sunscreen. Patients demonstrated a statistically significant reduction in the appearance of post-inflammatory discolouration and uneven skin tone, including a 41% average reduction in the appearance of melasma, according to the company. Dr Alexis Granite, a consultant dermatologist practising at the Cadogan Clinic and Mallucci London, said, “In clinic, I use the serum as a complement to professional discolouration treatments, such as chemical peels. I also recommend Discoloration Defense Serum for daily home use by patients whom wish to break the pigmentation cycle and take a long-term approach to the care of their skin to provide a clearer, more revitalised complexion.”

Dermal fillers

New MD Code injection techniques to launch Plastic surgeon Mr Mauricio de Maio is unveiling two new dermal filler injection techniques to treat the chin and jawline, in conjunction with global pharmaceutical company Allergan.

The new MD Codes – the 7-POINT-SHAPE for women and 9-POINT SHAPE for men – include a combination of Juvéderm dermal filler products and treatment points for the cheek, chin and jawline for results lasting 18-24 months. According to Allergan, both protocols feature Juvéderm Volux, a structural facial filler and the latest innovation in the Juvéderm range designed to sculpt the chin and jawline, and Juvéderm Voluma with lidocaine. To launch the new MD Codes, Mr de Maio will host an immersive digital tutorial webinar to medical professionals through the Allergan Medical Institute on September 12. The session will introduce the new protocols live, as well as introduce Juvéderm Volux, demonstrating how and when to use this product alongside Juvéderm Voluma with lidocaine to revitalise the lower face.

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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Conference

Galderma to host unmissable education at ACE 2020

Vital Statistics A UK study of more than 20,000 adults indicated that women who work more than 55 hours per week may have a higher risk of depression (United Kingdom Household Longitudinal Study, 2019)

94% of dermatologists agree that unregulated tanning salons are contributing to skin cancer cases in the UK (British Skin Foundation, 2019)

The UK arm of global pharmaceutical company Galderma has been confirmed as the Headline Sponsor of the award-winning Aesthetics Conference and Exhibition (ACE) taking place on March 13-14 2020.

Galderma is gearing up for its biggest ACE to date, hosting four two-hour sessions in the main auditorium. Each session will be available to healthcare professionals only and prior event registration will be required via DocCheck. Galderma is excited to bring industry renowned injectors and highquality education to the stage of ACE this year.

The free education is worth two CPD points for every session attended and will be open to 250 doctors, dentists and nurses. Toby Cooper, head of medical solutions at Galderma UK said, “We want to reach a wide audience of healthcare professionals to inform them of the significant benefits we will be looking to deliver to the market in 2020 and beyond. ACE is the ideal place to do this due to its wide reach and strong attendance figures.” From September, product distributor Med-fx has been confirmed as Galderma’s sole-preferred distributor. Together, the companies will reveal a ‘suite of unparalleled services’ at ACE, which Cooper says will unlock significant benefits for the whole industry, including patients. Cooper continued, “We will use ACE as our launch platform and look forward to enhancing and adding to the services in the months and years that follow.”

Jenny Claridge, commercial director at Aesthetics Media, said, “We are thrilled that Galderma will be ACE’s Headline Sponsor in 2020. In a change of format this year, our headline sponsor will host two days of education on the latest updates to non-surgical aesthetic practice. With a stellar reputation and extremely knowledgeable KOLs, we are sure that these sessions will be a huge success and directly benefit delegates’ continued professional development.” Registration for ACE 2020 will be open in October. More details of the Galderma education at ACE and how you can confirm your place will be released in the coming months. To stay updated, opt-in to email communications on ‘ACE Updates’ via your Aesthetics website profile.

The top surgical procedure for males last year was rhinoplasty, up 3% from the previous year (British Association of Aesthetic Plastic Surgeons, 2019)

81% of small businesses still rely on email as their primary customer acquisition channel. 80% rely on it for customer retention (Emarsys, 2018)

The global hair removal device market is forecasted to rise to an estimated 1.35 billion US dollars by 2022 (Statista, 2019)

70% of aesthetic practitioners said that they would like more support when setting up their business

(Hamilton Fraser Cosmetic Insurance, 2019)

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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Events Diary 20th September International Association for Prevention of Complications in Aesthetic Medicine Symposium www.iapcam.co.uk 21st September British College of Aesthetic Medicine Conference www.bcam.ac.uk 10th-11th October CCR Expo & BAAPS Annual International Conference www.easyfairs.com/ccr-expo-2019 www.baaps.org.uk

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Learning

Allergan to host first Spark Exhibition Global pharmaceutical company Allergan will host the first Spark Exhibition on September 14 and 15. Allergan Spark is a support website that aims to provide ongoing clinical and business support for new and experienced healthcare professionals.

The exhibition will be open to doctors, dentists and nurses in the field of medical aesthetics held at the newly-refurbished headquarters in Marlow. The event, which is free to attend, will be more specifically targeted to those who consider themselves in the early years of their medical aesthetic journey, but is also suitable for more experienced colleagues to network, Allergan explains. The two-day agenda will feature Allergan product talks, live demonstrations by the company’s appointed training providers Cosmetic Courses and Harley Academy, and business consultant talks on topics including business planning, digital marketing, the patient journey and more. As well as this, there will be a number of clinical sessions on aseptic techniques, patient assessment, and anatomy and physiology, as well as an industry specific session with aesthetic supplier Healthxchange and Hamilton Fraser Cosmetic Insurance, discussing, amongst other topics, product supply, data management and photography.

Energy

7th-8th November British Association of Cosmetic Nurses Conference www.bacn.org.uk

7th December The Aesthetics Awards 2019 www.aestheticsawards.com

Book

New resource published on PRP and microneedling Thieme Medical Publishers has released a new book authored by US board-certified dermatologists Dr Amelia Hausauer and Dr Derek Jones, titled PRP and Microneedling in Aesthetic Medicine. The publisher explains that readers will learn how to evaluate and critically appraise various approaches to this treatment and leverage evidence-based methods to guide best practices. The book is also supported by more than 100 images illustrating anatomy and techniques, as well as 10 short online videos.

EMsculpt can now treat arms and legs Device manufacturer BTL Aesthetics has released a new applicator for its EMsculpt device called the Small Contour Applicator, which enables treatment of the triceps, biceps and calves. The device, which was originally designed to be used on the abdomen, thighs and buttocks, uses high intensity focused electromagnetic field (HIFEM) energy that aims to build muscle and reduce fat simultaneously. BTL Aesthetics explains that four 20-minute procedures are recommended and two of the new applicators are provided, allowing the areas to be treated simultaneously. Lee Boulderstone, managing director at BTL Aesthetics said, “Since launching EMsculpt in October last year and receiving a hugely positive response from physicians, patients and the national press, we’ve seen a substantial demand from physicians and patients to bring the technology to other tough-to-target areas of the body. We are therefore delighted to announce the launch of our small contour applicators in the UK.” Acquisition

ClearCourse acquires e-clinic Technology company ClearCourse Partnership LLP, commonly known as ClearCourse, has acquired clinic management software provider e-clinic.

According to the company, e-clinic is designed to streamline operations through workload automation and workflow management. In a statement released by ClearCourse, the company explained it will work closely with e-clinic’s senior team, providing operational expertise and financial resources to bolster and support the company’s growth strategy and continued platform development. e-clinic will also gain access to improved payments infrastructure and other technology products, including data validation services, from within the partnership, the company claims.

Gerry Gualtieri, CEO of ClearCourse, commented, “e-clinic is a dynamic new addition to ClearCourse Partnership. We see great opportunity for commercial synergies particularly around the provision of payments and membership management tools. We’re excited to work closely with the team to realise those synergies and support e-clinic’s continued growth and development.” Mark Lainchbury, managing director of e-clinic, added, “We’re very proud to have built e-clinic into the highly successful, market-leading business that it is today. By joining ClearCourse Partnership, we have access to a valuable range of resources and operational expertise that will allow us to continue to grow, develop and realise our ambitious plans for the future. We remain dedicated to creating the best possible product for our clients so that we can continue to improve patient care around the world.”

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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Skincare

New skincare sales platform Harley launches A new platform that aims to empower practitioners to sell skincare has launched. Named Harley, the technology is designed to make selling skincare easy and pleasurable for practitioners, whilst prompting repeat purchases and providing a premium, personalised service for each patient. Once a practitioner performs a skin consultation (in clinic or online), they enter the patient’s recommended product regime directly into the online platform, providing a URL for the patient to view. The patient can then decide to buy the products from the clinic or have the products posted directly to their doorstep by Harley. The company then takes a percentage of every skincare product sold. According to Harley, it’s ideal for patients who want to think about the products before purchasing, enabling them to purchase later via the link sent directly to their phone. Charmaine Chow, founder and CEO of Harley, said that 70% of patients added to the Harley platform end up purchasing skincare regimens. “Early adopters of Harley have enabled us to provide some encouraging statistics for those who are contemplating joining the platform. We estimate that the profit opportunity generated by using Harley without ‘physically’ stocking any product is between £150-300,000 per year for a mid-sized clinic.

These are very attractive economics, especially as we don’t charge to use the Harley platform and instead take a very fair percentage of profit,” Chow said.

Harley will be officially launching at CCR on October 10 and 11. The company will be at stand A22 and will also feature in the Clinic & Practice Management Conference agenda.

Industry

JCCP publishes prescribing guidance The Joint Council for Cosmetic Practitioners (JCCP) has published new guidance for responsible prescribing for cosmetic practitioners.

In a statement released by the JCCP and Cosmetic Practice Standards Authority (CPSA), they confirmed that they do not endorse or permit the remote prescribing of any prescription medicine when used ‘specifically’ for non-surgical cosmetic treatments. In circumstances when a prescriber delegates treatment to other practitioners, the JCCP highlights that the patient remains under the oversight of the prescriber, requiring that the prescriber must be familiar with the patient through an initial face-to-face consultation and diagnostic assessment. This applies to all prescription-only medicines used specifically for cosmetic purposes whether they be injectable, topical or oral, the JCCP stated. Alberto Costa, South Leicestershire MP and chair of the All Party Parliamentary Group on Beauty, Wellbeing and Aesthetics said he is in support of the new guidance. Costa said, “Remote prescribing for non-surgical cosmetic procedures can be unsafe and harmful and should not be used under any circumstances. This is a great first step to further protect consumers who choose to undergo non-surgical cosmetic procedures.”

Costa added, “This will help to close the ‘loopholes’ that currently exist in which injectables, which are prescribed by healthcare professionals, can be remotely prescribed and delegated to anyone without first assuring that professional face-toface patient assessment and clinical oversight is provided in all circumstances.”

The new guidance has also been reviewed with the General Medical Council and the General Dental Council, which have confirmed it is consistent with their own.

BACN UPDATES A roundup of the latest news and events from the British Association of Cosmetic Nurses

BACN REGIONAL MEETINGS Throughout September, the BACN will be traveling the country for regional meetings across the UK. One piece of feedback acquired from earlier meetings was the amount of peer-to-peer reviews allocated within agendas. BACN events manager, Tara Glover, has therefore increased the amount of time during the day for these vital and invaluable sessions to take place. As the industry changes at such a rapid rate, sharing experiences with products, patients and in practice has never been more important, and bringing together knowledge and support is really what the BACN is all about. Whether you are new to aesthetics and are looking to make some like-minded friends, or if you are an experienced practitioner who is keen to share knowledge and experience, these sessions are a safe space for open discussion and peer-to-peer learning.

• • • •

Bristol: September 4 Newcastle: September 6 Cardiff: September 11 Leeds: September 19

BURSARY PROGRAMME The BACN/Church Pharmacy Bursary Programme has launched and we are now taking applications for those looking for financial support to study the V300 Independent Prescribing qualification, or for those who are looking at undertaking innovative research within the study of aesthetics.

Application processes and further details surrounding the programme can be found on the education section of the BACN website.

BACN SOCIAL MEDIA PROFILES The BACN has an active social media presence and it’s a fantastic opportunity for members to showcase themselves as members of the largest association for aesthetic nurses in the UK. We are looking for members who want to promote themselves and offer insight into what it’s like to be a BACN member and a nurse working in aesthetics. If you are interested and want to find out more, drop an email to Gareth Lewis, BACN membership and marketing manager at glewis@bacn.org.uk.

This column is written and supported by the BACN

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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Devices

Sinclair Pharma expands into new UK territory Pharmaceutical company Sinclair Pharma has now appointed an account manager to represent the Yorkshire and Nottinghamshire regions. Louise Higginson has joined the company as aesthetic account manager and will be responsible for growing a new territory and expanding the use of Silhouette Soft threads, as well as dermal fillers Ellansé and Perfectha, in the North of England. Higginson has a background in the dental sector, but most recently worked at regenerative medicine company BTI-Biotechnology where she was responsible for sales of platelet-rich plasma, platelet concentrate and autologous filler.

Jo Neal, Sinclair Pharma UK brand manager, said, “We are thrilled to have Louise on board, she is now the ninth member of our ever-growing UK and Ireland sales team, who are going from strength to strength as Sinclair continues to expand globally.”

3D-lipo launches 3D-HydrO2 Facial Aesthetic device manufacturer 3D-lipo Ltd has introduced the 3D-HydrO2 Facial machine to its portfolio.

According to the company, the 3D-HydrO2 uses seven different technologies to target facial skin concerns including hydration, oxygenation, antiageing, brightening, skin tightening and congestion for a more glowing, youthful appearance.

These technologies include radiofrequency skin tightening, hydro peel, deep cleanse, oxygenation, skin lifting, hydration and a cryo facial, which are combined for a complete prescriptive approach depending on the individual patient’s skin concerns, the company states. To celebrate the launch of the 3D-HydrO2 Facial machine, 3D-lipo Ltd are hosting an exclusive launch event on September 23 at its training centre and head office in Warwickshire.

Industry

Recruitment

CQC rates first aesthetic clinic as ‘Outstanding’ North-Leeds based clinic Aesthetic Health Ltd has become the first doctor-led aesthetic clinic to be graded as ‘Outstanding’ by the independent regulator of all health and social care services in England, the Care Quality Commission (CQC).

The CQC regularly inspects its registered clinics and provides them with an inspection report and rating, which can be accessed by the public and shows an overall judgement of the quality of care. The services are ranked as inadequate, requires improvement, good or outstanding and clinics are inspected at least once every five years. Although the CQC has confirmed that Aesthetic Health Ltd is the only doctor-led aesthetic clinic to be graded as ‘Outstanding’, they note that the focus of the inspection was on the treatment of disease, disorder or injury and diagnostic and screening services, rather than its antiageing treatments as these are not reviewed by the CQC. In their report, Dr Rosie Benneyworth, chief inspector of Primary Medical Services and Integrated Care at the CQC noted several points of outstanding practice. “These included offering care and treatment free of charge if treatment had the potential to be of significant benefit to vulnerable patients, a programme of local and national charity engagement, positive staff experiences with high levels of personal and professional support, and an empowering business culture that contributed to high standards of patient care and satisfaction,” she said in the report. Aesthetic practitioner Dr Julia Sevi, Aesthetic Health owner, said, “I am immensely proud that the dedicated work of the Aesthetic Health team has been recognised. They never settle for good if better is possible and are always going the extra mile to exceed expectations. An ‘outstanding’ grading recognises not only that required standards are fulfilled, but that the clinic goes above and beyond, setting aspirational standards of compassionate care and finding inventive solutions for our patients. Our clinic culture actively seeks and embraces every opportunity to serve our patients, to the highest standards, with individualised, safe and compassionate patient care, hence why CQC standards are integral to our clinic values.”

Enhance Insurance appoints new team member Insurance and risk management broker Enhance Insurance has appointed April Whiting as its new junior account holder. Whiting has experience in customerfocused environments and will be assisting with administrative duties and liaising with clients and insurers as part of her new role, Enhance Insurance explains.

Business development executive at Enhance Insurance, Sharon Allen added, “April has been a welcome addition to the team and in the short time that April has been with us she has demonstrated her commitment to customer service and eagerness to continue to develop her knowledge of the industry and products and we are very pleased to have her onboard.” April Whiting said, “Working at Enhance Insurance combines my passion for the beauty and cosmetics industry with the knowledge of insurance and customer care skills. The forward thinking of the Enhance team, along with their commitment to improve patient safety, was what drew me to join the team.”

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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Training

Facethetics Training launches Level 6 course in injectables Liverpool-based aesthetic training provider Facethetics Training has launched a new Level 6 course for healthcare professionals (HCPs), accredited

by Gatehouse Awards, which will appear on the Register of Regulated Qualifications, operated by Ofqual. The course is designed for HCPs looking to practice botulinum toxin and dermal filler injectable procedures and was devised by directors of the company, aesthetic nurse prescriber Yvonne Senior and training coordinator Alison Stananought. Senior said, “We’ve created something really in-depth and unique, with our students benefiting from e-learning, real-life injecting, supervision and assessment, as well as post-course support. By staging the path to Level 7 with the introduction of our first Level 6, we’ve been able to break down the learning process into a more cost and time efficient one.”

Learning

Skinade to host seminars this month Health supplement Skinade has confirmed that it will be hosting a series of educational seminars this month across the UK and Ireland. The company has explained that delegates who book onto one of the sessions will be able to expand their knowledge in the Skinade portfolio, including the recently launched Targeted Solutions and MD Pre+Post Care Programme. Louise Marchesin, sales and marketing director said, “We are incredibly proud to be launching these new and exciting product ranges and delivering our educational seminars this month. Attendees can expect an in-depth training on our new products as well as a recap on our core product too. There will also be input from some of our committed stockists and attendees will get the chance to be the first to stock our new ranges!” The first sessions will be held on September 9, 11, 16, 18 and 30 in Manchester, Edinburgh, London, Bath and Dublin, respectively.

Male patients

Superdrug treats 18% of male patients for injectables High street retailer Superdrug has announced that one in five of all patients treated in the last year on its Skin Renew Service featuring botulinum toxin and filler treatments have been male, with an average age of 45-49 years. Women treated were of an average age of 50-54 years, Superdrug reports. Aesthetic practitioner Dr Alex Parys isn’t surprised by these statistics. He commented, “The number of men seeking non-surgical aesthetic treatments has definitely seen an increase over the years, and these figures are reflective of the trend in my own practice, where nearly one in four of my patients are male. In terms of why more men are seeking treatments, I suspect one of the biggest factors is the rise of social media and reality TV such as Love Island, where the men featured are both much more open about having aesthetic treatments, but also are partially chosen for their good looks in order to attract both viewers and other contestants. In regards to the age ranges reported by Superdrug, these may be slightly out of the target demographics of Love Island, and could therefore represent other influences, such as divorce, mid-life stressors/crisis or a general boost for self-confidence.”

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Patrick Johnson, CEO of Celluma What should practitioners know about the Celluma?

To a certain degree, there is a misperception of LED therapy in aesthetics. It’s often mistaken for a ‘poor man’s laser’, and nothing is further from the truth. In aesthetics, we insult vital tissue in order to illicit a healing response on the part of the body. Unfortunately, the insult also triggers an inflammatory response, which slows the body’s healing abilities. So, we end up working at cross purposes. This is really when the Celluma becomes a valuable silver bullet.

Using the Celluma following any mildly or deeply ablative procedure will serve not only to reduce the inflammatory reaction, but also provide the body with additional energy to heal the tissue.

The Celluma is an ideal adjunct to almost any aesthetic treatment as a stand-alone service or in a series for antiageing, acne or tissue repair.

What kind of training is required and available?

The Celluma is a Class IIa medical device that can be easily used by anyone on staff. Smaller Celluma Panels may be resold to patients for maintenance between appointments. The Celluma is very safe and very easy to use.

Having said that, we offer Level 4-certified training in the UK for Celluma practitioners. The course not only covers the use and application of the Celluma, but also teaches the biochemistry and optical physics involved for optimal delivery of low-level light therapy. Course attendees will come away fully educated about the clinical benefits with protocols for immediate integration into practice.

What’s in the pipe line for Celluma?

We are very excited to introduce our newest additions, the Celluma DELUX and DELUX XL to the Celluma series of light therapy devices.

These two models are the first ever portable, space-saving, full-body LED devices. The Celluma DELUX and Celluma DELUX XL, which hang on the back of a door when not in use, offers all the advantages of a light therapy bed without the space requirement or exorbitant price tag.

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Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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Diversity

Majority of dermatologists agree on national ban for sunbeds A survey conducted by the British Skin Foundation has suggested that 77% of British dermatologists agree that sunbeds should be banned in the UK. The survey, answered by 245 dermatologists out of 650 in the UK, also found that 94% agree that unregulated tanning salons are contributing to skin cancer cases, with the same percentage agreeing that there should be stricter enforcement of age restrictions on their use. British Skin Foundation communications manager, Lisa Bickerstaffe commented, “The dermatologists’ opinions appear to support research stating the potential to get skin cancer, including melanoma, is increased in those who have also used sunbeds. We know that there is no such thing as a safe tan from UV rays, therefore, the British Skin Foundation, in line with other health organisations does not recommend sunbed use.” Consultant dermatologist and Aesthetics Clinical Advisory Board member Dr Christopher Rowland Payne said, “Sunbeds, like smoking, cause cancer.” He believes that more can be done to recognise sunbedusers in practice too. He explained, “Sunbed users can be recognised by healthcare professionals, aestheticians and beauticians by the six S’s, which stand for the Sunbed Suntan SacroScapular Sparing Sign; an easily recognised physical sign seen in sunbed users and abusers. It’s so important to stress the dangers of sunbed use to patients as not only are they linked with cancers they also cause brown spots, white spots, open pores and wrinkles.”

Allergan supports new LGBTQ+ campaign Global pharmaceutical company Allergan has confirmed its support for aesthetic practitioner Dr Vincent Wong’s campaign #IAMME. The campaign is the first of its kind designed for those of the LGBTQ+ community (which recognises lesbian, gay, bisexual, transgender, intersex, queer/questioning and asexual individuals) to promote safety inclusivity in the wellbeing and medical aesthetics specialty.

The #IAMME campaign will feature an eight-part video series, released on the first Wednesday of every month, where Dr Wong will share his key messages about finding pride from within, eradicating fear and creating inclusion for safer medical treatments. Dr Wong commented, “I strongly believe that there is room in the medical aesthetics industry to make a difference. I’m very proud and honoured to be working with a global pharmaceutical company, Allergan, in this exciting campaign.”

Digital

Mrs Sabrina Shah-Desai releases virtual reality app Reconstructive oculoplastic surgeon and founder of the Oculo-facial Aesthetic Academy (OFAA) Mrs Sabrina ShahDesai has launched a virtual reality (VR) app for delegates.

By wearing the VR headset, practitioners will be able to learn holistic facial assessment, advanced filler injection techniques, detailed cadaver anatomy and gain practical knowledge on how to use hyaluronidase to manage complications, Mrs Shah-Desai explains.

She commented, “I want to unleash the potential of aesthetic training by fusing it with modern technology, to give practitioners the best possible learning experience. We have come a long way from traditional classroom lectures and paper-based learning, and more and more practitioners are looking to update their knowledge using modern technology.

Delegates want to learn in their own time, without the expense and challenges of attending conferences and this is exactly what the OFAA virtual reality app offers.”

Skincare

Study reveals millennials have simplest skincare regime A UK study conducted by Mintel of 1,008 female internet users has found that over the last year, almost three in 10 (28%) women have reduced the number of products in their skincare routine.

It also revealed that 54% of millennials were the most likely to have simplified their routines. In the last 12 months, the number of women using a day cream declined from

66% to 60%, night cream fell from 48% to 44% and blemish balm, colour correct and daily defence creams declined from 21% to 15%. Serums in particular were the only product not to have seen a decline in their usage. On the other hand, facial cleansing wipes saw one of the biggest drops from 54% to 43%, possibly due to the Government’s plastic waste ban reported

last year. Alex Fisher, global skincare analyst at Mintel added, “Disposable wipes have been hit particularly hard as consumers become more aware of the product’s negative effects on the environment. As sustainability grows in importance, many beauty consumers are deliberately cutting out these single-use products.”

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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Supplement

New supplement launches Nutritional supplement company, Advanced Nutrition Programme, has launched the Skin Moisture Lock, a new skin supplement that combines hyaluronic acid with ceramides.

The company states that the hyaluronic acid works to smooth and plump the skin whilst the ceramides seal in moisture at the epidermal layer and help support the skin’s natural barrier, promoting more youthful, smooth and supple skin. The product was also subject to a small pilot study whereby 12 participants aged between 30-61 had an increase in skin hydration by 64%, improved wrinkle depth by 28%, improved skin smoothness by 20% and improved skin integrity by 20% over a 12-week period. Advanced Nutrition Programme recommends users take between one and two soft gels daily with food.

Digital

SkinMed launches new website Dermatological research and distribution company SkinMed has launched a new website, skinmed.co.uk. The company explains that it has taken on board feedback from SkinMed-accredited clinics to allow practitioners to register for a free Skinmed online account to access new information. This will include the latest science and innovation, product information, digital protocol booklets and the Clinical Marketing Suite, as well as the soon to be launched SkinMed ambassador forum and online training facility. SkinMed has also introduced an online training page, which shows the latest upcoming training dates, a blog showcasing products that have been featured in the press, as well as a patient-friendly clinic finder.

Device

Business of Hair to take place this month Following a successful first year in 2018, the second Business of Hair seminar will take place at the Crown Plaza in Solihull, Birmingham on September 28. The one-day event aims to help hair restoration professionals with business skills and covers topics such as building effective websites, using social media, basic marketing techniques, GDPR, insurance, and how to incorporate a CRM system into a business. Founder of Business of Hair Danny Large said, “After the success of last year’s Business of Hair seminar we are looking forward to welcoming delegates to this year’s event. The aim of Business of Hair is to help practitioners involved in hair restoration to improve their business skills as well as to educate on best practice in terms of marketing and how to run a business.” This year’s event includes speakers such as website, marketing and social media professional Mark Bugg, the CEO and founder of Pabau CRM systems William Brandham, insurance professional Janine Revill from Cosmetic Insure, journalist Vicky Eldridge, trichologist Eva Proudman, hair surgeon Dr Ted Miln, managing director at hair wholesaler Farjo Saks Janan Farjo, and director of UK aesthetic distributor AestheticSource Lorna McDonnell-Bowes, who is this year’s keynote speaker.

Topicals

Cocoon Medical appoints new KOL Aesthetic manufacturer Cocoon Medical has appointed aesthetic practitioner Dr Mayoni Gooneratne as a key opinion leader for the company’s Cooltech device.

Cocoon Medical explains that the CE-marked Cooltech cryolipolysis device is designed to target stubborn fat areas without the discomfort and recovery time associated with surgery. Dr Gooneratne said, “At my clinic, we have had a phenomenal success with the machine and return visits from happy patients wanting more areas treated. I believe this device will revolutionise the way patients perceive body sculpting and the way our industry delivers cryolipolysis.”

Medik8 introduces clarity peptides Global skincare company Medik8 has added the Clarity Peptides to its product offering, a 10% niacinamide-infused peptide serum with peptide crystalide and zinc PCA. The company states that the serum is designed to tackle blemish-prone skin whilst promoting the skin’s natural translucency, restoring radiance.

Medik8 explains that crystalide targets the natural protein that is responsible for minimising cell waste, which can cause a dull complexion, whilst niacinamide blocks the transfer of melanin pigments into skin cells, helping to slow down the process of pigmentation. As well as this, zinc PCA minimises sebum production, stopping the formation of blemishes and reducing inflammation, according to the company.

The product is designed to be used morning and evening across the face, neck and décolletage.

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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Certification

Dermalux range receives CE mark Aesthetic Technology Ltd, manufacturer of the Dermalux LED systems has received medical CE certification for the Dermalux MD range.

According to the company, receiving the CE mark will mean that Dermalux customers will be able to state medical claims for the treatment and management of acne, psoriasis, musculoskeletal pain and wound healing. Cosmetic indications also include rejuvenation, pigmentation and sensitive skin conditions. Managing director, Dale Needham explains, “For our Dermalux MD Range to have achieved Medical CE Certification for the treatment and management of such chronic skin conditions, is fantastic; not just for us as a company but also for our clients and subsequently, thousands of their patients.”

Business

3D-lipo Ltd expands team Aesthetic device manufacturer 3D-lipo Ltd has hired Olivia Manuel as its newest business development manager.

According to 3D-lipo Ltd, the appointment is due to the success of the company’s Business Development scheme, which launched in May 2019. The company notes that Manuel is a qualified nurse, specialising in plastic surgery and aesthetics, and has more than seven years’ experience within the industry. Manuel will be working throughout the Home Counties, Central and West London, helping 3D-lipo Ltd clinic owners to maximise the success of their clinics. Scott Julian, national sales manager at 3D-lipo Ltd, said, “As a business development manager at 3D-lipo Ltd, Olivia will be available for dedicated appointments to both existing and prospective clients. 3D-lipo Ltd’s Business Development programme gives clients the opportunity to benefit from exclusive updates and insights into all the latest from 3D, including marketing advice, training information as well as face-to-face support, and presenting the latest equipment from 3D-lipo Ltd. We are thrilled to have Olivia on the team.”

Dermatology

Almirall calls for partners to develop new dermatology therapies AlmirallShare, a proprietary of Spanish pharmaceutical company Almirall, has launched to aim to find medical professionals to identify, validate or test new treatments for chronic immune-inflammatory diseases of the skin.

Diseases to be covered include psoriasis, atopic dermatitis and pemphigus vulgaris, and the call is open until October 31. Scientists in universities, research centres, start-ups, bio-techs or pharmaceutical companies worldwide are all encouraged to to take part.

The company will also offer grants of up to €250,000 and scientific support to the selected proposals, it states. “Many chronic immune-inflammatory diseases, irrespective of the organ affected, share common mechanisms, pathways and players. Psoriasis has therapies in common with multiple sclerosis and rheumatoid arthritis; atopic dermatitis with asthma; pemphigus with lupus, to name a few. We would be delighted to explore with our partners a target, pathway or therapy, related to any immune-inflammatory disease, that can be of use on a dermatological indication,” said Nuria Godessart, head of biology at Almirall.

News in Brief Derma-Seal secures stockists Aftercare spray Derma-Seal will now be distributed by medical aesthetic suppliers Wigmore Medical, John Bannon Pharmacy and Church Pharmacy, as well as being available on Amazon. The product was previously only available directly through the Derma-Seal website. Consultant plastic and aesthetic surgeon Mr Dalvi Humzah, one of the product’s developers, said, “We have seen considerable growth in the last six months, with many clinics using Derma-Seal post injection to prevent infection, and I am confident that working with these pharmacies will accelerate this growth.”

CoolSculpting celebrates 10-year anniversary The non-surgical fat reduction treatment CoolSculpting is celebrating 10 years since receiving market approval in 30 countries on September 12. According to the company, more than seven million treatments have been completed worldwide. Nancy Ghattas, associate vice president UK and Ireland country manager at Allergan said, “We’re delighted to be celebrating this iconic milestone. It is a true pioneering and marketleading brand, with over seven million treatments performed globally.”

IAPCAM to hold complications course in September The International Association for Prevention of Complications in Aesthetic Medicine (IAPCAM) is holding a fresh cadaver wet lab course the day before its conference in September.

The one-day course, titled Anatomical Basis of Facial Rejuvenation with Dermal Fillers And Management of Complications Wet Lab, will take place on Thursday September 19, the day before the IAPCAM conference on Friday September 20 at St George’s University of London in Tooting.

Sally Durant Training correction In the August issue of Aesthetics, it was reported that Sally Durant Training had gone into administration. The director of Skin Group (Training) Ltd, has advised this was incorrect. The assets of the company were acquired by Skin Group (Training) Ltd, part of Skin Group International, on June 21. She said, “Skin Group will continue to deliver the Sally Durant courses and we have been in touch with all students that have paid in full about completing courses in progress.”

She also confirmed that the Confederation of International Beauty Therapy and Cosmetology (CIBTAC) has approved this arrangement. Aesthetics apologises for any confusion caused to Sally and Skin Group.

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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The Galderma and Med-fx Partnership Everything you need to know about the new partnership for enhanced aesthetics solutions On September 8, Galderma and Med-fx will operate under a sole-preferred distributor model for Galderma’s Azzalure and Restylane brands in the Head of Galderma’s United Kingdom and the Medical Solutions Business in Republic of Ireland. Here UK & Ireland Toby Cooper, Head of Galderma’s Medical Solutions Business in UK & Ireland, explains what the change means for customers and what they can expect.

Why did Galderma decide to change its distribution model?

The increasing demand for aesthetics treatments in recent years has led to higher numbers of active injectors and products. Now more than ever, healthcare professionals and their patients need to have full confidence in the safety and quality of the product and treatment they’re receiving. We are committed to excellence in patient safety and customer care, and our new distribution model with Med-fx has been designed to help raise industry standards by improving how we meet these demands.

How will the new distribution model better meet demands for the safety and quality of treatments?

On September 8, Med-fx will become the sole-preferred distributor for all Galderma Azzalure and Restylane products in the UK and Ireland, and will operate under a ‘Raising Standards in Aesthetics’ principle. This means Med-fx will only supply Galderma products to qualified healthcare professionals, reflecting guidelines provided by the Joint Council for Cosmetic Practitioners (JCCP). To support safety and quality standards further, Galderma and Med-fx will provide a market-leading Customer Care Service package, including specialist training, to its customers.

What else can customers expect from the Galderma and Med-fx partnership?

In addition to our commitment to improve the safety and quality of patient outcomes, we are focused on delivering a truly market-leading experience to our customers that will improve their businesses. Customers will benefit from a new Customer Care Service package, which will include a Training and Education platform available nationwide and for all experience levels. We look forward to sharing more detail about this in the coming months.

What other detail is available about the delivery of products under the new model, and Galderma and Med-fx’s commitment to market-leading customer service?

Together we are committed to providing excellence in customer service. In addition to a continued, reliable supply of products, we are working hard to improve Med-fx’s existing and impressive customer service performance, which includes an On Time In Full rate of 99.3%, a Net Promoter Score of 65 (where 50 is considered ‘exceptional’) and a record of answering customer calls in an average of six seconds.

What was the process to appoint Med-fx and why was it selected?

We appointed Med-fx as our solepreferred distributor following a rigorous review and selection process. Med-fx’s commitment to high quality standards and customer service and its innovative ideas impressed our team, and the business shares our ambition to improve the safety and quality of patient outcomes under the ‘Raising Standards in Aesthetics’ principle.

We look forward to implementing our

new model and to further developing our Customer Care Service package. We would also like to thank all the distributors who took part in the process, both for their submissions and for their partnership under the previous model.

What is the impact of the appointment on other distributors?

Following September 8, other distributors who have an active account with Galderma will still be able to purchase products under the Azzalure and Restylane brands. This will be under our standard terms and conditions. However as our preferred partner, Med-fx (or their appointed partners) will have priority supply of products.

It’s been reported that there have already been changes to some distributors, what does that mean?

The contracts with some distribtuors have ended early but they are able to sell stock which they have already purchased, and therefore may be able to fulfill orders until that runs out. Med-fx are on standby to assist any customers seeking an alternative supplier during this time.

How can customers continue to get Azzalure and Restylane? How should they sign up to Med-fx?

Products sold under the Azzalure and Restylane brands will only be available to qualified healthcare professionals eligible to join the JCCP register. Existing Med-fx customers don’t need to do anything, and we’re inviting all other customers who fit that criteria to contact Med-fx online or by phone. Opening an account is a simple process – after completing a short form, your account will be running within one working day.

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The agenda for next month’s Galderma webinar Registering for the webinar What if I’ve already registered with DocCheck?

Sharon Bennett

Dr Lara Watson

Dr Priyanka Chadha

On October 14, pharmaceutical company, Galderma UK will be supporting the third Aesthetics webinar, titled Abobotulinum toxin type A in Action: Marketing Guidance & Treatment for Lateral Canthal Lines. The webinar will begin at 7pm and is expected to run for one hour.

Attendees will learn essential advice on the regulations of the marketing and advertising of abobotulinum toxin type A from aesthetic practitioners Dr Lara Watson and Dr Priyanka Chadha, before nurse prescriber Sharon Bennett performs a demonstration on successfully treating lateral canthal lines in an older female, younger female and a male. Bennett will also cover the action of botulinum toxins, abobotulinum toxin type A’s reconstitution and indications, the anatomy of the treated area, as well as sharing advice on treatment best practice and how to avoid and minimize risks. The webinar is only available for doctors, surgeons, nurses and dentists with a valid professional licence. You must submit your licence (GMC/NMC/GDC certificate) and proof of identity certificates (e.g. driving licence/passport) to DocCheck

by Thursday October 10 to attend. For those who registered for the previous webinar, you will not be required to do this again. You will just need to confirm your attendance on the Aesthetics website.

If you have already registered with DocCheck and had confirmation of your professional licence then you do not have to register again. Simply: 1. Visit aestheticsjournal.com/webinar_galdermaoct2019 to login. You will then be prompted to use your DocCheck password to confirm you are a doctor, surgeon, nurse or dentist.

2. Tick the box to confirm you would like to pre-register for the webinar 3. You’ll receive reminder emails for the event .

What if I haven’t registered with DocCheck?

Visit doccheck.com and provide your medical certification as proof of your profession. This will include proof of identification (driver’s licence or passport) and proof of medical profession (a GMC/NMC/GDC certificate).

You may also be asked to include extra documentation such as a personal diploma from a university. Your information will be checked and once it has been verified you can then visit the Aesthetics webinar page, use your DocCheck password and confirm you would like to pre-register for the webinar by ticking the box. IMPORTANT – you will need to register and provide your medical certificate to DocCheck by October 10 in order to guarantee that your registration will be processed in time for access to the webinar. This process can take up to 24 hours.

What if I am having trouble registering with DocCheck?

If you are experiencing issues with your DocCheck registration, please try the following: • Ensure there are no spaces in your postcode and press SUBMIT again • Ensure your postcode is all in capital letters and press SUBMIT again If you are still having issues with your DocCheck registration, please contact them directly: cream@doccheck.com

How do I stay updated?

To receive email updates of the webinar, update your Communications Preferences on our website to receive ‘Communication from Aesthetics partners’. If you have any questions please contact Aesthetic Media: E: contact@aestheticsjournal.com T: 0203 096 1228

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Don’t miss the largest aesthetic event this Autumn A look at the unmissable CCR 2019, taking place on October 10 and 11 Celebrating its seventh and best year yet, CCR will be making its return to Olympia London on October 10 and 11. Set to welcome more than 5,000 attendees, 200 brands, and more than 120 speakers, CCR remains the only platform in the UK that unites the surgical and non-surgical communities. The exciting two-day event will unwrap the latest news and innovations in aesthetics, through live demonstrations and thought-provoking and skill-enhancing content delivered by foremost industry experts.

As a leading educational platform, CCR continues to raise industry standards with its careful selection of its partners. Delegates attending can expect free CPD-certified conferences including those on clinic and practice management, dermatology and injectables and getting started in aesthetics, curated with advice and learning to practitioners at all levels, and with a range of specialties and interests. CCR 2019 promises to not only showcase the latest the industry has to offer but will be attended by key opinion leaders providing valuable insight into industry challenges, regulations and safety. Chairman and renowned consultant plastic surgeon, Mr Norman Waterhouse, will be supported by the CCR 2019 Advisory Board of 33 industry experts, who have shaped the scientific agenda to support clinical development and education. Mr Waterhouse comments, “Since its inception seven years ago, CCR has become the go-to event for aesthetic medicine and surgery in the UK. The CCR programme this year comprises an extensive speaker line-up with experts discussing the latest topics in the specialty. Our comprehensive programme of both surgical and non-surgical content has always set CCR apart and firmly at the forefront of the industry; this year is no exception.”

The JCCP will cover topics on ethics in aesthetics, body dysmorphic disorder, complication management and more, and a Live Laser Hack with tattoo removal, veins and acne treatments from leading laser brands, Advanced Esthetic Solutions and Novus Medical.

CCR is also the only event to unite the surgical and non-surgical communities through the co-location of surgical meetings. Now in its

Event highlight

This year’s event highlights include two days of exclusive training takeovers from Allergan SCULPT IT with Juvéderm Volux on the Live Demo Stage. Plastic surgeon Mr Nimrod Friedman will host the Vivacy STYLAGE Symposium and Dr Rita Rakus will host the saypha® – say “yes to your phantastic lips!” by Croma.

34th year and its 5th year alongside CCR, the British Association of Aesthetic Plastic Surgeons (BAAPS) Annual International Conference will take place at CCR, as well as the International Society of Aesthetic Plastic Surgery (ISAPS) Symposium UK taking place on October 12. The dedicated BAAPS Village on the show floor provides an opportunity for exhibitors with a focus on aesthetic surgery to network with and target more than 450 surgeons. New for 2019, is a comprehensive symposium headed up by consultant dermatologist and secretary of the British Cosmetic Dermatology Group (BDCG) Dr Anjali Mahto, called What’s New and True in Cosmetic Dermatology. From 2-5pm on October 10 find out about ‘Topical Treatments that Work’, and ‘Nutraceuticals and Beauty Supplements’, plus GMC guidelines for the responsible use of social media.

SkinCeuticals will also be hosting a talk centring around what’s new in pigmentation; Dr Alexis Granite will be speaking on the subject. On October 11, director of Save Face, Ashton Collins explains the latest Save Face data on consumer complaints with analysis from Clinical Director of Save Face Emma Davies and Dr Christian Jessen, Public Ambassador. 1,624 Consumer Complaints – The Story Behind the Data: Why are 83% of complaints regarding treatments provided by lay people? What behaviours distinguish the regulated healthcare professionals? What are the lessons and how do we influence the choices consumers make?

CCR has also confirmed the appointment of its Press Ambassador, health and beauty editor-at-large of Tatler Magazine and editor of the renowned Tatler Cosmetic Surgery Guide, Francesca White.

As well as reporting from the event, Francesca will be collating key insight into the industry and its exciting innovations coming out of the conference and speaker programme, and opening up the world of aesthetics to consumers. White comments, “I am delighted to be this year’s CCR Press Ambassador, and always on the lookout for the latest in aesthetic medicine, the new techniques being introduced by the top doctors and surgeons, and the upcoming trends and regulations to be aware of.” CCR 2019 is set to be the best year yet, building on previous years to deliver the latest and most innovative content, demonstrations, new treatments and education for aesthetic professionals, all under one roof.

To register for your complementary admission ticket, log on to www.ccr-expo-com and enter the code 10088.

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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Group, said that the recent findings reflect their own. However, he notes, “What is quite alarming is that the statistics are so high; if we compared these findings to 10 years ago, I am sure that this would not have been the case.”

What do the latest results suggest?

Aesthetic Complications Aesthetics looks at the most recent complication statistics from the British College of Aesthetic Medicine Complications from non-surgical aesthetic treatments are constantly in the spotlight, with almost daily reports in the consumer media. But, as we know, there is limited data available that indicates the rate of complications occurring across the UK. In 2019, however, there has been an improvement in this data collection. Earlier this year, independent accreditation body Save Face and the Aesthetic Complications Expert (ACE) Group released reports on complications and patient complaints across the specialty.1-3 Hamilton Fraser Cosmetic Insurance also shared data on complications experienced by its customers4 and The British Association of Cosmetic Nurses (BACN) also released data from its members earlier this year.5 In February, the British College of Aesthetic Medicine (BCAM) provided statistics from its annual review of 344 members that highlighted the instances of adverse events that they have experienced. The overall findings were that BCAM members have a low incidence of complication rates, with a rate of 4.0, 3.3 and 2.8 events per 1,000 treatments for toxin, dermal fillers and lasers, respectively.6 BCAM has since released results from its

annual audit, which brings to light new statistics that reflect complication rates outside of the association.7 This pooled data represents analysis of more than 225,000 individual treatment episodes reported by 270 members of BCAM, who are a mixture of doctors and dentists, over the last year.

BCAM’s latest findings state that: • 77% reported treating other practitioners’ dermal filler complications • 64% reported treating other practitioners’ toxin issues • 25% reported treating laser/IPL problems • 25% reported treating thread lift problems BCAM president and aesthetic practitioner Dr Paul Charlson comments, “Due to the unregulated nature of the industry, the complication results we have gathered aren’t really surprising, and my own clinical experience does reflect these results. I do believe there is an increasing number of complications happening in the industry, which needs to be addressed.”

Aesthetic practitioner Dr Martyn King, co-founder and chairperson for the ACE

According to Dr Charlson, the latest complication statistics don’t necessarily indicate that the overall complication rates in the industry are high, but he says, “From an industry level, I think these stats are saying that basically there are many practitioners who are not dealing with their own complications. For one reason or another, patients are going elsewhere to sort out their complication, which I don’t agree should be happening.” Aesthetic practitioner and director of the International Association for Prevention of Complications in Aesthetic Medicine (IAPCAM) Dr Beatriz Molina, adds, “What I think is significant is that previous BCAM stats show there is a very low instance of complication rates from members, but up to 77% of them are treating other people’s problems, which is very high. To me, this highlights that there is a group of inexperienced practitioners who can’t deal with adverse events. I think it will be interesting to see more stats to really identify what group or types of practitioners are causing these issues.” As an example, data released by the BACN indicated that out of the members who received complications, 93% were able to manage it themselves.5 Dr King believes the latest BCAM figures are due to a combination of factors, including treatments being performed by people without any medical background, the fact that treatments are now far more popular and available than before, and the general public looking for the best bargain price. “To meet this demand, treatments are being performed by practitioners with very little experience in their own field, often being newly qualified, as well as lack of experience in aesthetic medicine. In previous years, practitioners often were very experienced in their own discipline and treatments were more conservative and these practitioners were able to manage their complications without needing the assistance of another practitioner,” he explains. Dr Charlson believes there is a common scenario in which complications are occurring.

He states, “Generally, what we find is happening is that a patient might first get

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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treated by an inexperienced or poorly-trained practitioner and then get a complication, whether it be an unaesthetic result or something more serious. They then either realise that their original practitioner is not able to handle the situation, or sometimes they might even be completely uncontactable, so find another practitioner, often who is a medical professional, who has the training and expertise to handle the complication,” he explains.

The positive thing about these statistics, Dr Charlson believes, is that he thinks they indicate that the public are choosing highly experienced practitioners to finally assist them.

Reducing complications All interviewees are passionate about endorsing best practice and ensuring high levels of patient safety, agreeing that there are developments that can be made to improve the number of complication taking place in the UK. Dr Molina says, “For practitioners, the more training they do the better. They also need 100% accountability for their procedures, otherwise they shouldn’t be treating. More patient education is also needed, so they aren’t trivialising these treatments and going to someone with inappropriate skills. Associations are attempting to increase this at the moment, but it’s a huge challenge to get the message across.” Dr King adds that more complications’ data and statistics are essential to better educate the public to choose their practitioner wisely. “If the public were aware of the extent of some of these complications, I am sure many would not even entertain having treatment, but if they were to do so, would certainly spend more time researching their practitioner and not just looking at the cheapest option,” he explains, adding, “The ACE Group

also strongly encourages practitioners to report complications to manufacturers and the MHRA to provide more evidence for the safety of products that are used. Finally, complications’ data may help to gain greater regulation within the aesthetics industry which is very much needed.” Dr King also suggests that manufacturers and suppliers play a role. “This is to ensure that practitioners using their products are appropriately qualified, appropriately trained and products are purchased from legitimate sources,” Dr King explains.

Dr Charlson summarises, “The reality is that everyone gets complications, but if you can’t deal with your own; for example, if you are administering dermal fillers but can’t prescribe hyaluronidase, then I would question if you should be operating independently.

Instead, I would suggest that practitioners should be under the wing of somebody who can sort the problems out, should they arise. The industry needs to be regulated, which is what many people continue to highlight.”

REFERENCES 1. Save Face, Consumer Complaints Audit Report 2017-2018 <https://www.saveface.co.uk/wp-content/ uploads/2018/11/Save-Face-Consumer-Complaints-Report-2017-18-FINAL-1118.pdf> 2. Data on file obtained from ACE Group.

3. Megan Close, News Special: Lip Filler Complications, January 2019. <https://aestheticsjournal.com/ feature/news-special-lip-filler-complications> 4. Advertorial: Dealing with Complaints, 2019. <https://aestheticsjournal.com/feature/advertorial-dealingwith-complaints> 5. BACN Membership Survey, Dec 2018-Feb 2019. Data on File.

6. BCAM, The BCAM Annual Review 2018. <https://bcam.ac.uk/wp-content/uploads/2018/07/BCAMAnnual-Review-Report-2018-P.-Myers.pdf> 7. BCAM, Press release, British College of Aesthetic Medicine, London, UK, 23rd July 2019, <https:// bcam.ac.uk/press-release-july-31st-2019-aesthetic-medicine-overwhelmingly-a-young-female-issuereveals-our-latest-survey-of-aesthetic-doctors-dentists/>

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Introducing Tor-bac Alison Stevenson, managing director of manufacturer Tor Generics Ltd, introduces the new single-dose bacteriostatic saline solution Practitioners offering injectable procedures will be familiar with the use of bacteriostatic saline solution to reconstitute medicinal products for intramuscular/intradermal injection. Those who use the Tor-bac brand will know that each millilitre of solution contains sodium chloride 9mg and 0.9% (9mg/ml) benzyl alcohol added as a bacteriostatic preservative, which is less

painful at the site of administration compared to an ordinary saline. Traditionally, however, bacteriostatic saline solution has only been available in 30ml vials.

Until now. Practitioners can now purchase ten 5ml ampoules of Tor-bac, meaning they can use one ampoule per patient. In addition, they are easier to administer and compliant with both single-use botulinum toxin and hyaluronidase applications. With Tor-bac, there’s no risk of cross contamination and the single-use doses means they are cost effective too!

Aesthetic nurse prescriber Emma Davies says, “Since a single patient treatment rarely requires more than 2.5ml of saline to reconstitute a single vial of toxin, either practitioners are wasting a great deal of product, or they are in breach of regulations, by reusing a 30ml multi-dose vial for multiple patients.

As such, the new 5ml vials offer a valuable solution!”

To find out more and purchase your 5ml ampoules, get in touch with: Church Pharmacy: 01509 357 300 info@churchpharmacy.co.uk www.tor-generics.com

REFERENCE: 1. Centre for Disease Control, ‘Frequently Asked Questions (FAQs) regarding Safe Practices for Medical Injections’ < https://www.cdc.gov/ injectionsafety/providers/provider_faqs_multivials.html> Last accessed: 19 March 2018.

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Retaining Your Reception Team Aesthetic professionals advise on how to reduce turnover amongst front-of-house staff Staff retention is likely to be a challenge for all aesthetic clinic owners. You dedicate your time and, often, money to train a new team member, only for them to leave you in a few months’ time. And then, you have to restart the recruitment process all over again – using even more of your precious time and money. So how do you get out of this vicious cycle and build a strong and reliable reception team?

According to the Chartered Institute of Personnel and Development (CIPD), a professional association for human resource management specialists that offers advice and guidance across all areas of employment, the following factors can improve staff retention:1 • Basic pay and benefits • Employee selection • Career development and progression • Flexibility • Employee wellbeing In this article, Aesthetics explores some of these factors in more detail, with specific advice from nurse prescribers Jackie Partridge of dermalclinic in Edinburgh and Jacqueline Naeini of Cliniva in Barnsley. We also gain insight from Vicki Vilas, the operations and marketing manager at recruitment specialist ARC Aesthetic Professionals.

Team structure As well as a clinic manager, Naeini employs two part-time receptionists, and a ‘floating receptionist’ who comes in one Saturday per month to cover holidays and offer further support.

She says ensuring they understand how they should work together is essential. “I do this rather than having one full time receptionist as it’s a lot easier to manage staff absence from sickness and holiday,” she explains, noting that this is also of benefit if your team member should choose to leave, as it reduces the chance of not having a receptionist if it takes longer to employ someone new. Partridge has a similar approach with two members of her reception team who split the week between them. She says, “I feel that limiting the number of this team is important, so that there is less chance of things being missed during hand over between too many people.”

Recruitment The strategy for retaining your reception team members should start before they’ve even joined the company, the professionals interviewed for this article highlight. They confirm that interest in front-of-house roles are not usually a problem, but sifting through unsuitable

applications certainly is. Naeini says that of 70 applicants for her latest reception team role, she interviewed just 15 and didn’t employ one. “I’d rather not have anyone than have the wrong person for the job, so we have waited until the right person came along, which they now have!” Naeini says. When looking for an employee with relevant skills and experience, Naeini notes that it can be difficult to find someone with specific experience in an aesthetic clinic, so she instead seeks people who have worked in a similar environment, for example a doctor’s surgery or dental practice. This, she says, ensures they recognise the importance of patient confidentiality and booking appointments, as well as good customer service. Other skills she looks for are flexibility, due to later opening times and weekend working, and the ability to be adaptable and assist with a variety of tasks.

To narrow suitable candidates down, some recruitment companies advise incorporating to a two-minute video into the selection process, in which the person explains why they believe they are the perfect person for the job. It can be easily shot on a phone and really demonstrates which candidates are actually interested in the role.2 Vilas advises practitioners hold more than one interview with candidates, noting, “You may absolutely love an applicant when you first meet them, but the longer you get to spend with candidates, the more you will be able to understand whether they truly are a good fit for your clinic.” You can also tie this in with introducing the candidate to your team, which she says will allow you to get an insight into how well the team will work together, as well as allowing other staff members feel included in the process. During the interview, Vilas recommends asking competencybased questions to put certain skills to the test, such as teamwork, problem solving and decision making. “Ask open questions where your interviewee cannot give simple ‘yes’ or ‘no’ answers,” she says, adding, “For example, you could ask someone to describe a situation where they overcame a difficulty or solved a problem, or give an example of a time when they worked with colleagues to achieve a great result.” She also highlights the benefits of including some sort of test(s) in the hiring process, saying, “If you need a receptionist to have immaculate written English, ask your candidates to complete a brief assessment to demonstrate this. You could give candidates some examples of emails that patients may send, and ask them to draft a concise response.” For practitioners

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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based in Scotland, the recruitment process is particularly stringent. Partridge explains that there is a set recruitment process for clinics registered with Healthcare Improvement Scotland, which is part of their inspection process. This includes adherence to the staffing regulations listed in the IHC legislation and adherence to best practice standards in Scotland. An example of this would be, where appropriate, Protection of Vulnerable Groups checks, health clearances for staff performing clinical work and checks to ensure staff have the appropriate qualifications, skills and experience necessary.3 “All of this has to be in place before they’re allowed to step foot in the building to work because they’re accessing patient data,” says Partridge, emphasising, “It took six weeks to get through the process with the latest lady we’ve taken on, so can you imagine how frustrating it is if they get half way through their probation and decide the role’s not for them!”

Induction and probation From the moment a new starter joins your clinic, it is essential that they are clear on their role and responsibilities to understand where they fit in the organisation, advise those interviewed. Therefore, a detailed induction process is essential. In 2017 the CIPD carried out a survey on resourcing and talent planning, which found that of 40% of organisations that were undertaking specific retention initiatives, only 50% were improving their induction process,4 emphasising the need for more companies to consider it.

The CIPD states that, ‘Induction shouldn’t be treated as a ‘tick box’ exercise; it’s a key opportunity to introduce new employees to the culture and ways of working of the business… an effective induction process can help them settle in, become productive more quickly and to help prevent them from leaving within their first six months in the job’.5 It also emphasises that without a successful induction, new employees can get off to a bad start and lack clarity on their role and how it links to the organisation’s goals. In extreme cases, the new employee leaves, either through resignation or dismissal. CIPD advises that an induction should cover:5 • Practical information about organisational procedures (for example, building orientation, health and safety, and information about systems used) • Company strategy and services (for example, company values and products and services) • Job specific information • Introduction to the wider team

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Naeini, who has recently recruited a new receptionist, says her induction period will take three weeks and covers all of these points, with specific training on each area of the role. She explains, “My new team member will spend time learning from everyone as, of course, we all have different skills and areas of expertise. Company representatives will also come in to provide specific product training.”

For Partridge, new starters will watch an animated movie that they can work their way through. “We start this online campaign prior to them joining us, with a countdown to them starting and saying how much we are looking forward to them joining the team,” she says, explaining, “This then continues when they have joined to cover all aspects of their induction. It also allows us to ensure that each team member has indeed understood and engaged in every topic required from how to deal with angry customers to fire safety.”

Both practitioners interviewed have threemonth probationary periods in place, however there is no law specifying the length a probationary period should be or even if you should have one at all, leaving it up to the employer to decide what is most suitable for their business.6 Partridge and Naeini agree that considering training costs is important.

“You don’t want to fork out lots of money for someone who is going to leave you and take their skills elsewhere in six months’ time,” emphasises Partridge. For a successful probationary period, HR publication First Management Practice advises that employers should make clear the levels of standards that are expected in both written and verbal communication, as well as setting regular review dates to discuss progress and offer additional support when necessary. If an employee is experiencing difficulties, it is recommended that the manager should not wait until the next scheduled review, but address immediately. They advise the following approach:7 • Reinforce the areas where the employee is doing well • Be open and honest with the employee about his/her shortcomings. Provide documentary evidence when possible • Give the employee the opportunity to respond. There might be some other factor behind the problem • Try to reach an agreement on the nature of the problem. If joint agreement can be reached, the employee is more likely to react positively to suggestions • Offer guidance and support on how to overcome the difficulties. This might include extra training or closer supervision

• Ensure the employee understands the degree of progress required and that successful completion of the probationary period dependent on it • Warn the employee that if this standard is not reached it will be necessary to terminate his/her employment

Salaries and benefits Of course, having an attractive rate of pay and progression plan in place is likely to have a positive influence on staff retention.

Research from the CIPD indicates that individuals are attracted, retained and engaged by ‘a whole range of financial and non-financial rewards’, advising that companies should establish ‘a reward strategy that clearly articulates the aims of the various reward elements and how they are integrated’, which is, ‘complemented by appropriate communications to explain to staff what behaviours and performances the organisation is rewarding, how, why and when’.8 Salary information service Payscale estimates that the average hourly rate for a receptionist in the UK is £7.88,9 which is similar to the National Living Wage of those aged 18 and above. As of April 2019, the National Living Wage for 18-20-year-olds is £6.15 per hour, rising to £7.70 for 21-24-yearolds and £8.21 per hour for those aged 25 and above; equating to around £17,000 for a 40-hour week. There is no London weighting for this.10 It is also worth noting that The Living Wage Foundation has suggested that the ‘Real Living Wage’ should be £9 across the UK and £10.55 in London for those aged 18 and above. This calculation has been made according to the cost of living.11 According to Vilas, as the aesthetics industry can cover everything from a small laser hair removal salon to the high-end clinics who deal with A-listers and royalty. This means there is a wide range of reception salaries, so clinics won’t necessarily pay minimum wage.

In her experience, she says that receptionists in London generally tend to earn £20-24,000 per annum, while outside of London the rate is more likely to be £18-22,000. For reception managers and clinic coordinators who have more responsibility, Vilas says the salaries increase to approximately £25-32,000 in London and £24-26,000 in other parts of the country. Naeini says she pays her staff more than the National Living Wage, emphasising, “You’ve got to invest in your staff to get the best from them.”

Like with pay grades, the CIPD advises that an appropriate communications strategy is adopted when detailing employee benefits

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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so staff recognise when and how they can take advantage of these.12 As well as offering a standard benefits package that could include things such as a pension scheme, private medical insurance, cycle to work policy or other such incentives, the practitioners interviewed acknowledge that they offer benefits that will be exclusive to aesthetic clinics.

Naeini gives all new staff a free skincare consultation and provides appropriate skincare from her range. As well as being beneficial to her employees, she says it is also good for business. “The team are then able to talk confidently, from personal experience, about the skincare we stock with patients they encounter, which is a much softer sell,” she notes. If there is a quiet time between appointments, she will also allow the team to have device-led treatments, while any injectable treatments are paid for by the employee at product cost-price. As Naeini has a training facility in her clinic, she also allows staff to be treated for free if they act as models. Similarly, Partridge offers discounted treatments to her staff. “We also enjoy team building days out; the most recent one was clay pigeon shooting!” she says.

In addition, entering her reception team and taking them to the Aesthetics Awards is something Naeini has done every year since the clinic opened. “I think they deserve it, they work so hard. It’s an opportunity for me to say thank you to them for everything they’ve done this year and they really appreciate it,” she says.

Staff development According to LinkedIn’s 2019 Workforce Learning Report, 94% of employees would stay at a company longer if it invested in their careers, with the vast majority of millennials (87%) saying that professional growth and development opportunities are top priorities when seeking a job.13 “I’d say that it is unrealistic to expect receptionists to stay in the same role for any longer than a year if they are given no chance to progress or develop their role,” says Vilas, emphasising, “Talented reception staff tend to want to progress, and the aesthetics industry does offer opportunities for them to do so.”

She outlines that front-of-house staff can progress from receptionist to clinic coordinator or reception manager, then to patient coordinator or assistant manager, and then finally to clinic manager. Alternatively, some may have an interest in training as an aesthetician or another role in your clinic,

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for which they are not yet qualified. The practitioners advise that by contributing to or funding the cost of training for this, you can retain these members of staff who now bring added value to your clinic.

And it doesn’t have to be a typical job title change that will satisfy your team members’ thirst for development either, note the practitioners. Allowing them to take on new challenges such as updating the clinic’s website content and managing your social media channels are examples of new duties your reception team can undertake; benefitting their professional development, as well as taking the responsibility away from you or reducing the cost of this being outsourced. Of course, if clinic owners wanted to adopt this approach then it is essential that reception teams are given thorough training, advise the professionals interviewed. This could either be in-house from more experienced members of staff or, if necessary, external courses. “This will make them feel valued and reassure you that they have the appropriate skills to implement their new tasks successfully,” says Partridge.

General management According to research company Udemy, nearly half of employees said they’ve quit a job because of a bad manager.15 So, what can clinic owners do to ensure their management doesn’t impact their reception teams’ retention? The CIPD states, ‘Feedback is a critical element in performance management, not only because it directs the focus on learning and improvement, but also because it allows individuals to monitor their progress towards goals and stay motivated’. It also advises that performance conversations should be open exchanges in which the employee is fully involved, noting, ‘A high level of involvement is important to make sure employees actively engage with the feedback and reflect on how they can develop and improve’.16 To make the most out of these conversations, the CIPD recommends:16 • Asking good questions – when to use open or closed questions, and how to probe in a way that encourages people to expand on their views or feelings • Active listening – take in what is being said, notice body language, help people respond in a way that helps the conversation • Giving constructive feedback – focusing on evidence and examples, not subjective opinion, reinforcing positives and strengths,

and knowing when to be directive and when to take a coaching approach Thorough documentation of these meetings is, of course, essential. For Naeini, having regular one-to-ones with her team members is essential to allow employees to voice any concerns and giving her the opportunity to track progress. Partridge agrees, adding, “We also have an anonymous staff suggestion box which is checked monthly. This allows staff to anonymously point out areas for improvement.”

Retention success While change is inevitable and clinic owners will certainly see reception team members come and go throughout their career, having a detailed plan that covers all aspects of an employee’s journey will likely support and improve staff retention rates.

Those interviewed highlight that for your reception team in particular, recognising and acknowledging the value these team members bring to your clinic, through both praise, new opportunities and career progression, should only serve to encourage them to stay with you for the long-term.

REFERENCES 1. Chartered Institute of Personnel and Development, Employee turnover and retention (UK: CIPD, 2019) <https://www.cipd.co.uk/ knowledge/strategy/resourcing/turnover-retention-factsheet > 2. Launchpad, The benefits of adding video interviewing to your recruitment process (UK, Launchpad, 2019) <https://www. launchpadrecruits.com/benefits-of-video-interview> 3. More information available: Healthcare Improvement Scotland 4. Chartered Institute of Personnel and Development, Resourcing and Talent Planning 2017 (UK: CIPD, 2017) <https://www.cipd. co.uk/Images/resourcing-talent-planning_2017_tcm18-23747. pdf> 5. Chartered Institute of Personnel and Development, Induction (UK: CIPD, 2019) <https://www.cipd.co.uk/knowledge/ fundamentals/people/recruitment/induction-factsheet> 6. Citizens Advice, Contracts of Employment (UK: Citizens Advice, 2019) <https://www.citizensadvice.org.uk/work/rights-at-work/ basic-rights-and-contracts/contracts-of-employment/> 7. First Practice Management, Everything you need to know about probationary periods (UK: First Practice Management, 2014) <http://www.firstpracticemanagement.co.uk/blog/posts/ everything-you-need-to-know-about-probationary-periods/> 8. Citizens Advice, Reward and Pay (UK: Citizens Advice, 2019) <https://www.cipd.co.uk/knowledge/fundamentals/people/pay/ reward-factsheet> 9. PayScale, Average receptionist hourly pay in United Kingdom (US: PayScale, 2019) https://www.payscale.com/research/UK/ Job=Receptionist/Hourly_Rate 10. Gov.uk, National minimum wage and national living wage rates (UK: Gov.uk, 2019) <https://www.gov.uk/national-minimumwage-rates> 11. Living Wage Foundation, Real living wage increases to £9 in UK (UK, Living Wage Foundation, 2019) < https://www.livingwage. org.uk/news/news-real-living-wage-increases-2018> 12. Chartered Institute of Personnel and Development, Reward and pay (UK: CIPD, 2019) <https://www.cipd.co.uk/knowledge/ fundamentals/people/pay/reward-factsheet> 13. LinkedIn, Workplace Learning Report, (US: LinkedIn, 2019) < https://learning.linkedin.com/content/dam/me/business/en-us/ amp/learning-solutions/images/workplace-learning-report-2019/ pdf/workplace-learning-report-2019.pdf> 14. Udemy, 2018 Employee Experience Report (US: Udemy, 2018) <https://research.udemy.com/research_report/udemy-in-depth2018-employee-experience-report/> 15. Chartered Institute of Personnel and Development, Performance appraisal (UK: CIPD, 2019) <https://www.cipd. co.uk/knowledge/fundamentals/people/performance/ appraisals-factsheet>

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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Jaw Classifications and Anatomy Dentist and aesthetic practitioner Dr Tracey Bell explores the anatomy of the jaw and details the classifications to consider before aesthetic interventions Jaw refinement is becoming an increasingly popular area of medical aesthetics.1 It is intended that this paper will educate readers about skeletal classifications of the jaw, facial profiling, relevant soft tissues, danger zones, and the effect of jaw ageing for successful treatment using non-surgical interventions.2

Skeletal classifications of the jaw Various skeletal classifications of the jaw have been recommended to date. These classifications are essential to help practitioners identify physiological and aesthetic abnormalities and recommend treatments which are best suited to the individual’s needs.

Angle’s classification system Of the classification systems proposed to date, Angle’s Classification of Malocclusions system by US dentist Edward Angle, is the most widely known and applied in practice. This is one framework that depicts and grades a misalignment between the teeth and the two dental arches as they appear when the jaw closes.3 This can lead to an unaesthetic overbite or underbite, as shown in Figure 1.

This classification system can be used by a practitioner to plan orthognathic surgery, which re-sets the jaw to regain harmony between the maxilla and the mandible. It can also be used in aesthetic medicine to plan injectable treatments involving a change in the soft tissues, which may mimic changes in skeletal relationships (Class I of the classification).4 Class I: the relationship between the maxilla and the mandible in Class I is in an anteroposterior direction in surgical interventions.5 The corresponding mandible position and jaw position ratio could be used in the case of non-surgical procedures.6 Class II: describes a state where the maxilla lies ahead of the mandible, with reference to the anterior cranial base, and the maxilla is pronated.5 Class III: the maxilla lies posterior (behind) the mandible, with reference to the anterior cranial base, and the maxilla is retrognathic

(abnormal mandible position causes an ‘overbite’).5 This could be corrected with non-surgical procedures by using the corresponding mandible position and facial photographs.6 However, there are various limitations of the Angle Classification for Malocclusions system that professionals should be aware of when performing aesthetic procedures. For example, the first permanent molars are not fixed points due to poor contact point relationships in the skull anatomy; this can lead to inaccuracies in planning, performance and result in dissatisfied patients.6 By the same logic, this system cannot be implemented when the individual’s molars are not present, such as either when they have not yet grown through or perhaps have been lost, or when the individual tooth malpositions are not evident, for example, in impaction.6 In regards to treatment, practitioners should also be aware that Angle’s classification is purely based on the anteroposterior relationship.6 Therefore, a limitation of its use is that it purely considers skeletal relationships and not soft tissue relationships.

Lateral-maxilla or maxillary asymmetry Further classifications take mandibular asymmetry and maxillary/ mandibular special relationships into consideration. There is not an exact grading system, but the aforementioned system can be characterised by distinct dentoalveolar asymmetry, centered nasal floor and occlusal plane and asymmetric lip elevation.7 This diagnostic classification considers the lateral-maxilla category, where the asymmetry of the upper arch of the maxilla exists with a discrepancy between the sagittal midline of the visage and the upper midline.2 An off-centre maxillary midline is generally considered unattractive within the adult smile.2 A standard skeletal classification, outside of overbite or underbite, is an excessive gingial display or the ‘gummy smile’, also known as the ‘toothless smile’ and ‘long face syndrome’.8 This has been termed a smile where greater than 2mm of the gingiva are visible when the individual smiles.2 This appearance can occur due to dental eruption, hyperfunction of the upper lip elevator muscle, unwarranted development of the maxilla bone or a combination of the three.9 In such cases, orthognathic surgery to manipulate the maxilla can be an option, alongside botulinum toxin type A injections and micro-autologous fat transplantation.10 Hyaluronic acid (HA) fillers Skeletal Class III Skeletal Class I Skeletal Class II are also employed and can be injected into Figure 1: Angle’s Classification of Malocclusions, which can cause an aesthetically unpleasing various points of the face depending upon underbite (Class II) or overbite (Class III). The orange arrows demonstrate the misalignment of teeth in Classes II and III of the framework.4 the desired result.

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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Jaw angles Different jaw angles and classifications can significantly shift the frontal view shape of the face. Those of all different racial backgrounds regard the oval face shape to be the most aesthetically pleasing and youthful.10 The classifications primarily focus on the angle of the mandible, which is positioned on the posterior border and meets the lower edge of the ramus.3 The mean mandible angle in males is 128 degrees, whereas it is 126 degrees in women.11 The mandible angle can be classified into three groups using the five-point Likert scale; these are extraversion, introversion or standard depending upon the location of the gonion, which is located at the lowest, posterior, and lateral point on the mandible angle.12 Introversion and a narrower angle can lead to a squarer face, whereas extroversion and an overly wide angle can lead to an oval face.12 Within these bounds, three common manifestations of aesthetically displeasing results are generally seen. These include:13 1. Reduced ascending ramus height 2. Reduced horizontal body length 3. Lateral deficiency Radiological investigations are usually required to diagnose issues of jaw angle, clinically. For example, a radiological evaluation is required to assess hyperostosis surrounding the mandible angle.14 Likewise, cephalogram and three-dimensional scanning can be a useful tool when assessing mandible angle protrusion or flaring (gonial eversion), in addition to more subtle measurements of symmetry, deviation of convexity to the body and relation of the jaw to the chin.14 This demonstrates how the medical aesthetic professional needs to maintain a range of clinical skills and an ability to synthesise an array of investigative data if they are to appropriately advise patients on a course of action to develop the patient’s desired result.

Where angle classifications are concerned, jaw refinement tends to focus on mandibular contouring.15 In surgery, the aim is usually resection of the angular portion or narrowing genioplasty, in conjunction with a mandibular portion resection – also known as V-line surgery.15 Further to this, mandibular porous polyethylene implants can be inserted to accentuate areas of the jawline. Injectable products can also be used in some cases. Fillers can be used to better define the angle of the mandible at the pre and post jowl hollows, to make the jawline appear visibly straighter.16 Calcium hydroxylapatite and high G prime HA fillers are common choices in such cases.16

It is important to understand this classification when diagnosing patient complaints and directing treatment towards accentuation or divert attention from key areas of the jawline Samizadeh and Wu investigated population preference where specific facial profiles were concerned.1 The researchers provided two different sets of female facial profiles to 1,417 participants. The profiles in Group A correspond to Angle’s skeletal classification system, and the profiles in Group B added the anteriorly-projected chin into these three classifications.1 Results suggested that 85% of respondents opted for the skeletal classification Class I profile in Group A, and 60% favoured the straight skeletal classification Class I profile in Group B.1 This research, which has elucidated that what is considered as attractive and beautiful in the female image, can help aesthetic practitioners in communication, consultation, prioritisation and treatment planning to deliver the best outcomes for the individual.1 A further study investigating facial profiling showed that attractiveness ratings were higher for plane profiles, compared to the convexconcave profile, with a non-significant discrepancy between convex and concave profiles.18

Jaw ageing Facial profiling Beyond Angle’s three categories, the Concave-Convex classification further classifies the facial profile into convex, concave, plane, convex-concave and concave-convex.17 It is important to understand this classification when diagnosing patient complaints and directing treatment towards accentuation or divert attention from key areas of the jawline. A demonstration of these types is shown in Figure 2.

Convex

Concave

Tissue regions and bone matter gradually alter with the natural ageing process, and the jaw physiology is no exception to this. Previous research has shown that as a young adult transitions from a teenager and into their 20s, the mandible grows to exceed that of the maxilla.19 The consequences of this are a straighter profile and reconciliation of the lower incisors.19 Likewise, Bishara et al. noted small increases in jaw length in participants between the ages of 25-46.20,21

Plane

Convex-Concave

Figure 2: Classifications of facial profiles17

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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There is evidence to suggest that ageing of the jaw and its regions can vary depending on age, and this can alter the preferred or optimal treatment to deliver the desired result

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reduced skin moisture.26 As such, oestrogen replacement hormonal therapies are a popular choice rather than surgical interventions or injectables, and the patient must be aware of all their treatment options before selecting one which is appropriate for them.

This is significant as 91% of the 125,697 facelift procedures which were performed in the US in 2017 were done so on females.27 Likewise, a vast majority (98%) of these procedures in 2017 were performed on individuals over the age of 45.27 Similarly, 94% of the 7,230,967 US-based non-surgical botulinum toxin type A procedures in 2017 were performed on females.27 However, it is important to note that facial construction procedures are not purely a treatment chosen by the older population. In Samizadeh and Wu’s research, the majority of surveyed participants who came forward were between 25-35 years old.1 This particular study showed that a majority of participants, both men and women, preferred an oval face shape with a smoothly tapered jaw angle, a round and pointy chin and straight nose profile.1

Relevant soft tissues and danger zones Small degrees of mandibular growth have also been reported in the literature, with mandibular growth almost twice that of the total maxillary growth.22 It is thought that this occurs through a process of an upward and forward rotation when posterior vertical growth surpasses that of anterior vertical growth.22 Further to changes in bone structure, soft tissues alterations are also apparent with increasing age. As a person ages, the nasolabial line descends, the face appears to lengthen, and jowling occurs in the jaw region.23 Gravity is a contributing factor to the presence of this jowling. The descending of the soft tissues is a natural process that comes with age and consequences in progressive laxity and ptosis of the skin, subcutaneous tissue and fascia retaining ligaments and fat, but one which drives affected individuals to seek interventions.17 Furthermore, soft tissues, such as deep and subcutaneous facial fat, can atrophy with time due to reabsorption and the volume of the soft tissue may also increase (hypertrophy).17 Genetic characteristics can influence soft-tissue ageing, hormonal shifts over time and environmental inputs.24 Environmental characteristics, or extrinsic forces, include inadequate nutrition, dehydration, extreme temperatures, cigarettes or other toxins and exposure to strong ultraviolet light. These external forces tend to consequence in dysplasia and structural adjustment of the dermal and epidermal layers.25 Comparatively, intrinsic influencers, such as genetics, tend to cause the loss of dermal and epidermal factors which are responsible for the structure of the jaw.25 It is due to the fluctuation in these influencers that some individuals will have soft tissue that appears well preserved while, in other patients of the same age, the soft tissue may appear to degenerate to a much greater extent. Likewise, in some instances, the skin may appear to have not aged while the deeper soft tissue can lose structural landmarks, such as cutaneous laxity.25 Knowledge of the cause of aesthetic issues is significant when developing a treatment plan which is moulded to the patient’s needs.

There is evidence to suggest that ageing of the jaw and its regions can vary depending on age, and this can alter the preferred or optimal treatment to deliver the desired result.25 These discrepancies largely focus on hormonal differences. For example, declining oestrogen levels in women in older age are correlated with cutaneous deviations, such as fine wrinkling, dryness and atrophy.25 Further associations with reduced oestrogen in postmenopausal women include epidermal thinning, tissue laxity, reduced dermal collagen concentration and

Beyond the skeletal structure of the jaw, the layers of the region comprise hard tissues, soft tissues, mimetic muscles, and investing fascia. Together these make up the superficial musculoaponeurotic system (SMAS).17 One of the most relevant and commonly manipulated soft tissues of the jaw is the superficial subcutaneous fascia; the lowermost layer of the integumentary system of soft tissue at the top of the jaw and below the ears.17 More specifically, the superficial subcutaneous fascia is identified as meshed into the parotid fascia and integrating the platysma muscles as a broadening of the cervicalinvesting fascia.28 In a soft tissue rhytidectomy (surgical facelift) procedure, this area is subject to precise incisions, undermining, re-draping and tightening.28 Relevant soft tissues also include the hypertrophy of excess fat formation surrounding the jaw and neck, which can lead to a loss of definition in the region and widening of the neck-jaw angle.28 Aside from relevant soft tissues of the jaw, there are various associated danger zones which should be avoided for the patient’s safety. These include the facial nerve, part of which follows the skeletal line of the jaw; damage could lead to facial paralysis.29 Facial danger zones in non-surgical procedures include the glabellar area, nasolabial groove and angular artery.30 Manipulation of these zones in non-surgical procedures could lead to blindness, skin necrosis or a cerebrovascular event.30 Danger zones also relate to the underlying vasculature of the face, where the cutting into or perforation through injection of the associated vessels could significantly impact on the patient’s safety, such as bleeding under the skin or profuse anastomosis of the facial vessels.30 There are six facial danger zones relating to the vasculature in non-surgical procedures; these are categorised into the glabella, temple, nose, perioral area, infraorbital region and nasolabial fold.20 The superficial temporal artery runs from the temple inferiorly down through the jaw and drains into the jugular and is a significant danger zone in this area.19 Likewise, in the nasolabial fold, two-thirds of the facial artery is concealed under memetic musculature, and the vessel crosses the midline of the jaw.19 Scheuer et al. highlight that medical aesthetic professionals must know the anatomy of the facial vasculature but that even with this knowledge, there is an individual variation so even the most experienced of professionals can face challenges.20 This emphasises the need to always work with caution in the surrounding areas of danger zones and hold the appropriate emergency medical equipment on-site in the case that urgent medical attention is required.20

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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Conclusion There are a number of anatomical, safety and preference factors which should be considered when providing aesthetic treatments in the jaw region. There are three primary skeletal classifications which relate to malocclusion, with skeletal Class I the most commonly sought of the three. Each of the classifications is influenced by the angle of the mandible, where radiological investigations are usually required to diagnose abnormalities clinically. The underlying skeletal structure is also fundamental to the outcome of a convex, concave or straight facial profile. Research has shown that the ‘straight’ classification is most popular among respondents.1 The structure of the face is also made up of soft tissues, such as the superficial subcutaneous fascia.

Aesthetic practitioners need to be wary of danger zones when working in the jaw region, particularly the facial nerve, superficial temporal artery and nasolabial fold. Finally, the change in skeletal structures and soft tissues with age have been discussed and should be understood by injectors. The majority of these changes occur in later life and do so due to various extrinsic and intrinsic factors. The patient’s safety and preferences are paramount at all stages of the procedural journey. An understanding of angles classification and dentition, and options available, are vital parts of treatment planning in aesthetic patients where facial profiling or contouring is requested.

Dr Tracey Bell has 25 years’ experience as a qualified dentist, is an aesthetic practitioner and has contributed to various publications to date. Dr Bell is the owner of four dental and aesthetic clinics in the Isle of Man and the UK and has a Master’s in Dental Law and Ethics, a General Diploma in Law, and completed a Bond Solon Expert Witness Course.

She is also programme lead at Salford University, for the Non-surgical Facial Aesthetic PGcert starting in October 2019.

REFERENCES 1. Carruthers, Jean, et al. “The Convergence of Medicine and Neurotoxins: A Focus on Botulinum Toxin Type A and Its Application in Aesthetic Medicine—A Global, Evidence Based Botulinum Toxin Consensus Education Initiative: Part II: Incorporating Botulinum Toxin into Aesthetic Clinical Practice.”

Dermatologic Surgery 39.3pt2 (2013): 510-525.

2. Gatterman, Meridel I., and Bonnie L. McDowell. ‘Management of Muscle Injury and Myofascial Pain Syndromes.’ Whiplash. Mosby, 2012. 85-118.

3. Baek, Seung Hak, Hyock Soo Moon, and Won Sik Yang. ‘Cleft type and Angle’s classification of malocclusion in Korean cleft patients.’ The European Journal of Orthodontics 24.6 (2002): 647-653.

4. Baek, Seung Hak, Hyock Soo Moon, and Won Sik Yang. “Cleft type and Angle’s classification of malocclusion in Korean cleft patients.” The European Journal of Orthodontics 24.6 (2002): 647-653.

5. Williams, Alan. C., and Christopher. D. Stephens. ‘A modification to the incisor classification of malocclusion.’ British journal of orthodontics 19.2 (1992): 127-130.

6. Shell, Tracey L., and Michael G. Woods. “Facial aesthetics and the divine proportion: a comparison of

surgical and nonsurgical class II treatment.” Australian orthodontic journal 20.2 (2004): 51.

7. Ghafari, J. “Vertical maxillary asymmetry: a prevalent lateral roll in spatial orientation.” Orthodontics: The Art and Practice of Dentofacial Enhancement 13.1 (2012): e127-39.

8. Monaco, Annalisa, Oriana Streni, Maria Chiara Marci, Giuseppe Marzo, Roberto Gatto, and Mario Giannoni. ‘Gummy smile: clinical parameters useful for diagnosis and therapeutical approach.’ Journal of Clinical Pediatric Dentistry 29.1 (2005): 19-25.

9. Sucupira, Eduardo, and Abraham Abramovitz. ‘A simplified method for smile enhancement: botulinum toxin injection for gummy smile.’ Plastic and Reconstructive Surgery 130.3 (2012): 726-728.

10. Liew, Steven, Woffles Wu, Henry H. Chan, Wilson W. S. Ho, Hee-Jin Kim, Greg J. Goodman, Peter H. L. Peng and John D. Rogers. ‘Consensus on changing trends, attitudes, and concepts of Asian beauty.”

Aesthetic Plastic Surgery 40.2 (2016): 193-201.

11. Mao, Xiaoyan, Fu Xi, Niu Feng, Chen Ying, Jin Qi, Qiao Jia, Gui Lai. ‘Three-Dimensional Analysis of Mandibular Angle Classification and Aesthetic Evaluation of the Lower Face in Chinese Female Adults.’ Annals of Plastic Surgery 81.1 (2018): 12-17.

12. Han, Kihwan, and Junhyung Kim. ‘Reduction mandibuloplasty: osteotomy of the lateral cortex around the mandibular angle.’ Journal of Craniofacial Surgery 12.4 (2001): 314-325.

13. Büttner, Michael, and Maurice Yves Mommaerts. ‘Contemporary aesthetic management strategies for deficient jaw angles.’ PMFA News 2.4 (2015): 6-9.

14. Jin, Hoon, and Byung Gun Kim. ‘Mandibular angle reduction versus mandible reduction.’ Plastic and Reconstructive Surgery 114.5 (2004): 1263-1269.

15. Niamtu, Joe. ‘Facial Implants Mandibular Angle’. <https://www.lovethatface.com/before-and-aftergalleries/lower-facial-procedures/mandibular-angle-implant-gallery/> 16. Moradi, Amir, Azadeh Shirazi, and Roy David. “Nonsurgical Chin and Jawline Augmentation Using Calcium Hydroxylapatite and Hyaluronic Acid Fillers.” Facial Plastic Surgery 35.02 (2019): 140-148.

17. Mentz, Henry A., Amado Ruiz-Razura, Christopher K. Patronella, German Newall. ‘Facelift: measurement of superficial muscular aponeurotic system advancement with and without zygomaticus major muscle release.’ Aesthetic Plastic Surgery, 29.5 (2005): 353-362.

18. Naini, Farhad B., et al. “Assessing the influence of lower facial profile convexity on perceived attractiveness in the orthognathic patient, clinician, and layperson.” Oral surgery, oral medicine, oral pathology and oral radiology 114.3 (2012): 303-311.

19. Love, Rita. J., Jim. M. Murray, and Antonios. H. Mamandras. ‘Facial growth in males 16 to 20 years of age.’ American Journal of Orthodontics and Dentofacial Orthopedics 97.3 (1990): 200-206.

20. Bishara, Samir E., Jakobsen, Jane, Treder, Jean and Nowak, Arthur. ‘Arch width changes from 6 weeks to 45 years of age.’ American Journal of Orthodontics and Dentofacial Orthopedics 111.4 (1997): 401-409.

21. Sharma, Padmaja, Ankit Arora, and Ashima Valiathan. ‘Age changes in jaws and soft tissue profile.’

The Scientific World Journal 2014 (2014).

22. Gosain, Arun K., Klein, Marc H. Sudhakar, Peddireddi Vivien, Prost, Robert. ‘A volumetric analysis of soft-tissue changes in the ageing midface using high-resolution MRI: implications for facial rejuvenation.’ Plastic and Reconstructive Surgery 115.4 (2005): 1143-1152.

23. Friedman, Oren. ‘Changes associated with the ageing face.’ Facial Plastic Surgery Clinics 13.3 (2005): 371-380.

24. Verdier-Sévrain, Susan. ‘Effect of estrogens on skin ageing and the potential role of selective estrogen receptor modulators.’ Climacteric 10.4 (2007): 289-297.

25. American Society of Plastic Surgeons. ‘Plastic Surgery Statistics Report’. (2017). <https://www. plasticsurgery.org/documents/News/Statistics/2017/plastic-surgery-statistics-full-report-2017.pdf> 26. Verdier-Sévrain, Susan. ‘Effect of estrogens on skin ageing and the potential role of selective estrogen receptor modulators.’ Climacteric 10.4 (2007): 289-297.

27. American Society of Plastic Surgeons. ‘Plastic Surgery Statistics Report’. (2017). <https://www. plasticsurgery.org/documents/News/Statistics/2017/plastic-surgery-statistics-full-report-2017.pdf> 28. Scheuer, Jack, Sieber, David A., Pezeshk, Ronnie A., Campbell, Carey F., Gassman, Andrew A., Rohrich, Rod. ‘Anatomy of the facial danger zones: maximising safety during soft-tissue filler injections.’ Plastic and Reconstructive Surgery 139.1 (2017): 50e-58e.

29. Björk, Arne, and Mogens Pallilng. ‘Adolescent age changes in sagittal jaw relation, alveolar prognathy, and incisal inclination.’ Acta Odontologica Scandinavica 12.3-4 (1955): 201-232.

30. De Silva, J. “Facial danger zones: avoiding serious complications in nonsurgical filler injections.”

Aesthetics, (2015): 26-28.

Question Time

2. What is the average mandible angle in females?

A. 70 B. 126 C. 146 D. 110

3. Generally, what is the preferred facial profile for females?

A. Convex B. Concave C. Convex-concave D. Plane 4. The facial hard tissues, soft tissues, mimetic muscles and investing fascia are commonly termed as what?

A. Superficial musculoaponeurotic system B. Aponeurotic muscular system C. Lymphatic system D. Jugular system

5. Which of the changes below is not normally associated with ageing of the facial tissues?

A. Decreased tissue laxity B. Descending of the nasolabial line C. Facial fat atrophy D. Dermal dysplasia Visit our website to receive a certificate confirmation of your CPD point. www.aestheticsjournal.com/cpd

ANSWERS 1:B, 2:B, 3:D, 4:A, 5:A

1. What term is the Class II category of Angle’s classification of malocclusion better known by at the public level?

A. Overbite B. Underbite C. Normal D. Disjointed

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nasal procedures, I recommend that 1ml of bacteriostatic saline is used to reconstitute a 100U vial of onaBTX-A in order to prevent unintentional diffusion of the toxin to adjacent muscles. Treatment intervals for these procedures should not be more frequent than every three months.7

Nasoglabellar lines Nasoglabellar lines, commonly referred to as ‘bunny lines’, are formed by the contraction of the transverse nasalis. The lines may be accentuated in people who habitually wrinkle the nose – those who wear heavy glasses or have chronic rhinitis, for example – or may simply be a result of ageing.11 The approach to treatment needs to be tailored according to the individual patient. Initial treatment is usually an injection of 2-5U in the transverse nasalis on either side of the nasal spine (Figure 1). This has been observed to result in satisfactory improvement of wrinkles in around 40% of patients, with 60% experiencing persistent nasoalar, nasociliary or naso-orbicular wrinkles.3 One approach to assessing persistent wrinkles is to monitor the pattern of any additional wrinkles over two weeks following the initial injection and treat accordingly with further injections of 2U in the requisite areas.3 Dr Ahmed El Houssieny offers guidance on It is important that the injections associated with treating using botulinum toxin A to address some nasoglabellar lines are administered medially and not key aesthetic nasal concerns laterally into treated muscles to limit diffusion. Diffusion in the lip levators, the levator labii superioris alaeque Non-surgical rhinoplasty (NSR) is an increasingly popular nonnasi (LLSAN) and the levator labii superioris, can result in asymmetry invasive option for men and women who wish to address or upper lip ptosis, which may affect functions such as speaking the effects of ageing on the nose or to modify congenital and eating.6 Diffusion in the orbicularis oculi can affect lacrimal 1,2 characteristics. Not only does NSR save on cost and recovery time function.11 Injections that are too low and too deep into the nasal associated with surgery, but it also allows for subtle changes that are in sidewalls can result in injection into the angular artery or vein or keeping with today’s emphasis on achieving facial harmonisation.1,2 cause ecchymoses or haematoma.6 Needle placement should be Although many are familiar with the use of dermal fillers to achieve intradermal or superficially subcutaneous in this area to minimise NSR, botulinum toxin type A (BoNT-A) has been shown to be a spread.6 Any patient requesting treatment of nasoglabellar lines alone safe and effective treatment option for several aesthetic nasal should be considered for treatment of glabellar lines at the same time, procedures.3-5 However, because the use of BoNT-A in the mid-face, according to published literature.12 Conversely, it is recommended that including the nose, is off-label, it is of particular importance that the nasoglabellar lines should also be treated if glabellar line treatment treating clinician has a detailed knowledge of both the muscles of the is requested. This is to prevent compensatory contraction of either face and their action and interaction. the transverse nasalis or the procerus, causing either horizontal lines Injecting into the correct plane and limiting spread and diffusion of at the nasal root or secondary nasoglabellar lines if only one area is the toxin is, in my experience, crucial in the mid and lower face where treated.13 For treatment of the procerus, 3-5U are recommended.12 6 muscles often interdigitate. Furthermore, the muscles in this area However, as discussed above, this is off-label and I believe that only can be more sensitive to the effects of BoNT-A and lower doses are experienced practitioners should treat the nasoglabellar lines. usually required.7 In this article, I outline some key procedures and offer my guidance to facilitate precise, safe and effective treatment of this central facial feature.

Nasal Correction Using Toxin

Procerus

Consulting patients At the initial consultation, the clinician should assess patient expectations and be clear about what might be achieved. When selecting a treatment option, literature suggests that the approved type A toxins available are similar, although vary in terms of units, chemical properties, biological activities and weight and, hence, are not interchangeable.8,9 It is important to ensure that the patient has no contraindications to the use of the toxin (such as pregnancy or lactation)10 and to be aware of any medical conditions. Doses cited in this article are for onabotulinum toxin A (onaBTX-A). When reconstituting the toxin for

Orbicularis oculi Transverse nasalis Levator labii superioris alaeque nasi Levator labii superioris Dilator naris Depressor septi nasi Figure 1: Facial musculature and key injection points

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Nasal tip ptosis Drooping of the nasal tip can be the result of ageing or of gravity, combined with the hyperkinetic action of the depressor septi nasi.13 In some individuals, movement of the nasal tip occurs naturally during speech. It should be noted that BoNT-A will not be effective in individuals with a genetic downward-pointing nasal tip that is not dynamic.6,13 Static causes such as nasal septum or cartilages require a different approach. Identifying the aetiology of the ptosis is, therefore, key to successful treatment. Asking the patient to give a forced smile can show if the tip is actively rotated.13 Another integral element to treatment is an assessment of the musculature of the individual patient. The depressor septi nasi is not the only muscle responsible for depressing the nasal tip.14 For example, interdigitation of fibres in the depressor septi nasi and the dilator naris means that, in a small number of individuals, smiling or the formation of certain sounds can lead to widening of the nasal aperture and rotation of the tip.13 In some patients, the dynamic action of the depressor septi nasi and LLSAN muscles can result in the upper lip being pulled upwards as the tip of the nose is pulled downwards, leading to a horizontal upper lip crease when the mouth is animated.6 This line can be treated by injecting 1-3U of BoNT-A into each LLSAN and depressor septi.6 In order to inject precisely into the depressor septi nasi, the patient should extend their upper lip downward, elongating the muscle and separating it from the orbicularis oris. The columellar can then be injected while the clinician holds it or pushes the tip of the nose with the non-injecting hand (Figure 1). Stronger muscles require higher doses, so it is important to assess the strength of each muscle by observing them during rest and movement, as well as through palpation.15 Stronger muscles can be indicated by deeper lines, greater movement and larger mass.15 The depressor septi nasi, for example, will be stronger in some patients than others.6,13 A typical dose ranges from 2-5U. Where there is interdigitation of fibres between the depressor septi nasi and the dilator naris, an additional injection into the ala on both sides of the nasal tip will be required to lift the tip. An additional 4-5U in the nasal ala dorsum is suggested.13 However, minimum amounts of BoNT-A should always be used to avoid diffusion into the lip levators, as discussed above.6

Nasal flare The voluntary or involuntary contraction of the dilator naris muscle can occur naturally or due to stress. The resulting opening of the nostrils is exaggerated, causing the columella and septum to be revealed.11,13 Small doses of BoNT-A can weaken the dilator nasi, producing an overall narrower nasal aperture that does not interfere with breathing in.6 Suitable patients for treatment with BoNT-A are those who can flare their nostrils at will.11 Individuals with a wide nasal bridge and alar base may have particularly well-developed dilator naris muscles as well as the medial alar portion of the LLSAN.6 Subcutaneous injection should be into the dilator naris at the alar rim of each ala nasi and should be given where contraction is greatest (Figure 1).6,13 This is usually at the mid-point. As with the other nasal procedures I have discussed, lateral injection should be avoided so to prevent diffusion into the lip levator muscles. Dosage recommendations range from 2-10U of onaBTX-A per side.7,13 No adverse effects have been noted with this treatment approach.6,11,13

Nasal dorsum hyperhidrosis Excessive perspiration of the bridge of the nose occurs more rarely than at sites such the axilla, palms and feet, but it is nonetheless a

condition which may cause social embarrassment to the individual affected.4 It is thought to be more common in men than in women and to worsen with age.11 Patients who undergo treatment with BoNT-A report not only decreased levels of hyperhidrosis but also improved quality of life.16 BoNT-A inhibits the release of the neurotransmitter acetylcholine that stimulates the eccrine sweat glands.16 As injection is intradermal, it can be painful so pain relief is recommended.4 My preference is for a topical local anaesthetic. Injections are given over the affected area with a space of 1cm between each one.11 It is important that they are applied symmetrically. A case study of two patients experiencing nasal dorsum hyperhidrosis reports effective treatment and no adverse effects from administering a total of 20 injections of 0.1ml per unit to each patient, where a 100U vial of onaBTX-A was reconstituted with 10ml of normal saline.4

Conclusion Due to the anatomical complexities of the mid-face, knowledge and observation of facial anatomy is crucial to achieving the safe and effective treatment of aesthetic nasal concerns using BoNT-A. Assessing the structure and action of the facial muscles in each patient enables the optimal choice of injection points and dose of toxin. Precise administration of the toxin using minimal volumes is of particular importance in achieving symmetry and avoiding motor disruption to the mouth and eyes. By applying experience, knowledge and careful judgement when treating the nasal area, the clinician is able to work with the patient to achieve the facial harmonisation that treatment with BoNT-A can offer.

Dr Ahmed El Houssieny is a trained anaesthetist with a passion for aesthetics. He is an Honorary Lecturer at the University of Chester and an education provider on cosmetic procedures. Dr El Houssieny is registered with the General Medical Council, as well as being a member of the British Society of Aesthetics.

REFERENCES 1. Aesthetics Journal. Non-surgical rhinoplasty is on the rise. 2017. <https://aestheticsjournal.com/news/ non-surgical-rhinoplasty-on-the-rise> 2. Sundaram H, Liew S, Signorini M, Vieira Braz A, et al. Global aesthetics consensus: hyaluronic acid fillers and botulinum toxin type A—recommendations for combined treatment and optimizing outcomes in diverse patient populations. Plast Reconstr Surg 2016 May;137(5):1410–1423.

3. Tamura BM, Odo, MY, Chang B, Cucé LC, Corcoran Flynn T. Treatment of nasal wrinkles with botulinum toxin. Dermatol Surg. 2005;31(3):271–275.

4. Geddoa E, Balakumar AK, Paes TRF. The successful use of botulinum toxin for the treatment of nasal hyperhidrosis. Int J Dermatol 2008;47(10):1079–1080.

5. Cigna E, Sorvillo V, Stefanizzi G, Fino P, Tarallo M. The use of botulinum toxin in the treatment of plunging nose: cosmetic results and a functional serendipity. Clin Ter 2013;164(2):e107–113.

6. Benedetto AV. Cosmetic uses of botulinum toxin A in the mid face, in, Botulinum Toxins in Clinical Aesthetic Practice, Second Edition. Edited by Benedetto AV. (Boca Raton, FL, USA, Taylor and Francis, 2011). pp101–139.

7. Carruthers J, Carruthers A. Aesthetic botulinum A toxin in the mid and lower face and neck. Dermatol Surg 2003;29:468–476.

8. Lorenc ZP, Kenkel JM, Fagien S, Hirmand H, et al. Consensus panel’s assessment and recommendations on the use of 3 botulinum toxin type A products in facial aesthetics. Aesthet Surg J 2013 Mar;33(1 Suppl):35S-40S. 9. Samizadeh S, De Boulle K. Botulinum neurotoxin formulations: overcoming the confusion. Clin Cosmet Investig Dermatol 2018; May:11:273–287.

10. De Maio M, Rzany B. Botulinum Toxin in Aesthetic Medicine. (Berlin, Germany, Springer, 2009). pp18–19.

11. Schavelzon D, Blugerman G, Wexler G, Martinez L. Botulinum toxin in the nasal area, in, Miniinvasive techniques in Rhinoplasty. Edited by Serdev N. (Rijeka; Intech; March 2016). <https://www.intechopen. com/books/miniinvasive-techniques-in-rhinoplasty/botulinum-toxin-in-the-nasal-area> 12. Bertossi D, Cavallini M, Cirillo P, Fundarò SP, Quartucci S. Italian consensus report on the aesthetic use of onabotulinum toxin A. J Cosmet Dermatol 2018; Oct;17(5):719–730.

13. Dixit R. Midface indications, in, Aesthetic Dermatology: Current Perspectives. Edited by Sharad J. Vedamurthy M. (New Delhi, India, Jaypee Brothers Medical Publishers, 2019). pp120–128.

14. Gruber RP, Kwon E, Berger A. Commentary on: The lower nasal base: an anatomical study. Aesthet Surg J 2017;33(2):233–236.

15. Anido J, Arenas D, Arruabarrena C, Domínguez-Gil A et al. Tailored botulinum toxin type A injections in aesthetic medicine: consensus panel recommendations for treating the forehead based on individual facial anatomy and muscle tone. Clin Cosmet Investig Dermatol 2017:10 413–421 16. Doft MA, Hardy KL, Scherman JA. Treatment of hyperhidrosis with botulinum toxin. Aesthet Surg J 2012;32(2):238–244.

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

Aesthetics Awards Finalists

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THE PRESTIGIOUS AESTHETICS AWARDS IS BACK, AND THE 2019 FINALISTS HAVE BEEN CONFIRMED!

Voting and judging closes October 31

Awards presented in front of 800+ guests

GET INVOLVED AND VOTE FOR YOUR WINNERS! Certain categories will be partly judged and partly voted-for by you, giving you the opportunity to celebrate the products you value and thank the suppliers who do so much to support the running of your practice. Your opinion counts, so head to our website to check out the finalists on the following pages and login to aestheticsawards.com to cast your votes today!

Voting will consist of 30% of the final score in the applicable categories. Please note that voting is IP address monitored and individuals can only vote once. Multiple votes under the same name will be discounted from the final total. Multiple votes from within organisations will also be monitored.

JUDGING â&#x20AC;&#x201C; HOW DOES THIS WORK? We are proud to have an esteemed judging panel, of more than 60 aesthetic professionals. Six judges will be assigned to each category, chosen specifically for their knowledge and expertise in that area, as well as to ensure that conflicts of interest are avoided.

The full list of judges can be found on the Aesthetics website.

36

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Taking place at Park Plaza Westminster Bridge Hotel

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COMPANY FINALIST S PHARMACY DISTRIBUTOR OF THE YEAR VOTE NOW!

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>> CALECIM® Professional Serum (Church Pharmacy) >> Epionce (Epionce / Eden Aesthetics) >> Heliocare 360 (AesthetiCare) >> Medik8 Crystal Retinal 1 & 3 (Medik8) >> NeoStrata Skin Active Range (AestheticSource Ltd) >> Obagi Medical (Healthxchange Pharmacy) >> PCA Skin Hyaluronic Acid Boosting Serum (Church Pharmacy / PCA SKIN) >> SkinCeuticals Blemish+Age Defense (SkinCeuticals) >> Your Signature Range (5 Squirrels)

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Aesthetics Awards Finalists

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TRA INING PROVIDE R FINALIST S THE DALVI HUMZAH AESTHETIC TRAINING AWARD FOR BEST SUPPLIER TRAINING PROVIDER VOTE NOW! >> AestheticSource Ltd >> Alumier Labs >> Cynosure UK Ltd Clinical Training Team >> HA-Derma Ltd >> Healthxchange Academy >> Lynton Lasers Ltd >> Teoxane UK THE SINCLAIR PHARMA AWARD FOR BEST INDEPENDENT TRAINING PROVIDER VOTE NOW! >> Avanti Aesthetics Academy >> Cosmetic Courses >> Dermaplaning Training Courses >> Inspired Cosmetic Training @ La Belle Forme Clinic >> Medical Aesthetics Training Academy Ltd >> Oculo-Facial Aesthetic Academy >> Revivify >> Totally Aesthetics

REGIONAL CLINIC FINALIST S THE CELLUMA AWARD FOR BEST CLINIC LONDON

THE AESTHETICARE AWARD FOR BEST CLINIC NORTH ENGLAND

>> Adonia Medical Clinic >> Cadogan Clinic >> Juvea Aesthetics >> LINIA Skin Clinic >> London Professional Aesthetics >> The Clinic by Dr Mayoni >> The Glasshouse Clinic >> True Medispa >> VIVA Skin Clinics

>> AESTHETIC HEALTH >> Burgess Hyder Dental group >> CAREFORSKIN AESTHETICS >> Cliniva Medispa >> Discover Laser Ltd >> Emma Chan Ltd >> Innersense Aesthetics >> LoveSkin Clinic >> Rachel Goddard Aesthetics >> SDS REJUVENATE MEDISPA >> Skyn Doctor

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>> Elite Aesthetics >> HEALTH & AESTHETICS LTD >> Illuminate Skin Clinic >> Medcentres Plus Ltd t/a Salisbury Cosmetic and Beauty Clinic >> Perfect Skin Solutions >> Sandbanks Clinic >> Weston Beauty Clinic

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BEST CLINIC MIDLANDS AND WALES BEST CLINIC SCOTLAND >> Air Aesthetics Clinic >> Hampton Clinic >> Outline Clinic

38

>> Dermal Clinic >> Dr Nestorâ&#x20AC;&#x2122;s Medical & Cosmetic Centre >> Face & Body Ltd Aesthetics | September 2019

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Aesthetics Awards Finalists

OTHER CLINIC FINALIST S THE AESTHETICSOURCE AWARD FOR BEST NEW CLINIC, UK & IRELAND >> Define Clinic >> Dr Rasha Clinic >> Eternal Clinic >> Facetherapy NI >> Grand Aura Skin & Wellbeing Clinic >> KLNIK >> Lumiere Clinic >> Sazthetics >> Smooth Line Clinic >> The Clinic Burton >> The Glasshouse Clinic >> Wentworth Aesthetics

>> Tinkable Aesthetic Clinic >> The Laser and Skin Clinic >> The Consultant Clinic >> Clinetix CLINIC RECEPTION TEAM OF THE YEAR

BEST CLINIC GROUP, UK & IRELAND (10 CLINICS OR MORE) >> Courthouse Clinics >> Therapie Clinic

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>> Adonia Medical Clinic >> Clinetix >> Cliniva Medispa >> Define Clinic >> Dr Nestor’s Medical & Cosmetic Centre >> HEALTH & AESTHETICS LTD >> Illuminate Skin Clinic >> Outline Clinic >> Rachel Goddard Aesthetics >> The Glasshouse Clinic

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>> 5 Squirrels >> Allergan Spark >> Clever Clinic >> clinicsoftware.com >> e-clinic >> Fertile Frog >> Kendrick PR >> Truly Content Ltd >> Web Marketing Clinic

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“Absolutely amazing, totally inspirational, we have loved the event. Meeting everyone in one place has also given my team a huge boost for the year ahead!

The Awards were well organised, and the comedian was hysterical!

Lovely lovely night!”

Dr Sally Ann Dolan, medical director of SDS Rejuvenate MediSpa

Aesthetics | September 2019

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IN D IVI DUA L P RAC TITIONER FINALIST S THE SPRINGPHARM AWARD FOR AESTHETIC NURSE PRACTITIONER OF THE YEAR >> Adrian Baker >> Emma Coleman >> Tracey Dennison >> Sarah Gilles >> Rachel Goddard >> Aine Larkin >> Claudia McGloin >> Jacqueline Naeini >> Jackie Partridge >> Melanie Recchia >> Elizabeth Rimmer >> Yvonne Senior >> Alison Telfer >> Susan Young THE JOHN BANNON AWARD FOR MEDICAL AESTHETIC PRACTITIONER OF THE YEAR PHARMACY

>> Dr Yusra Al-Mukhtar >> Miss Sherina Balaratnam >> Dr Jonquille Chantrey >> Dr Nestor Demosthenous >> Dr Benji Dhillon >> Dr Ifeoma Ejikeme >> Dr Brian W. McCleary >> Dr Beatriz Molina >> Dr Dev Patel >> Dr Emma Ravichandran >> Dr Simon Ravichandran >> Dr Souphiyeh Samizadeh >> Dr Daron Seukeran >> Mrs Sabrina Shah-Desai >> Dr Sophie Shotter >> Dr Rekha Tailor >> Dr Patrick Treacy THE SCHUCO AESTHETICS AWARD FOR OUTSTANDING ACHIEVEMENT IN MEDICAL AESTHETICS The exceptional accomplishments and significant contribution to the profession by an individual with a distinguished career in medical aesthetics will be recognised with the trophy for Outstanding Achievement in Medical Aesthetics. The winner of this category will be announced at the ceremony and is not open to entries.

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“It was amazing to be a finalist at the Awards, although we didn’t win, it gave our team a real boost!”

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Case Study: Treating Acne Scars Nurse prescriber Adrian Baker shares a case study combining microneedling, LED and topicals for treating acne scars Acne vulgaris is a common skin condition affecting 650 million people worldwide with a 95% prevalence of acne in adolescence.1 It is reported that 12-14% of cases will continue into adulthood with psychosocial effects2 and 20-35% will develop moderate to severe acne that has an increased risk to cause textural skin changes to the superficial and deep dermis.1,3 These dermal changes result in permanent scarring of the skin, leading to substantial physical and psychological distress, particularly in adolescents.4 It is crucial that acne treatments are sought early on, and that acne scarring is not overlooked, in order to reduce the incidence of psychological distress. For this reason, treatments should be effective and delivered in a timely manner.

Treatment options There are a variety of treatment options available for acne scarring, which can include topical preparations, dermabrasion, laser resurfacing, non-ablative and fractional laser, punch excision, subcutaneous incision, chemical peels, dermal grafting, and fillers, as well as focal treatment with trichloroacetic acid, and skin microneedling (automated or roller devices).3 With such a variety of treatment modalities available, both evidence of efficacy and safety profile needs to be taken into account when deciding upon which treatment is suitable for the patient.

Aust et al. state that the ideal treatment for acne scarring should preserve epidermal integrity whilst also promoting the normal formation of collagen and elastin structures within the dermis.5 Treatments that disrupt the epidermal integrity such as punch excision, ablative laser resurfacing, and deep peeling agents remove the epidermis in its entirety and can give rise to biological adverse skin responses, resulting in post-inflammatory hyperpigmentation (PIH) and further scarring.6 With this in mind, in my opinion, microneedling brings us closer to the ideal scar treatment as epidermal integrity is maintained by needles that penetrate, but do not remove, the epidermis, thus reduce the

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risk of adverse outcomes.5 Upon penetration of the stratum corneum, small channels are created, known as micro-conduits, that lead to a natural inflammatory healing cascade; stem cells located within the dermal papilla are activated7 and platelets and neutrophils are recruited to release growth factors TGF-alpha, TGFbeta, and platelet-derived growth factor (PDGF).8 This, in turn, stimulates the fibroblastic action of collagen and elastin production in the papillary dermis.9 The mechanical action of the needles passing through scar tissue is also thought to play a role in the breakdown of existing fibrous collagen type III that forms within scar tissue, replacing over time with the preferred collagen type I.10 Newer treatment modalities, such as fractional lasers and non-ablative lasers, also appear to provide effective results through a similar mechanism of action.11 However, a study in 2016 revealed that microneedling is a more cost-effective approach, with comparably effective results, a better safety profile and less downtime than non-ablative fractional laser treatments.12

Considerations

Whilst microneedling has been shown to be an effective treatment of acne scarring,13 downtime and discomfort can remain problematic, albeit less so than other forms of treatment in my opinion. Erythema, oedema, and microbruises are the most commonly-reported side effects,3,7,11 however, there are very few studies detailing the average time that this can last.

In my experience, post-procedural erythema can last three to four days post acne scar microneedling because an aggressive needle depth of 1.5-2mm is required.14 In a busy world where recovery time is often restricted for patients, one strives to reduce post-procedural side effects as soon as possible without reducing the efficacy of the treatment itself. As erythema and oedema are the result of the natural immune response to heal, it could be hypothesised that any treatment given to address this skin response could in fact reduce the efficacy of the treatment itself.

Acute inflammation, which occurs immediately after an injury, is a temporary event to limit further injury as well as to begin the repair and healing process.15 When inflammation persists, however, not only is the patientâ&#x20AC;&#x2122;s downtime prolonged, but excessive healing responses are activated which could increase the risk of adverse events.15 For this reason I chose to include cord-lining stem-cell conditioned media into my microneedling protocol. This fluid contains epithelial and mesenchymal secreted bioactive molecules, including proteins, cytokines, and growth factors, that are able to effectively communicate with the epidermal and dermal cells of the skin via the paracrine effect.16 The paracrine effect is the process in which stem cells can communicate to local cells via bioactive signaling molecules.17,18 This multitude of paracrine factors form part of a complex network that confers stability to the cells as well as amplification of the regenerative response, thus exerting beneficial effects upon injured tissues via biomodulation, promoting angiogenesis and tissue regeneration and inhibiting fibrosis, apoptosis and inflammation.17,18

My protocol I devised my own clinical protocol for the treatment of acne scarring in my clinic, called CellRenew Microneedling. Utilising a combination of gentle enzymatic peeling, automated microneedling with cord-

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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lining stem-cell conditioned media,16 and the use of post-procedural red LED light therapy, I have seen a noticeable improvement to the outcomes I am achieving.

My observation in practice is that I have also reduced the number of treatments I need to provide. This means the number of occasions that my patients need to undergo what could be considered an uncomfortable procedure is reduced.

Case Study Assessment A 24-year-old female presented in clinic and informed me that she had suffered with acne since adolescence. She sought treatment advice for acne scarring however, upon consultation and examination, she still had acneic lesions to her cheeks and forehead. Her acne was assessed as moderate which presents as open and closed comedones, papules and pustules.19 There was also evidence of scars that had already formed from previous lesions.

We discussed the importance of treating her active acne in the first instance and gaining control over the occurrence of new lesions, before exploring scar treatments. She had a past history of both topical and systemic antibiotic use, of which she had not found to be effective in gaining control of new lesions. She stated that she was keen to explore non-antibiotic routes. She had considered systemic isotretinoin via her GP referral, but after reviewing side effects, felt she did not want to pursue this.

Treatment plan Initial treatment for six weeks with topical treatments, including retinol 1%, salicylic acid 2%, a gentle gel cleanser and mineral UV protection, was advised to begin with. This simple regime was recommended so as to target the pathogenic factors of acne through the downregulation of excessive sebum production and inflammation, and decrease corneocyte adhesion and microbial activity.20,21 The mineral UV protection was advised to reduce the occurrence of PIH. I reviewed the patient at six weeks where I noted that there was improvement to her overall lesion count. The patient was also pleased and encouraged that the regime was working. Prior to starting, I had advised that it may take up to six weeks until she saw the beginning of lesion control, and 12 weeks for significant improvement.20 I advised the patient to continue the topical regime for another six weeks. There was no need to change anything as her progression was as expected.

I reviewed the patient again at 12 weeks and I was pleased with her progress. She had no acneic lesions present and visibly-reduced comedones. A plan was made to begin treatment for scarring using Before

After topical treatment

Figure 1: Images show moderate acne before treatment and 12 weeks after topical regime

It is crucial that acne treatments are sought early on, and that acne scarring is not overlooked, in order to reduce the incidence of psychological distress

my protocol. The patient was asked to remain on the skincare throughout the course of treatments to maintain acne lesion control.

To start the protocol, I cleansed the skin and then applied the Enzyme Re-Texturising Peel from AlumierMD for five minutes. The purpose of this aspect of the treatment was to prepare the skin for application of Calecim Professional cord-lining stem-cell conditioned media during and following microneedling. Fruit enzymes are able to effectively degrade the tight epidermal junctions of keratinocytes and permeabilise the skin barrier for topical formulation absorption.22 Whilst microneedling alone provides micro-conduits for deeper skin delivery of stem-cell conditioned media molecules, the de-keratinised skin will improve the passage of the cord-lining conditioned media to pass into the whole epidermal surface.

Following the enzyme peeling, a thick layer of LMX4 topical anaesthetic cream was applied for 20 minutes and half of the LMX4 was then removed from one side of the face and cleansed with Clinisept+. The summary of product characteristics for LMX4 states that treatments should be performed soon after removal to ensure comfort,23 therefore, I choose to remove topical anaesthetic from only one side to allow the other side to continue the anaesthetic effect and maintain comfort when treated.

It should be noted that just as the de-keratinised skin will allow for greater permeability of topical therapeutics,22 it will also increase topical anaesthetic absorption, and consideration should be made for lidocaine toxicity and medical history interaction.24 On the positive side, topical anaesthetics that are applied to skin surfaces After first session

After second session

Figure 2: Images show after first and second CellRenew Microneedling session, which were six weeks apart

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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that have been de-keratinised show a greater degree of effect in less time.24 I then began the microneedling stage on the cleansed half of the face. Calecim Professional After three treatments Serum was applied to the skin throughout the procedure as a skin glide. Microneedling to the whole area was treated at a depth of 0.5mm to bony areas and 1mm to non-bony areas.

Figure 3: Result six weeks after The needling pattern was third treatment of CellRenew provided in small sections as a Microneedling protocol back and forth glide, with slight overlap, travelling back again, and then cross-hatching in the same glide motion. A second pass of microneedling at 1.5-2mm was then performed to focus specifically over scars. This second pass allows for micro-conduits to be placed at varying depths within the scar tissue. The LMX4 was removed from the other side of the face and cleansed again with Clinisept+. The process was repeated to this side. The Calecim Serum was then gently pressed onto the skin of the whole face until half the bottle (2ml) was used. Once dry, a sterile gel was applied to the whole face. I use a non-cytotoxic hydrogel that is provided with the SkinPen Precision microneedling cartridge.

This aims to support a moist wound-healing environment while hydrating the skin.25 The patient was then bathed under the SlimFit LED mask using a combination of red, blue and near infrared LED light, with frequencies 415 nm, 630 nm and 830 nm, for 20 minutes.26 This dual therapy acts to provide antibacterial (blue light), fibroblast stimulating (red light), and wound healing (near infra-red) benefits.27 Aftercare was discussed and the remaining half bottle, plus another bottle, of Calecim Serum was given to the patient to apply regularly over the next 24 hours. Following this application, the patient was advised to apply the aqueous gel used previously. A bland colloidal oat-based cream was given to be applied for three days. This acts to supports a non-inflammatory path for skin remodeling and supports barrier repair and renewal.28 I then recommended that the patient continue her normal skincare regime, as previously advised, to maintain acneic lesion control. She had a further two treatments of the whole protocol, spaced six weeks apart.

Before protocol treatment

The result The patient was able to achieve near total scar recovery within her treatment course. I reviewed her six weeks’ after her third treatment and she was delighted with the results. There were no complications experienced throughout the treatment course, other than transient erythema for one to two days and dry flaking skin for up to one week.

Our next plan is for the patient to remain on her advised skincare for acne management and to return once a year, for single treatments of my protocol, to maintain her skin appearance.

Summary Acne has a large prevalence in society, particularly in younger individuals. If not effectively managed in a timely manner, both physical and psychological scarring can occur. The case study I have presented has shown how, in my practice, I am effectively treating acne scarring, as well as other applications of effective skin functioning and form, such as textural improvements too.

Adrian Baker is a registered nurse prescriber and has worked within the field of aesthetics for nine years. He is the director of Lumiere MediSpa based in Oxford. He is the co-author of the RCN accredited BACN Aesthetic Nursing Competency Framework from 2013-2016, created to assist nurses in the UK to develop their skills and careers in the aesthetic medical profession. Baker has also been published for his thesis on acne management.

REFERENCES 1. National Institute for Health and Care Excellence, ‘Clinical Knowledge Summaries: Acne Vulgaris’, (2018), <https://cks.nice.org.uk/acne-vulgaris#!backgroundSub:2> 2. Ghodsi SZ; Orawa H, Zouboulis CC, ‘Prevalence, Severity, and Severity Risk Factors of Acne in High School Pupils: A Community-Based Study’, Journal of Investigative Dermatology (2009) 129(9): 2136–41.

3. El-Domyati M; Baracat M; Awad S; Medhat W; El-Fakahany H; Farag H, ‘Microneedling Therapy for Atrophic Acne Scars: An Objective Evaluation’, Journal of Clinical and Aesthetic Dermatology (2015) Jul; 8(7): 36–42. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4509584/> 4. Sharad J, ‘Combination of Microneedling and Glycolic Acid Peels for the Treatment of Acne Scars in Dark Skin’, Journal of Cosmetic Dermatology, (2011), 10(4): 317-323. <https://onlinelibrary.wiley.com/doi/ abs/10.1111/j.1473-2165.2011.00583.x> 5. Aust MC; Fernandes D; Kolokythas P; Kaplan HM; Vogt PM, ‘Percutaneous Collagen Induction Therapy: An Alternative Treatment for Scars, Wrinkles, and Skin Laxity’, Plastic and Reconstructive Surgery, (2008) 121(4): 1421-9.

6. Alster TS and West TB. ‘Resurfacing of Atrophic Facial Acne Scars with A High-Energy, Pulsed Carbon Dioxide Laser’, Dermatologic Surgery, (1996) 22(2): 151–5.

7. Iriarte C; Awosika O; Rengifo-Pardo M; Ehrlich A, ‘Review of Applications of Microneedling in Dermatology’, Clinical, Cosmetic and Investigative Dermatology (2017) 10: 289–298. <https://www. ncbi.nlm.nih.gov/pmc/articles/PMC5556180/> 8. Fernandes D, ‘Minimally invasive percutaneous collagen induction’, Oral and Maxillofacial Surgery Clinics of North America (2005), 17(1):51–63. <https://www.ncbi.nlm.nih.gov/pubmed/18088764> 9. Doddaballapur S, ‘Microneedling with Dermaroller’, Journal of Cutaneous Aesthetic Surgery (2009) 2 (2):110–111. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2918341/> 10. Fabbrocini G; Fardella N, Monfrecola A; et al, ‘Acne Scarring Treatment Using Skin Needling’, Clinical and Experimental Dermatology (2009) 34: 874–879. <https://www.ncbi.nlm.nih.gov/ pubmed/19486041> 11. Fabbrocini G; Annunziata MC; D’Arco V; et al, ‘Acne Scars: pathogenesis, Classification and Treatment’, Dermatology Research and Practice (2010) 2010: 893080. <http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2958495/ > 12. Cachafeiro, T; Escobar, G; Maldonado, G; Cestari T; Corleta, O, ‘Comparison of Nonablative Fractional Erbium Laser 1,340 nm and Microneedling for the Treatment of Atrophic Acne Scars: A Randomized Clinical Trial’, Dermatologic Surgery, (2016) 42 (2): 232-241. <https://journals.lww.com/ dermatologicsurgery/Abstract/2016/02000/Comparison_of_Nonablative_Fractional_Erbium_Laser.14. aspx> 13. Ablon G, ‘Safety and Effectiveness of an Automated Microneedling Device in Improving the Signs of Aging Skin’, Journal of Clinical Aesthetic Dermatology (2018) 11(8): 29–34. <https://www.ncbi.nlm.nih. gov/pmc/articles/PMC6122507/> 14. VORODUKHINA O, ‘An Introduction to Medical Microneedling’ Aesthetics Journal 10 JUL 2017 <https:// aestheticsjournal.com/feature/an-introduction-to-medical-microneedling> 15. DORIZAS A, ‘Good Inflammation, Bad Inflammation’, Prime journal, JUNE 25, 2018 <https://primejournal.com/good-inflammation-bad-inflammation/> 16. Lim I and Phan T, ‘Epithelial and Mesenchymal Stem Cells From the Umbilical Cord Lining Membrane’, Cell Transplantation (2014), Vol. 23, pp. 497–503.

17. Linero I and Chaparro O, ‘Paracrine Effect of Mesenchymal Stem Cells Derived from Human Adipose Tissue in Bone Regeneration’, Plos One (2014) 10 (3) <https://doi.org/10.1371/journal.pone.0107001> 18. Kusuma G; Carthew J; Lim R, and Frith J, ‘Effect of the Microenvironment on Mesenchymal Stem Cell Paracrine Signaling: Opportunities to Engineer the Therapeutic Effect’, Stem Cells and Development, (2017) 26 (9). <https://doi.org/10.1089/scd.2016.0349> 19. Van Onselen J, ‘Prescribing for Mild to Moderate Acne’, Nurse Prescribing, (2010) 8 (9): 424-431.

20. Baker A, ‘Treatment of a 25-Year-Old Female Patient with Moderate Acne Vulgaris’, Journal of Aesthetic Nursing, (2014) 3 (1): 2052-2878. <https://www.magonlinelibrary.com/doi/abs/10.12968/ joan.2014.3.1.28> 21. Arif T, ‘Salicylic Acid as a Peeling Agent: A Comprehensive Review’, Clinical, Cosmetic and Investigative Dermatology, (2015) 8: 455–461. <https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4554394/#> 22. Stremnitzer C; Manzano-Szalai K; Willensdorfer A; Starkl P; Pieper M; König P; Mildner M; Tschachler E; Reichart U; Jensem-Jarolin E, ‘Papain Degrades Tight Junction Proteins of Human Keratinocytes In Vitro and Sensitizes C57BL/6 Mice via the Skin Independent of its Enzymatic Activity or TLR4 Activation’, Journal of Investigative Dermatology, (2015) 135 (7): 1790-1800. <https://www.sciencedirect. com/science/article/pii/S0022202X15373267> 23. Electronic Medicines Compendium (2019) ‘Summary of product characteristics: LMX4 Lidocaine 4% w/w Cream’, <https://www.medicines.org.uk/emc/product/5938/smpc> 24. SOBANKO J; MILLER C; AND ALSTER T, ‘Topical Anesthetics for Dermatologic Procedures: A Review’, Dermatologic Surgery (2012) 38 (5): 709-721. <https://onlinelibrary.wiley.com/doi/abs/10.1111 /j.1524-4725.2011.02271.> 25. Bellus Medical (2019), ‘Lift HG’, <https://bellusmedical.com/products/lift-hg/> 26. SlimFit Aesthetics (2018), ‘SFLED Mask: How it works’, <https://slimfitaesthetics.com/sf-led-mask> 27. Ablon G, ‘Phototherapy with Light Emitting Diodes Treating a Broad Range of Medical and Aesthetic Conditions in Dermatology’, Journal of Clinical and Aesthetic Dermatology, (2018) 11(2): 21–27. <https:// www.ncbi.nlm.nih.gov/pubmed/29552272> 28. Bellus Medical (2019) ‘Skinfuse Rescue Calming Complex’, <https://bellusmedical.com/products/ skinfuse-post-procedure-protocol/skinfuse-rescue-calming-complex/.>

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Victorians believed that when someone died, the first person to look in the mirror would be next.6,7 Mirrors have also been perceived to have power over us, with the belief that a broken mirror causes seven years’ bad luck, dating back to Roman times.8 There are examples of mirrors and combs carved on some of the stones in the Pictish culture, where mirrors were thought to be highly sought after and only owned by those of high status.9 In short, there has always been a fixation with our reflection in humans, irrespective of culture, creed or time.

Understanding Appearance Psychology

The selfie culture

Today’s world of instant communication is probably best represented by the so called ‘selfie culture’.10 The selfie phenomenon of the Facebook, YouTube and Instagram generation is not actually new. Access to technology has allowed Aesthetic practitioner and hypnotherapist the proliferation of images and the ability to share those images with a public willing Dr Kathleen Long details the history of the mirror otherwise but, like the mirror, our desire and how practitioners can use it to improve patients’ or to share our reflection and perception of perception of their looks self has been around for a long time. In my opinion, the only difference between now Mirror Mirror on the wall, how did you become so essential to us and the past is the places where one’s images are shared. Take Frida all? Let’s face it, we all take a sneaky peek at our reflection when Kahlo, who shared her innermost feelings and pain through her 55 we pass a mirror in a hallway or even a shop window. Do you check very much acclaimed self-portraits. Van Gough produced around 30 yourself out in the car visor mirror occasionally, perhaps? It’s not only self-portraits, so was no stranger to the selfie, and Picasso, although a female thing either. Men are just as guilty of that quick sideways somewhat more abstract and less prolific, was a dab-hand at the look at their own reflection.1,2 Maybe we are all becoming vainer selfie. Their audience wasn’t on social media; instead all the best art than we used to be, but then again, perhaps this compulsion and galleries across the globe. The only difference today is that anyone even obsession, in some cases, is more embedded in our cultures can share their image in an instant with the wider world. and psyche than we would care to admit or even realise. One 2012 In 2014, national and international media reported on the ‘selfitis’ survey conducted by Simple Skincare suggests that women look condition, defined as individuals who feel compelled to continually in the mirror an average of eight times a day.3 While another survey post pictures of themselves on social media.11-14 Reports claimed that conducted in 2014 by Betta Living interestingly suggested that the ‘selfitis’ may be linked to some categorised psychiatric conditions and average adult UK man will spend 56 minutes looking at his own that it was to be classed as a genuine mental disorder.12 reflection every day, whereas British women spend 43.5 minutes Dr David Veal, a psychiatrist specialising in the treatment of obsessiveon an average day.1 In the same year, lifestyle brand Avaj also found compulsive and bipolar disorders, was quoted by the press as saying, that men look at their own reflection more often than women in their ‘Two out of three of all the patients who come to see me with body survey (23 times vs. 16 times per day).2 dysmorphic disorder (BDD) since the rise of camera phones have a compulsion to repeatedly take and post selfies on social media sites’.11 The mirror through the ages Although the reports about the ‘selfitis’ condition were a hoax, The mirror has been part of our human experience for many originating from a spoof news website,12,14 it has prompted some thousands of years. Greek myths tell the tale of Narcissus, a beautiful research to be done since then. A study involving 1,296 Polish men man who wasted away after spending too much time looking at his and women showed that obsessive taking of selfies and posting to reflection in the water. Seeing his reflection, he fell in love with it, but social media has been found to be linked to symptoms common to each time he bent down to kiss it, it seemed to disappear. Narcissus some mental health issues.12 Narcissism, which was higher in men, grew increasingly thirsty, but would not leave or touch the water for low self-esteem, loneliness, self-centeredness, and attention-seeking fear of losing sight of his reflection. The tale does not have a happy behaviour, were all found to be linked to selfie posting.15 As well as this, 3 ending, as needless to say, he died of thirst. Narcissus eventually the Nottingham Trent University, in conjunction with the Thiagarajar became the origin of the modern term ‘narcissism’.5 Bram Stoker’s School of Management, undertook a study of 400 Indian participants Dracula has no soul and hence no reflection in the mirror, which was on selfies, concluding that the ‘selfitis’ condition does indeed exist. in keeping with myths in ancient cultures who believed that their They developed a ‘Selfitis Behaviour Scale’ which can be used to reflections showed their souls. In some cultures and religions, it was, assess its severity.12 Perhaps with more research, ‘selfitis’ may soon and still is, the norm to cover the mirrors when someone dies. The make the Diagnostic and Statistical Manual of Mental Disorders (DSM)

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Recognising BDD I try to avoid treating patients with BDD as it usually only reinforces their insecurity and, as medical professionals, we have a duty to give patients good advice as they often present at an aesthetic clinic first, rather than to their own GP or mental health team.19 BDD patients can be difficult to spot and, in my experience, can be very manipulative in their quest for treatment. They will sometimes say things such as ‘I’ve heard you’re the best’, which I rarely regard a compliment, and is always an alarm bell for me, as it’s often followed with comments about going to several practitioners who were all ‘rubbish’ and the results were ‘awful’ and sometimes there’s ‘litigation in the pipeline’. Skin picking and continually touching the often imaginary flaw, as well as excessive use of camouflage makeup also makes my antennae stand to attention. BDD and OCD20 can often co-exist.

I now have a BDD questionnaire21 as part of the consultation and whilst it is by no means fool proof, it at least raises awareness that I have some knowledge about it amongst these patients. I also have a book on BDD on show and it is available for patients to read, as well as a DSM.

– often referred to as the ‘psychiatric DSM bible’16 – and become categorised as a real psychiatric condition.

Practical considerations of mirror use in clinic Often the first thing a patient will ask when they come to my clinic is, ‘What do I need done?’ My answer is always the same – ‘nothing’ – and then I give them the mirror and ask them to tell me what they like about their reflection. I find that this starts the consultation off with a good, positive experience for the patient as the majority will find something that they like. This practice also breaks the ice in a first consultation, as patients are often nervous and self-conscious about their appearance. Sometimes the patient struggles to see anything positive about their appearance when looking in the mirror and I may help them by pointing out how good their skin is, how nice their hair is or the colour of their eyes. I then ask them what, if anything, they would like to change or improve. Often they will say ‘what do you think, you’re the expert?’ My response is normally ‘no you’re the expert on you, not me’, which I find gives them the freedom to discuss what is bothering them and allow them to take some control over what is often an anxious situation for them. It also avoids you pointing out something they didn’t even notice in the first place!

Some patients have a very negative rapport with their own image and it’s important that we give people as positive a mirror experience as we can. When some patients look in the mirror they may have been looking at their own reflection every night in despair, believing that having aesthetic treatments will solve everything that they feel is wrong in their world. That’s why it’s important to not only discuss the positive impact of the treatment you are providing, but also its limitations. We all know the importance of managing the patient’s expectations. As a clinical hypnotherapist, I know that the reflection of self in the mirror is very powerful. One way to help ensure your patients have a positive rapport with themselves is to advise them to only think of the positive things in their life/appearance when they look in the mirror before bed. This is important because I want them to go to sleep with positive thoughts that their unconscious mind will turn over as they sleep. A recent study of 3,548 individuals made a connection between optimism and positive self-reported sleep behaviour, so try it.17 You have nothing to lose but negative processing. Sometimes I have a patient who comes in and has a very negative image of their reflection caused by past trauma like a car accident or physical abuse. The physical scars can be very small but there’s often significant emotion attached to them. I use

a technique called ‘collapsing anchors’ to shift the emotion, which is a simple neurolinguistic programming technique that aims to change negative feelings or emotions to make the patient less upset when they look in the mirror.18 Combined with a positive mirror experience, I have found that the collapsing anchors technique can be transforming.

Summary

The mirror can be a powerful tool in your clinic and is too often used to focus on perceived or real flaws. Patients come to see us with cosmetic concerns that are often tied up with emotional issues, so giving them a good experience is as important for the patient as it is for your clinic, and for you as a clinician. By giving your patient, and yourself, a good mirror experience you will not only help improve their selfesteem, but you will be in a better frame of mind yourself!

Dr Kathleen Long qualified in 1976 and currently works as a locum GP and aesthetic practitioner. She is the president of the British Medical and Dental Hypnosis Society (Scotland) and president elect of the European Hypnosis Society. She is a Master Practitioner in neurolinguistic programming. Dr Long is also a member of the British College of Aesthetic Medicine and is on the board of directors.

REFERENCES 1. Betta Living, Is male vanity at an all-time high in the UK?, 2014. <https://www.bettaliving.co.uk/blog/ articles/2014/02/is-male-vanity-at-an-all-time-high-in-the-uk/> 2. Avaj, ‘Mirror Mirror on the wall who is the vainest of them all – Men or Women?’, 2018. <https://www. avaj.co.uk/2018/01/23/mirror-mirror-on-the-wall/> 3. ABC, News Radio. Study: Women Look in a Mirror at Least Eight Times a Day <http:// abcnewsradioonline.com/health-news/study-women-look-in-a-mirror-at-least-eight-times-a-day.html> 4. Burgo Joseph, The Narcissist You Know: Defending Yourself Against Extreme Narcissists in an AllAbout-Me Age, 6th November 2015.

5. Encyclopaedia Britannica, Narcissus, <https://www.britannica.com/topic/Narcissus-Greek-mythology> 6. Reference.com, Why Do People Cover Mirrors After Someone Dies? <https://www.reference.com/ world-view/people-cover-mirrors-after-someone-dies-b36280ca1c1c6359> 7. YouIrish.com, Irish Burial Traditions. <https://www.yourirish.com/traditions/irish-burial-traditions> 8. Mirror History, Broken Mirror - Is Breaking a Mirror Bad Luck? <www.mirrorhistory.com/mirror-facts/ broken-mirror/> 9. Carla Nayland, Pictish symbol stones - the comb and mirror symbol. <www.carlanayland.org/essays/ picts_comb_mirror.htm> 10. Sing V & Yadav A, ‘A study to assess the selfitis behaviour a selfie syndrome (level of selfitis) among nursing students’, International Journal of medical Research and Review Vol 6, no 08 (2018).

11. Sarah Graham, Take a lot of selfies? Then you may be MENTALLY ILL: Two thirds of patients with body image disorders obsessively take photos of themselves, Daily Mail Online, 2014. <https://www. dailymail.co.uk/sciencetech/article-2601606/Take-lot-selfies-Then-MENTALLY-ILL-Two-thirds-patientsbody-image-disorders-obsessively-photos-themselves.html> 12. Janarthanan Balakrishnan & Mark D. Griffiths, An Exploratory Study of ‘Selfitis’ and the Development of the Selfitis behavior Scale, International Journal of Mental Health and Addiction, June 2018 ,Vol16, Issue3,pp 722-736 13. Sarah Knapton, ’Selfitis’ - the obsessive need to post selfies - is a genuine mental disorder, say psychologists, The Telegraph, 2017. <https://www.telegraph.co.uk/science/2017/12/15/selfitisobsessive-need-post-selfies-genuine-mental-disorder/> 14. Pol Pinoy, American Psychiatric Association Makes It Official: ‘Selfie’ A Mental Disorder, The Adobe Chronicles, 2014. <https://adobochronicles.com/2014/03/31/american-psychiatric-association-makesit-official-selfie-a-mental-disorder/> 15. Sorokowski et al., Selfie posting behaviors are associated with narcissism among men, Personality and Individual Differences, October 2015.

16. American Psychiatric Association, Diagnostic and Statistical manual of Mental Disorders. <https:// www.psychiatry.org/psychiatrists/practice/dsm> 17. Hernandez R et al., The Association of Optimism with Sleep Duration and Quality: Findings from the Coronary Artery Risk and Development in Young Adults (CARDIA) Study. Behav Med. 2019 Jul 24:1-12.

18. NLP World, NLP Training: Conversational Collapse Anchors. <https://www.nlpworld.co.uk/nlp-trainingvideos/how-to-collapse-negative-anchors-conversationally/> 19. L.M. Drummond, Body Dysmorphic disorder, somatic symptoms and related disorders’, CBT for Adults, London: Royal College of Psychiatrists, 2014, pp.155-170 20. L.M. Drummond, Obsessive-Compulsive Disorders: All you want to know about OCD for people living with OCD, Carers and Clinicians, Cambridge: Cambridge University Press and Royal College of Psychiatrists, 2018., pp.87-111 21. Veale, D, et al., Development of a Cosmetic Procedure Screening Questionnaire (COPS) for Body Dysmorphic Disorder, JPRAS, April 2012, Volume 65, Issue 4, Pages 530–532

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can be almost translucent, as well as being an area that can be pigmented in some individuals. With age, the amount of connective tissue elements, such as elastin, degenerate5,6 and this can affect the tone of the skin.7 This is important as it will impact how the dermal filler is held within the tissues.

Darkening, or hyperpigmentation of the periorbital skin, can also affect this area and contribute to the fatigued appearance that patients complain about.8 Whilst any concavity in the tear trough can lead to shadowing, it is important to differentiate this to actual darkening of the skin itself. To do this, have a look at the area under good lighting and at different angles to help to discern whether there is simple shadowing due to a tear trough deformity or the skin itself is more pigmented.

Ophthalmologist Miss Jennifer Doyle shares her whether If the appearance is due to the concavity causing top tips for successful tear trough treatments shadowing, this should respond nicely to treatment with dermal filler,8 discussed in more detail below.

The area under the eyes presents a common cosmetic concern.

Those who have hyperpigmentation of the periorbital skin may Hollowing, shadowing and dark circles are often requests that can respond better to skin treatments that aim to lighten the skin.9 Some lead to patients feeling like they look older or more tired than they examples include hydroquinone, arbutin and vitamin C. Patients, actually are. Aesthetic practitioners often try and address these especially those with hyperpigmentation, should be advised to ensure concerns with filler treatment, however it can be a difficult area to they protect the area from exposure to ultraviolet (UV) radiation with a treat successfully. In this article, I highlight the things to consider when broad-spectrum sunscreen.8 treating this area, and how to achieve the best results for your patients. As the skin is thin in this area,4 underlying vasculature can be more visible.9 It can also make the area more prone to the Tyndall Introducing the tear trough effect when treated with HA filler.10 The Tyndall effect is a bluish The tear trough is the area underneath the lower eyelid and above the discolouration of the skin caused by superficial injection of HA.11,12 It cheek (Figure 1). The term ‘tear trough deformity’ was first described also leaves the skin prone to becoming lax with age, and further key

by Flowers in 1993 to illustrate the concave hollow that can occur in connective tissue elements like collagen and elastin can be lost. the area.1 He explained how a shed tear follows the course of the In order to improve the skin quality, we have a few treatment nasojugal groove, which led to the term ‘tear trough’.1,2 Hyaluronic modalities that can help. Topical agents aiming to improve the skin acid (HA) based dermal fillers are commonly used to try and fill can be used. For example, retinoids have been shown to induce this depression, in an attempt to blend the junction between the epidermal thickening13 and promote collagen synthesis.14 Mechanical cheek and lower lid. It is a unique area to treat within aesthetics, as treatments including microneedling and platelet-rich plasma (PRP) can it cannot only be found as part of ageing changes, but the deformity also be used to improve the skin quality in the periorbital region.15 By 3 can also be seen in young patients with a presumed genetic basis. improving the quality of the skin, any filler treatment that is then carried Rejuvenation of the tear trough area can be achieved with several out is likely to have a better aesthetic result. treatment modalities, such as surgical, filler-based and skincare-based Excess skin and/or protruding orbital fat can give rise to bags under options, and it is important to recognise the benefits and limits of each. the eyes, which may require surgical intervention from an oculoplastic In my practice, I find the most important step to get right is evaluating surgeon in the form of blepharoplasty, to remove the excess tissue.16 what is causing the poor cosmesis of the tear trough area. When evaluating the tear trough, one must not only evaluate the morphology Ageing changes of the mid-face of the concavity, but also evaluate the character of the skin, and the As we age, we lose volume in our mid-face and this can influence presence of ageing changes in the mid-face. Counselling the patient the appearance of the tear trough area. From bony resorption of as to multiple factors at play in this area is key, as one treatment the orbit to descent and reduction of the malar fat pads, loss of modality may be insufficient support from the cheek area can also worsen the appearance of the to fully correct their tear trough;17 further contributing to the loss of a smooth transition Tear trough cosmetic concern. Product between the lower lid and cheek.18,19 Treating volume loss in the selection is also paramount. mid-face by using a highly cohesive filler and supraperiosteal bolus injections can help provide support to the cheek.18,19 This can reduce Character of the skin the amount of filler needed to be used in the tear trough itself and The character of the skin in carries less risk of side effects.20 this area is the first thing I consider when evaluating Filler selection and application a patient for tear trough Due to the delicate skin of this area, and poor lymphatic drainage; it is Palpebromalar groove treatment. The periocular important to use a suitable filler. Highly cross-linked fillers tend to be skin is some of the thinnest more hydrophilic and can interfere with lymphatic drainage resulting in Figure 1: Example of tear trough deformity and palpebromalar groove found on the body,4 and swelling.21 In order to prevent the development of an oval bulge in the

Treating the Tear Trough

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Before

After

Top treatment tips My top tips for successfully treating the tear trough include: 1. Treat volume loss in the mid-face to support the lower lidcheek junction, helping to improve the appearance of the tear trough and reducing the amount of product required in the tear trough area.

2. Always consider skin quality and optimise it first.

3. Always under-treat and inject less volume; remember filler is hydrophilic and will attract water.

4. Product selection is important; choose something that has a relatively low hydrophilic nature and low risk of causing the Tyndall effect.

tear trough, and to prevent the likelihood of causing the Tyndall effect, I use a less hydrophilic filler that is less likely to attract further water, which can result in swelling. My filler of choice is Teosyal Redensity II,22 but other fillers such as Belotero Balance have been shown to be safe to use superficially without causing the Tyndall effect.23 I would advise under-treating the area and injecting less volume to account for the hydrophilic nature of HA filler. At the consultation stage, I explain to the patient the reason for under-treating the area, because in the weeks following the treatment the filler is likely to attract water and create more volume.24 Palpebral part of orbicularis oculi muscle

Post septal fat

Tear trough

Orbital septum Malar bag

Orbital retaining ligament

Orbital part of orbicularis oculi muscle

Levator labii superioris alaeque nasi

Malar pad of fat

Figure 2: Anatomy of the eye

Considerations The tear trough is a difficult area to treat well and practitioners should seek further training to ensure they have the required anatomical knowledge and experience with filler treatments before attempting to treat this delicate area.25 Specific complications to be aware of when treating the tear trough include oedema, which can worsen the aesthetic appearance of the area and the Tyndall effect.10,26 Intravascular injection is also a risk; the blood supply to the eyelid and orbit contains anastomoses between the internal and external carotid arteries.26 This means there is a possibility of vascular occlusion, resulting in blindness or intracerebral injury, as well as skin necrosis.26 Whilst these complications are rare, I would advocate the use of a cannula rather than a needle when treating the tear trough to further mitigate the risk.

Summary

Figure 3: Patient before and after tear trough treatment using Redensity II. Images courtesy of Harley Academy.

Miss Jennifer Doyle has a Bachelor in Medicine and a Bachelor of Surgery with distinction, as well as a Master’s in Medical Sciences from the University of Oxford. She has completed the Level 7 in Injectables and is a lead trainer at Harley Academy. Miss Doyle currently works as an NHS registrar in Ophthalmology, as well as leading her clinic, Oxford Aesthetics.

REFERENCES 1. Flowers RS. Tear trough implants for correction of tear trough deformity, ClinPlast Surg.

1993;20:403–15.

2. Sherrell J Aston, Douglas S Steinbrech, Jennifer L Walden. Aesthetic plastic Surgery. Elsevier Health Sciences, 14 October 2012.

3. Berros P, Armstrong B, Foti P, Mancini R. Cosmetic Adolescent Filler: An Innovative Treatment of the “Selfie” Complex. Ophthalmic Plastic and Reconstructive surgery. July/August 2018. Volume 34.

Issue 4. Page 366-368 4. Bucay VW, Day D. Adjunctive skin care of the brow and periorbital region. Clin Plastic Surg.

2013;40:225–236 5. Ramos-e-Silva M, Boza JC, Cestari TF. Effects of age (neonates and elderly) on skin barrier function.

Clinics in Dermatology. Volume 30, Issue 3, May-June 2012, Payes 274-276 6. Baumann, L. (2007), Skin ageing and its treatment. J. Pathol., 211: 241-251.

7. Kim H J, Baek J H, Eo J E, Choi K M, Shin M K, Koh J S. Dermal matrix affects translucency of incident light on the skin. Skin Research and Technology/ Volume 21, Issue 1. 12 September 2014.

8. Sarkar R, Ranjan R, Garg S, Garg VK, Sonthalia S, Bansal S. Periorbital Hyperpigmentation: A Comprehensive Review. J Clin Aesthet Dermatol. 2016;9(1):49-55.

9. Roh MR, Chung KY. Infraorbital dark circles: definition, causes, and treatment options. Dermatol Surg. 2009;35:1163–1171.

10. Jaishree Sharad. ‘Dermal Fillers for the Treatment of Tear Trough Deformity: A Review of Anatomy, Treatment Techniques, and their Outcomes’. J Cutan Aesthet Surg. 2012 Oct-Dec; 5(4): 229–238.

11. Gladstone HB Cohen JL. Adverse Effects When Injecting Facial Fillers. Semin Cutan med Surg 26:34-39. 2007 12. Matarasso SL, Carruthers JD, Jewell ML, Restylane Consensus Group. Consensus recommendations for soft-tissue augmentation with nonanimal stabilised hyaluronic acid (Restylane). Plast Reconstr Surg. 2006 Mar; 117(3 Suppl): 3S-34S; discussion 35S-43S 13. Pilkington SJ, Belden S, Miller RA. The Tricky Tear Trough: A Review of Topical Cosmeceuticals for Periorbital Skin Rejuvenation. J Clin Aesthet Dermatol. 2015;8(9):39-47.

14. Bhawan J, Palco MJ, Lee J, et al. Reversible histologic effects of tretinoin on photodamaged skin. J Geriatr Dermatol. 1995;3:62–7.

15. Gordon H. Sasaki; Micro-Needling Depth Penetration, Presence of Pigment Particles, and Fluorescein-Stained Platelets: Clinical Usage for Aesthetic Concerns, Aesthetic Surgery Journal, Volume 37, Issue 1, 1 January 2017, Pages 71–83.

16. Naik MN, Honavar SG, Das S, Desai S, Dhepe N. Blepharoplasty: an overview. J Cutan Aesthet Surg. 2009;2(1):6-11.

17. Mendelson B, Wong CH. Changes in the facial skeleton with aging: implications and clinical applications in facial rejuvenation. Aesthetic Plast Surg. 2012;36(4):753-60.

18. Flowers RS (1991) Periorbital aesthetic surgery for men: eyelids and related structures. Clin Plast Surg 18:689–729 19. Mendelson, B. & Wong, CH. Changes in the Facial Skeleton With aging: Implications and Clinical Applications in Facial Rejuvenation. Aesth Plast Surg (2012) 36: 753.

20. Ezra D. Periocular Complications. Aesthetics Journal 16/11/2016 21. Sundaram H, Cassuto D., ‘Biophysical characteristics of hyaluronic acid soft-tissue fillers and their relevance to aesthetic applications’, Plastic and Reconstructive Surgery, 132 (4 Suppl 2) (2013) 5S–21S. 22. Teoxane press release, Teosyal Puresense Renensity [II]: A Different Gel Designed for Eye Circles, (2014) <https://teoxane.com/sites/default/files/redensity2_press_release.pdf> 23. Micheels P. et al., A Blanching Technique for Intradermal Injection of the Hyaluronic Acid Belotero.

Plastic and Reconstructive Surgery. 2013; October Supplement.

24. Matarasso SL. Understanding and Using Hyaluronic Acid. Aesthetic Surgery Journal, Volume 24, Issue 4, July 2004, Pages 361-364 25. Ablon G. Understanding How to Prevent and Treat Adverse Events of Fillers and Neuromodulators.

Plast Reconstr Surg Glob Open. 2016;4(12 Suppl Anatomy and Safety in Cosmetic Medicine: Cosmetic Bootcamp):e1154. Published 2016 Dec 14.

26. Hirmand H. Anatomy and Nonsurgical Correction of the Tear Trough Deformity. Plast. Reconstr.

Surg. 125:699, 2010.

The tear trough is a delicate area which should only be treated by appropriately qualified and trained medical professionals. Ensure that you assess the skin quality of your patients and select your dermal filler products appropriately.

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

Croma-Pharma launches Advertorial Croma

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th th C C R1 0 1 1 Oc tober2 019, London Aesthetics speaks to Croma-Pharma to learn more about its Croma-Pharma launches

UK-based affiliate

Starting in September 2019, Croma-Pharma GmbH, or Croma for short, will establish its own UK-based

Aesthetics speaks to Croma-Pharma to learn more about its hyaluronic acid products and its new affiliate office in the UK Leading hyaluronic acid expert in Europe

Starting 2019, GmbH, or Croma short, establish its own aesthetic UK-based medicine Croma isinaSeptember global player inCroma-Pharma the dynamically growing segment ofwill minimally invasive affiliate to market its aesthetic product portfolio in the UK. and a leading European manufacturer of hyaluronic acid. Croma is very experienced in the crosslinking of

hyaluronic acid, having started the process back in 2002. This makes Croma a true pioneer in the processing Leading hyaluronic acid expert in Europe of hyaluronic acid and enables the company to be successful in developing new products. The company sells Croma is a global player in the dynamically growing segment of minimally invasive nearly sixmedicine million hyaluronic acid syringes (injectables) annually through aesthetic and a leading European manufacturer of hyaluronic acid. a network of experienced in-house sales organisations, Croma is very in the crosslinking ofstrategic hyaluronicpartnerships acid, having started andprocess distributors. at the company the back inProduction 2002. This takes makesplace Cromaexclusively a true pioneer in the processing of hyaluronic acid enables the company to Austria. be successful in developing headquarters in and Leobendorf near Vienna,

er 2019, London new products. The company sells nearly six million hyaluronic acid syringes

(injectables) annuallyPharma through a network of in-house sales organisations, strategic About Croma partnerships and distributors. Production takes place exclusively at the company Founded in 1976, Croma is an Austrian family-owned company that headquarters in Leobendorf near Vienna, Austria.

specialises in the industrial production of hyaluronic acid syringes for the fields of medical aesthetics, ophthalmology and orthopaedics.

About Croma Pharma Croma runs 12 international sales companies Foundedcurrently in 1976, Croma is an Austrian family-owned companyand thatdistributes specialises its products inproduction more thanof70 countries. in the industrial hyaluronic acid syringes for the fields of medical

aesthetics, ophthalmology and orthopaedics. Croma currently runs 12 international sales companiesCroma and distributes its products in the UK in more than 70 countries.

“We have been crosslinking Croma has been hyaluronic acid crosslinking hyaluronic ac since 2002, making since 2002, making us a true pioneer in us a tr pioneer in the processing the processing of hyaluronic acid andand of hyaluronic acid developing new products developing new products”

Croma is pleased to welcome Julian Popple as its new Croma in the UK UK country manager who has launched a range of Croma is pleased to welcome Julian Popple as its new UK aesthetic products for number of companies including Andreas Prinz, CEO Croma-Pharma GmbH country manager who has launched a range of aesthetic Allergan, Sinclair Pharma and Galderma.

Together with his team, he will market and distribute products for a number of companies including Allergan, Sinclair Croma´s aesthetic In addition to the HAhis filler product from their own production site as the Pharmaportfolio. and Galderma.

Together with team, he willportfolio market and distribute Croma’s Julian Popple main product,aesthetic Croma portfolio. markets PDO liftingtothreads, a platelet-rich plasmafrom (PRP) system in cooperation with In addition the HA filler product portfolio their own production TM site as the main Croma skincare markets PDO lifting threads, platelet-rich plasma (PRP) Arthrex and theproduct, personalised Universkin in theaUK. Managing director ofsystem Croma,inAndreas Prinz, TM cooperation with Arthrex and the personalised skincare Universkin in the UK. Managing director of emphasise, “Croma aims to provide the best product quality to its customers, while also supporting them to Croma, Andreas Prinz, emphasises, “Croma aims to provide the best product quality to its customers, while also supporting them to grow their business. An own affiliate office in the UK enables a much closer relationship with our customers.” Furthermore, Croma will launch its new branded hyaluronic acid filler cooperation and stronger working relationship with our customers.” saypha® in the UK market at CCR on October 10-11. Please visit us at our exhibition booth number M40.

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A summary of the latest clinical studies Title: Facial Rejuvenation Using a Mixture of Calcium Hydroxylapatite Filler and Hyaluronic Acid Filler Authors: Chang JW et al.

Published: Journal of Craniofacial Surgery, August 2019 Keywords: Hyaluronic acid, Calcium hydroxylapatite, Facial rejuvenation Abstract: Calcium hydroxylapatite filler is a popular dermal filler, as it provides long-lasting results. However, it sometimes undergoes unexpected early volume loss, due to rapid gel absorption before neocollagenesis. To compensate for this phenomenon, hyaluronic acid filler was added to calcium hydroxylapatite filler for injection as a mixture. Twenty-five patients who scored 1 or 2 on the Merz 5-point scale for the nasolabial fold and jawline were injected with 3.0 mL of the mixture. The mixture was prepared with 1.0 mL of hyaluronic acid filler, 0.5 mL of lidocaine, and 1.5 mL of calcium hydroxylapatite filler. A visual analog scale (VAS) and the 5-point global satisfaction scale (GSS) were used for objective and subjective assessments. In a subset of patients, for histologic analysis, 0.1 mL of the mixture and 0.1 mL of only calcium hydroxylapatite filler were injected into the right and left postauricular areas, respectively. The histologic analysis was performed 6 months after implantation. The mean VAS and GSS scores for both sets of wrinkles were above “fair” at every follow-up, including at short-term and long-term periods. The skin biopsies from both postauricular areas from selected patients showed increased dermal collagen bundles without inflammation. The mixture of calcium hydroxylapatite filler and hyaluronic acid filler maintained constant volume with high satisfaction, as hyaluronic acid filler compensated for the unexpected early volume loss of calcium hydroxylapatite filler. This procedure can be applied safely, and it is also convenient, because no retouching procedure is needed.

Title: Comparison of Efficacy and Safety of Fractional Radiofrequency and Fractional Er:YAG Laser in Facial and Neck Wrinkles: Six-year Experience with 333 Patients Authors: Asiran Serdar Z, Tatkiparmak A Published: Dermatologic Therapy, August 2019 Keywords: Laser, radiofrequency, neck, face Abstract: Lasers and other light sources are popular treatment options for facial rejuvenation in recent years. In this study, we aimed to compare the efficacy and safety of fractional radiofrequency (RF) and fractional Erbium:YAG (Er:YAG) laser for facial and neck skin wrinkles, objectively. Three hundred and thirty-three patients treated with fractional RF and fractional Er:YAG laser were evaluated by two blinded dermatologists.

Fractional Er:YAG laser was more effective for the periorbital area; whereas fractional RF treatment was more effective for perioral, nasolabial and jawline areas. There was no statistically significant difference in side effects between two treatment groups. In conclusion, both modalities significantly improve skin wrinkles, however, it should be considered that there may be regional differences between the treatment outcomes of them. This article is protected by copyright. All rights reserved.

Title: A Novel Photonumeric Hand Grading Scale for Hand Rejuvenation Authors: Lee JH et al.

Published: Archives of Plastic Surgery, July 2019 Keywords: Hand rejuvenation, grading scale, volumisation Abstract: Few scales are currently available to evaluate changes in hand volume. We aimed to develop a hand grading scale for quantitative assessments of dorsal hand volume with additional consideration of changes in skin texture; to validate and prove the precision and reproducibility of the new scale; and to demonstrate the presence of clinically significant differences between grades on the scale. Five experienced plastic surgeons developed the Hand Volume Rating Scale (HVRS) and rated 91 images. Another five plastic surgeons validated the scale using 50 randomly selected images. Intra- and inter-rater agreement was calculated using the weighted kappa statistic and intraclass correlation coefficients (ICCs). Paired images were also evaluated to verify whether the scale reflected clinical differences. The intra-rater agreement was 0.95 (95% confidence interval, 0.922-0.974). The interrater ICCs were excellent (first rating, 0.94; second rating, 0.94). Image pairs that differed by 1, 2, and 3 grades were considered to contain clinically relevant differences in 80%, 100%, and 100% of cases, respectively, while 84% of image pairs of the same grade were found not to show clinically relevant differences. This confirmed that the scale of the HVRS corresponded to clinically relevant distinctions. The scale was proven to be precise, reproducible, and reflective of clinical differences.

Title: Nitroglycerin, or Not, When Treating Impending Filler Necrosis Authors: Carley SK et al.

Published: Dermatologic Surgery, July 2019 Keywords: Filler,complications, necrosis Abstract: Dermal necrosis is a rare yet serious risk associated with cosmetic filler injections, and although current consensus recommends the use of hyaluronidase injections in cases of hyaluronic acid filler, the efficacy of topical nitroglycerin as a treatment has not yet been fully investigated. To review the literature on tissue necrosis resulting from soft tissue augmentation and to highlight the use of topical nitroglycerin as a first-line treatment.

A review of the literature was performed with no time limitations resulting in 35 articles and 66 patients who experienced tissue necrosis secondary to injectable fillers. Articles were reviewed for pertinent information and presented. Only 7 of the 66 reported cases (10%) used topical nitroglycerin as a treatment. Six of 7 (85%) were successful in halting the impending necrosis. Fiftynine patients received alternative treatments, with hyaluronidase injection being the most common. Few reports of novel treatments for necrosis included the use of topical growth factors and injection of adipose-derived stem cells. Topical nitroglycerin is a potentially effective and underused treatment for tissue necrosis from soft tissue augmentation, but because data are very limited, topical nitroglycerin should be used in conjunction with hyaluronidase injections in cases of hyaluronic acid filler dermal necrosis.

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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Consent in Aesthetics Dr Claudia Petillon discusses the importance of consent following the famous Montgomery case and how to use it to implement best practice within your business The consent process is a vital part of the patient pathway and is far more than just getting the patient to sign on the dotted line. As we may have seen in recent press, the aesthetic practitioner is continually under scrutiny and often we are the subject of much criticism and horror stories following ‘botched’ procedures.1,2 Some of it is deserved, due to the practice of a small proportion of people; however, the vast majority of us give excellent care to our patients.

We have a duty of care to the patient to engage with them and to undertake our work in partnership with them.3 Much of what we do is inherently reversible and reasonably safe. For example, generally speaking, our botulinum toxin injections wear off over time and our fillers can be reversed with hyaluronidase, however it’s incredibly important to stress that nothing is risk free.

Complications can occur, and we must remember that we are dealing with ‘well’ patients. We are not curing them from an illness or disease, hence not performing a treatment is always an option. The treatments that we provide are elective.

When things go right, the majority of patients don’t complain, but we all are painfully aware that sometimes things can and do go catastrophically wrong. There is also no

denying that our patients are demanding.

They are critical of their appearance and are coming to us to improve their look; this is why it is incredibly important to express every possible outcome, good and bad, before any procedure takes place.

Whatever our attitudes to consent were in the past, the pivotal Montgomery case in 20154 was a landmark for informed consent in the UK and significantly changed the playing field for us as aesthetic practitioners.

Why is the Montgomery case important?

The Montgomery case had nothing to do with aesthetic practice, but the implications of it are important for all specialities. From a legal perspective, prior to Montgomery, the

Bolam Test in England was used to determine what should be disclosed in a consultation.5 This tested whether a doctor’s conduct would be supported by a responsible body of clinicians. Whenever someone puts themselves forward as a professional, which all medical aesthetic practitioners do, the rule applies. So, previously if a responsible body of aesthetic practitioners felt that the amount of information provided was reasonable and what they would have done, it was acceptable in law. The Bolam Test still stands as the basis of all clinical litigation, however I believe that the Montgomery case has changed the way people view it.

The case involved Nadine Montgomery, a woman with diabetes and of small stature. She was pregnant and delivered her son vaginally. He sadly experienced complications owing to shoulder dystocia resulting in hypoxic brain damage with consequent cerebral palsy. Montgomery brought a claim against Lanarkshire Health Board,6 alleging that she should have been advised of the 9-10% risk of shoulder dystocia associated with vaginal delivery, despite the mother specifically asking if the baby’s size was a potential problem.7 Montgomery sued for negligence, arguing that, if she had known of the increased risk, she would have requested a caesarean section. She was effectively deprived of choice.

The Supreme Court ruled in her favour in March 2015. It established that, rather than being a matter for clinical judgment to be assessed by professional medical opinion, a patient should be told whatever they want to know or what a patient in her position would reasonably need to know, not what the doctor thinks they should be told.7 The final judgement should be read and absorbed by us all. The ruling stated:6 • An adult person of sound mind is entitled to decide which, if any, of the available forms of treatment to undergo, and consent must be obtained before

When things go right, the majority of patients don’t complain, but we all are painfully aware that sometimes things can and do go catastrophically wrong

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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This case sent shock waves through the medical profession and in my opinion, really made practitioners contemplate the exact nature and aims of the consent process treatment interfering with her bodily integrity is undertaken • The doctor is therefore under a duty to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments • The test of materiality is whether, in the circumstances of the particular case, a reasonable person in the patient’s position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it It was a clear boost for patient autonomy over medical paternalism and we in the aesthetics world do need to heed the warning. We are interfering with our patient’s bodily integrity and so the consent process must be robust.

This case sent shock waves through the medical profession and in my opinion, really made practitioners contemplate the exact nature and aims of the consent process. Fear of litigation is a potent tool to change practice and sadly it sometimes takes cases like this to stimulate a shift in how we work.

In aesthetic practice In our aesthetic practice, the risks can often but not always, be addressed with the use of hyaluronidase, knowledge of anatomy and adherence to strict treatment protocols to name but a few, however some patients do still run into serious complications such as vascular necrosis or even blindness due to intravascular injection of filler material.8 We need to understand that we have now moved from the ‘reasonable practitioner’ to the ‘reasonable patient’ test as the marker for consent. What I mean by this is that we must understand what that patient, in their situation, would want or need to know.

With this in mind, we have a duty to educate patients and inform them about what we are going to do and what the possible

complications are. Furthermore, it is vital that we engage with the patient on their level and understand what they want and their specific circumstances. For example, I always assess what their baseline understanding is of the procedure and the potential benefits. I also try and understand the ‘why’ of their desire for treatment. It is an active process and not a passive one.

I’d also be sure not to over-complicate the patient with typical medical vocabulary with fear that they may not fully understand. For example, I would use the phrase ‘muscle that lifts your eyebrows’ rather ‘frontalis muscle’. We need to explain the procedure in layperson’s language, the various minor and major side effects and risks should be listed and explained in a non-intimidating manner.

Always remember that a patient cannot consent to negligent treatment and so, if a complication such as ‘looking worse’ is on the consent form and the patient ends up with a significant disfigurement due to a breach of duty, then the consent becomes meaningless and they are entitled to make a claim for negligence. So, for example if a patient develops an infection because you used an obviously contaminated product, they can still sue for breach of duty even if the risk of infection is clearly stated on the consent form.

I would strongly recommend adopting the practice of utilising procedure-specific informed consent forms, which can talk about the intricacies and inherent risks of the specific treatment the patient is to experience. I have a separate consent form and patient information sheet for every procedure I undertake. Clearly the risks of vascular occlusion are real in filler work but would be unlikely in anti-wrinkle injection treatment.8 Procedure specific complications such as ptosis after botulinum toxin injection are not relevant for facial peel work and their inclusion would only serve to confuse the patient.9 A signature is not enough. Quantification of the risks, for example by the use of percentages, where possible, is advisable.

This is based on benchmarked standards

which you can adapt to your own practice over time. I would encourage practitioners to document treatment alternatives, including the most obvious one of not doing anything and encourage their patients to actually read the form out loud or read it for them.

In my opinion, a final confirmatory sentence should read something like the following, ‘I acknowledge that I have read this form and have understood the contents. I have been given the opportunity to ask questions, and my questions have been answered to my satisfaction. The risks and benefits of this treatment have been explained to me as well as the option of not having the procedure at all. I understand that there are no guarantees’.

Conclusion It is important that we take our aesthetic practice seriously and make a conscious effort to engage with the patient to ensure we are working in partnership. Consent that consists of ‘Just sign here’ is a practice which should be discouraged. If something does go wrong, and we hold up a form telling patients that they agreed to something they did not, fuels litigation and complaints which we all wish to avoid for the sake of ourselves, the patient and the profession.

Dr Claudia Petillon is a general practitioner working in East Leake, Loughborough.

She embarked on her aesthetic career five years ago and loves the challenge of learning new techniques and delivering the best possible care for her patients. Dr Petillon is also a trainer for training provider, Cosmetic Courses.

REFERENCES 1. Eley A, Walker P, Campaign to tackle ‘botched’ cosmetic procedures, BBC, April 2019 < https://www.bbc.co.uk/news/ health-47967968> 2. BBC, Woman’s Botox party warning after lip filler swelling, December 2018 < https://www.bbc.co.uk/news/uk-englandleicestershire-46434480> 3. General Medical Council, Duties of a doctor registered with the GMC <https://www.gmc-uk.org/ethical-guidance/ethical-guidancefor-doctors/good-medical-practice/duties-of-a-doctor> 4. Royal College of Physicians and Surgeons of Glasgow, The Montgomery Case < https://rcpsg.ac.uk/college/influencinghealthcare/policy/consent/the-montgomery-case> 5. LawTeacher.com, Bolam v Friern Hospital Management Committee (1957) 1 WLR 582, March 2018 < https://www. lawteacher.net/cases/bolam-v-friern-hospital-management.php> 6. Supreme Court, Montgomery v Lanarkshire Health Board [2015] UKSC 11, March 2015 < https://www.supremecourt.uk/cases/docs/ uksc-2013-0136-judgment.pdf> 7. Chan S, Tulloch E et al., Montgomery and informed consent: where are we now?, The BMJ, May 2017 <https://www.bmj.com/ content/357/bmj.j2224> 8. Urdiales-Gálvez F, Delgado NE, Figueiredo V et al., Treatment of Soft Tissue Filler Complications: Expert Consensus Recommendations, Aesthetic Plast Surg, 2018 Apr;42(2):498-510.

9. Omoigui S, Irene S, Treatment of ptosis as a complication of botulinum toxin injection, Pain Medicine, April 2005 <https://www. ncbi.nlm.nih.gov/pubmed/15773880>

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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Discussing Pay Increases Operations and marketing manager Victoria Vilas shares advice for both employers and employees when handling requests for a salary increase Asking for a salary increase can be a nerve-wracking moment for an employee, so it is important to take the time to plan a professional approach and consider how to deal with the outcome. Being a fair and benevolent employer isn’t easy either, as you have the responsibility of managing clinic budgets while at the same time trying to incentivise your team. This practical guide includes tips for both employees and employers who are dealing with a request for a pay rise.

For the employee As an employee, you may reach a stage in your career where you have developed your skill and increased your level of responsibility to the point where you feel you are worth a higher rate of pay. If you’ve exceeded your targets, you’ve proved yourself to be a fantastic team player, and you’ve worked hard to ensure all patients leave the clinic delighted, then the time may be right to discuss your earnings.

Reasons you could ask for a pay rise In the UK, there is no legal requirement for employers to give their employees an annual pay rise in line with inflation, unless an employee is paid the national minimum wage or national living wage and the government announces an increase.1 Some employee contracts may state that pay will be reviewed annually, but your employer may review your pay and conclude that it will remain the same. So, don’t simply demand a pay rise because you think you are due one as each year passes. Instead, put together a case explaining how you are now worth more to the clinic business due to your increased responsibility, your unrivalled contributions or your level of expertise and seniority in the team.

The reasons you use to support your request should be entirely work-related. The management of your own personal finances is your responsibility, not your employer’s; you may have high rent or a mortgage to

pay, or simply wish to live a certain lifestyle, but these are personal issues, not reasons that make you worthy of receiving a higher salary from an employer, or more worthy of a pay rise than a colleague.

Performance that exceeds expectations, increased responsibility, and valuable contributions to the company and team are the reasons you should be using. It is reasonable to ask for a salary review if you can demonstrate that you have gone above and beyond your original job specification, but if you have simply done what is expected of you, you may need to manage your expectations.

Understand what you’re worth Before you ask for a higher salary, try to understand your current value. To get an idea of the salaries currently available to someone of your level of skill and experience, search online for adverts for jobs similar to your own, and note down the range of salaries offered.

When researching current vacancies, remember to narrow down your search to your location as pay rates can vary around the country and it won’t be an accurate assessment if you compare salaries in a small town to those in a major city.

It is not illegal to discuss your pay with your co-workers, but it isn’t fair to push your colleagues to disclose information they may wish to keep confidential. When considering your reasons for a pay rise you should refer to your remit only. It isn’t advisable to ask for more money based on someone else’s salary; it is best to request a raise based on your own contributions to the clinic business.

If you ask for a salary increase that is above the expected pay bracket for comparable roles in the industry, your request may not be taken seriously. Try and understand the limit to what you can ask for, and what may look reasonable. When deciding on the salary you will request, consider that asking for a figure that is 5-10% higher than your current salary may be far more acceptable than asking for a 20% increase.

Be proactive Try to back up your request for a salary increase with facts and figures. It’s a wise idea to support your request with evidence that you have exceeded expectations, or that you have taken on duties outside of your original remit. Or perhaps evidence that your current remuneration is lower than the industry average for an employee at your level of experience. Prepare a concise summary of your achievements for your manager.

Think of how you have contributed to the clinic business. Explain how you have been integral and how you as an individual have contributed to the clinic’s success. Describe any extra duties you have taken on, either officially or unofficially. Note down the dates and figures that show you have consistently met or exceeded your targets and received excellent feedback from patients. Don’t be afraid to sing your own praises, just stick to the facts when you do so and don’t make any claims you can’t back up.

Do capture the main points of your request in writing, to record what was discussed, but arrange a meeting to discuss your proposal in person with your manager, as you can then expand on your points during conversation.

After you’ve spent time putting forward your argument, allow your manager the time to consider it, too. Don’t expect your manager to give you an answer on the spot, as they may need to consider some performance statistics or discuss your request with other members of management first.

Be prepared for the outcome If your employer turns down your request for a salary increase, ask for a review date, and ask what you can do to work towards a pay increase. Be ready and willing to take on new challenges and tasks that could lead to a promotion. Don’t be dejected and let the news affect your performance, keep your head held high and continue to demonstrate that you are a valuable part of the clinic team.

Your employer will respect your professionalism, and this is likely to reflect on you favourably when you meet for your next salary review. If you truly feel that your employer is being unreasonable, then you may have to consider moving on. Repurpose the evidence of your achievements you used for your pay rise proposal and add them to your CV to help you stand out from the crowd when you apply for another job.

For the employers Whether you can or cannot consider awarding a salary increase, you should deal

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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Response from employer

Suitable

“I’d like to request a salary review based on the achievements I have made over the past year.”

“Let’s diarise a meeting this week so we can discuss your request further. Please bring examples of the achievements you wish to highlight.”

Unsuitable

“I’d like to discuss my salary because I’ve done everything you’ve asked me to.”

“I don’t think we have anything to discuss, and I don’t hold salary reviews on request.”

Suitable

“I’ve exceeded my targets and have mentored new employees, so I would like to request a pay rise based on my performance and my increased responsibility.”

“Thank you for your contribution to the team.

I’m happy to review your salary, but I’d like to do so when I’ve reviewed the clinic budgets, so let’s diarise a meeting in two months’ time.”

Unsuitable

“My colleague got a pay rise so when do I get mine?”

“I may have reviewed your colleague’s salary but I’m not discussing yours.”

Suitable

“During my last appraisal you agreed to increase my salary if I took on extra responsibility. I can demonstrate that I have met these requirements, so would like to request my raise, please.”

“I have reviewed your request, but I am not going to increase your wages as I believe you are being paid fairly for your remit. However, I’m happy to discuss this again next year if you take on some extra duties.”

Unsuitable

“My friend’s an aesthetician at another clinic and she gets paid more than me, so I deserve a pay rise.”

“I don’t care whether other clinics pay more, this is the salary I pay aestheticians and I see no reason to change.”

Table 1: Examples of salary increase discussions

with an employee’s request fairly, taking the time to consider their argument and your response, and to explain your decision.

Discussing potential pay increases in a clear and fair way will help demonstrate that you are a considerate employer, and good communication with your employees should help keep morale high.

Do your own research If you haven’t done any recent market research into salaries being offered by other clinics, don’t simply assume that your employee packages are fair. It is good practice to check market rates for clinic staff on a regular basis, so you can be sure you are staying competitive, and can attract and retain the best aesthetic professionals.

Retaining your best staff members is essential to your business, so take care not to lose your valuable team members to a clinic offering better rates of pay.

Review your employee packages on a regular basis and ensure you stay in line with the industry, increasing pay for employees where appropriate.

Consider your employee’s proposal carefully Consider that your employee may highlight achievements that have gone unrewarded. If you are not fully informed of an employee’s progress or achievements, do consult with managers who may have more of an insight.

If your team member’s proposal contains

a good argument for a pay rise, take the time to consider what increase would be fair, considering the team as a whole. For example, is this the only team member who has exceeded their targets or progressed to a more senior position? Should you be rewarding more than one employee given the reasons put in front of you? Check what your annual budget allows for and think of the remuneration of every member of the team before deciding on what you can commit to.

Don’t make empty promises Did you agree to review an employee’s salary at a given date? If so, make sure you remember to hold that pay review meeting, or you could lose the trust of your employees if they feel you do not deliver on your promises. Did you agree to give an employee a salary increase if they took on a particular duty or achieve certain targets?

Make sure you reward them as promised when they deserve it, don’t wait for them to ask. If you make promises you can’t keep, you may start to lose loyal team members.

If you are happy to agree to a pay review or increase at a later date, but want to cover yourself for all eventualities, state in documented form that your agreements may be subject to change, depending on the needs of the business. You will then be able to change your agreement if you have a less profitable year and need to revise your budgets, for example.

Record the main points of discussion from every meeting you have with an employee and make two copies so there is one for you to keep on file and one to give your employee. If you both hold a copy of the meeting notes, there will be no confusion over what was previously agreed, and less of a chance for either side to renege on the agreement.

Communicate your decision Whether you can or cannot approve a pay rise for an employee, explain your decision to your team member so they can understand your reasoning. If you are offering a salary increase, tell your employee the specific things they have done that has made them worthy of this rise. If you are not agreeing to an increase on this occasion, explain why, but also speak to your team member and suggest potential ways they can develop their role, and work towards the increase they requested. Agree to another review at a later date and set your employee targets to reach by that point.

Summary If you look to be a fair and considerate employer, you should still be able to motivate and gain the trust of your staff members, even if you can’t agree to reward them with a pay rise. If you are a fair and considerate employee, you will continue to act professionally and put effort into your work, whether or not you have received the exact raise you requested and will strive to achieve that pay rise through your performance.

Victoria Vilas is the operations and marketing manager at the recruitment consultancy ARC Aesthetic Professionals. A manager of teams and projects in the health and wellness content sectors for over a decade, Vilas has spent recent years focusing on the issues of staffing and practice management in the aesthetic medicine industry REFERENCES 1. Price, Alan, Annual pay rises – what could go wrong? (Manchester: Peninsula, 2017) <https://www. peninsulagrouplimited.com/2017/06/30/annual-pay-rises-gowrong/> FURTHER READING • Cotton, Charles, Pay structures and pay progression, CIPD, 2018 <https://www.cipd.co.uk/knowledge/fundamentals/ people/pay/structures-factsheet> • Gov.uk, The National Minimum Wage and Living Wage, Gov.uk, 2019 <https://www.gov.uk/national-minimum-wage>

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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Understanding the Employee Lifecycle HR advisor Tania Jarman outlines the five stages of employment and advises how they should be best managed Your approach to human resources (HR) and people management may have taken a backseat when building your business. It’s understandable that when starting out, finding your patients and growing revenue take priority. However, as your company grows it is really important to have a management framework in place that will grow with you.

This article will discuss the importance of understanding the employee lifecycle and how you can best support staff throughout their time within your business. The average person spends a third of their time at work.1 Therefore, my belief is that employers are responsible for empowering their people to lead meaningful and fulfilling lives outside of work as well as inside.

The employee lifecycle I find it helpful to think of the employee experience in five core steps: recruitment, onboarding/induction, development, retention and exit, showcased in Figure 1.2 This is a well-recognised and referenced tool used across HR and can be a useful resource when implementing HR into your business.

This is because it enables us to visualise how the employee engages with the organisation they are a part of. I find that mapping the employee journey drives two main benefits; better talent retention and reputation improvement.

Stage 1: Recruiting new employees The recruitment process can sometimes be the most challenging step as finding suitable employees that fit the brand and have relevant experience can become time consuming. Yet, it is extremely worthwhile.

Recruitment should also consider the future needs of the organisation, identifying individuals with potential for development.3 Attracting and recruiting applicants into key roles within aesthetics requires a carefully planned approach to ensure a quality and cost-effective hire. Choosing a preferred specialist recruitment consultancy for specialist roles, such as doctors and

nurses, who carry out search and selection exclusively on your behalf may be beneficial. I also find that networking at aesthetic industry events is very useful as it is such as close-knit specialty and often you can find out about vacancies just by talking to one another. As well as this, social media and job boards such as the one on the Aesthetics website, is predominantly the most cost-effective method of direct sourcing roles; however, you should ensure your post includes essential and desirable skills. Being specific at this stage will enable you to screen out those applicants who do not have relevant experience or skillset for the role.

It’s also important that proper documentation is submitted once the individual is recruited.

Not only from a legal perspective, but this also helps to instil trust between the employer and new employee too. Current employment law states that an employer must issue a contract of employment within two months of an employee joining.4 Employers are legally required to put some of the main particulars of employment in writing, including: name of employer and employee, date of employment, job location, pay, working hours, holiday entitlement and a full job description and title.4 Stage 2: Induction According to the Chartered Institute of Personnel and Development, an induction is an opportunity for a business to welcome their new recruit, help them settle in and ensure they have the knowledge and support they need to perform their role.5 For an employer, an effective induction may also reduce employee turnover and absenteeism.

For many businesses, an induction begins from the day their new employee actually starts and normally lasts a set

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period of time such as a few days or a week for example. However, many companies start the onboarding process before the employee has even set foot in the door. This can include sending company information packs or welcome boxes to keep them informed about the process and let them know what to expect, or simply invite them to lunch to meet the team first. An employee induction ideally should have timeline reviews after the first week, first month, third month and sixth month.

Here’s what I would recommend including in your induction process: • Orientation of premises or practice: depending on the size of your premises, this can be very straightforward or a little more complex. Regardless of size however, it’s important to get new employees familiar with their place of work.

• Health and safety: by law you are required to provide employees with any information they need to help them carry out their work safely. Provide them with your health and safety policy, as well as fire alarm procedures.6 • Expectations: explain your expectations of them as well as any probationary or monitoring period you might put them under. You should also include the terms and conditions of employment.

• Training and development: incorporate information about any training opportunities for your new employee.

Provide details of interactive training services that might be available, such as the company intranet. You may also want to create a personal development plan for them at this stage.

Recruitment

Employee Lifecycle

Exit

Retention

Figure 1: The employee lifecycle2

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

Onboarding

Development

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Stage 3: Development Do you have a system or process in place to measure performance? Is it effective? Or has it become the annual event that everyone avoids? In my opinion, good performance management is critical for organisational success. Employees must understand what’s expected of them, and to achieve those goals they need to be managed so that they’re motivated, have the necessary skills, resources and support, and are accountable.

Broadly speaking, good performance management revolves around regular, effective feedback on progress towards objectives. It’s multifaceted, not a technique in itself, and in my experience there’s no single best approach. It should align with organisational strategy and suit the type of jobs in question. Some of the most popular options around managing performance consists of an annual performance appraisal or monthly one-to-one review meetings, both of which work particularly well when combined. The process will generally consist of a set of core objectives based upon the job role skills and competencies.

These objectives can be expressed as targets to be met (such as sales levels or new treatments learned), ad-hoc tasks to be completed by specified dates, or ongoing standards to be met.

Assessing and feeding back on performance is a critical factor in making targets effective, as monitoring progress towards objectives is strongly motivational.

With this in mind, performance appraisals should be a regular occurrence; for example, every month for your clinic staff and perhaps every quarter for senior management working on bigger projects.

Within aesthetics specifically, I would also recommend ensuring that all of your clinical staff keep up-to-date with their Continuing Professional Development (CPD) accreditation, which as well as being used for appraisals, depicts commitment to self-development and professionalism enabling individuals to adapt to changes in the industry. This very journal recognises the importance of this, with a monthly CPD article and accredited sessions at the Aesthetics Conference and Exhibition.

There are also many other associations out there that I would advise looking into based upon your own interests and roles.

Stage 4: Retention A positive culture gives businesses a clear competitive advantage.7 It can reduce the risk of poor quality work, complaints and a high

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staff turnover. Management trainer Victor Lipman explains that since an employee’s relationship with his or her direct manager is the single most important factor influencing engagement, the responsibility falls to management to improve motivational levels, and I couldn’t agree more.8 Below are some recommendations to further retain staff and motivate your workers: • Align individual with the high-level business aims and targets: this should be brand or corporate visionary statements, financials and technology or innovation aspirations. Include incentives or bonus schemes that give employees at all levels of an organisation a chance to benefit when a company achieves an important milestone, target or industry award.

This can naturally boost and highlight individual and team performance. For example, you could ask employees to trial perspective new technologies and feed back to the business owners or even introduce an employee of the month scheme. Sharing positive feedback and recognising employee contribution can go a long way to maintaining motivation.

• Take a genuine interest in the future path of an employee’s career: it can really support an employee’s morale and motivation if a manager genuinely cares about what their future interests and career direction are. Mentoring and suggesting additional training or coursework can be helpful to employees.

• Be aware of their work/life balance: sensitivity can be greatly appreciated.

Small gestures often make a big difference. For example, offer some flexibility in schedules and be understanding about things such as family commitments and doctor’s appointments.

• Listen: whether an employee has ideas for job improvement or wants to share problems, express concerns, frustrations or conflicts, people appreciate being heard.

• Praise: assuming they are doing a good job, tell them. Simple words of encouragement are easy, free and can be very motivational.

Stage 5: Exit It’s important to ask yourself within this stage, why employees are leaving and the impact that employee turnover has on the organisation, including the associated costs.

This data can be used to develop a retention strategy that focuses on the particular issues

and causes of turnover specific to the organisation. Tools such as confidential exit surveys and staff attitude surveys can help managers understand why people leave the business and enable appropriate action to be taken to address it. Linking back to stage two of induction, ensuring that new joiners have realistic expectations of their job and receive sufficient induction training will help to minimise the number of people leaving the organisation within the first six months of employment.

Summary Building trust across an organisation will have a profound impact. Supporting positive relationships and flexible solutions for individual employees is vital. In essence, I believe that managers today need to make time, grow trust and engage with tenderness in order to build positive workplace relationships and a supportive culture.

With a comprehensive employment contract, a set of policies and procedures that protect you and your staff, and strong communication, you will be helping your team to do their best at work in an empowering and supportive environment, allowing you to be well on your way to unlocking the secrets to a happy and engaged team.

Tania Jarman is an associate of the Chartered Institute of Personnel and Development, accredited career coach and occupational assessor. She has a HR career spanning over 25 years in both the private and public sector, including providing HR support to GP practices and pharmaceutical manufacturers. Jarman manages her own HR consultancy, Libra HR, which provides tailored HR solutions.

REFERENCES 1. Gettsyburg College, 1/3 of your life is spent at work <https:// www.gettysburg.edu/news/stories?id=79db7b34-630c-4f49ad32-4ab9ea48e72b&pageTitle=1%2F3+of+your+life+is+spen t+at+work> 2. StarMeUp.com, The 5 Stages of Employee Lifecycle, November 2017 <https://www.starmeup.com/blog/en/useful-tips/employeelifecycle/> 3. CIPD, Recruitment process overview, February 2019 <https:// www.cipd.co.uk/knowledge/fundamentals/people/recruitment/ factsheet> 4. CIPD, Employment Law <https://www.cipd.co.uk/knowledge/ fundamentals/emp-law> 5. CIPD, Induction, November 2018 <https://www.cipd.co.uk/ knowledge/fundamentals/people/recruitment/inductionfactsheet> 6. Health and Safety Executive, Health and safety made simple < http://www.hse.gov.uk/simple-health-safety/> 7. Propellernet, What’s costing the UK economy £23.6 billion a year, April 2018 < https://www.propellernet.co.uk/whats-costinguk-economy-23-6-billion-year/> 8. Lipman V, 5 easy ways to motivate and demotivate employees, Forbes, March 2013 <https://www.forbes.com/ sites/victorlipman/2013/03/18/5-easy-ways-to-motivate-anddemotivate-employees/#5eb915c549ff>

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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How did you begin working together?

Working with Your Partner Aesthetics speaks to business owners about what it’s like to work with their spouse and how it can positively impact your business Do you, or someone you know, work with a partner or spouse? Perhaps you even own and run a business together or are thinking of doing so? At Aesthetics, we have the privilege of networking with hundreds of aesthetic professionals at leading industry events such as the Aesthetics Conference and Exhibition, the Aesthetics Awards, and the forthcoming CCR in October. What we often notice when talking to professionals at these events is the high number of individuals who co-own and run aesthetic clinics, while also sharing a personal life.

Aesthetic nurse Kerry Hanaphy notes, “Medical professionals have actually been ‘power coupling’ for a long time, even though it seems more common now. We have lots of friendsof-friends who met in medical school and married thereafter. Working in the same field brings many opportunities as it does challenges. However, it can bring a better work-life balance when you’re managing family obligations, and financial planning and schedules can be managed more effectively as a duo.”

This trend isn’t restricted to the medical profession. According to an accounting software company FreeAgent, there are around 1.4 million couples in the UK who run businesses together.1 So, Aesthetics speaks to three couples who are working together, as well as living together, and investigates how they manage their business and personal relationships, what their challenges are, and how can they be overcome for a successful work-life balance.

Kerry Hanaphy, nurse at the Kerry Hanaphy Clinic and Dr Barry O’Driscoll, dental surgeon at the Kerry Hanaphy Clinic

Dr Roy Saleh, aesthetic practitioner at the Saleh Aesthetic Clinic and Sylvia Saleh, clinic manager at the Saleh Aesthetic Clinic

Frances Turner Traill, independent nurse prescriber and clinical director at FTT Skin Clinics and John Traill, financial director at FTT Skin Clinics

Kerry & Barry: We met at a medical conference and instantly hit it off. I (Kerry) had begun to consider launching my own clinic and Barry had a lot of experience in business, so his input was invaluable to me. The conversation of Barry and I working together started out from a need to have a dentist onsite in our clinic for us to be able to offer toxin treatments and prescriptions. It was a perfect fit and perfect timing.

Roy & Sylvia: We both worked within other organisations, that were both within the NHS and private sectors. Once our children had grown up and finished their education, we decided to open our own aesthetic clinic. Now, Roy has been working within the industry for 33 years and we have been working together for 11.

Frances & John: John was made redundant from his job as an electronic specialist; he was at the top of his game internationally and we knew the next job would mean a move abroad with less family time and more international travel. So, I (Frances) suggested working together as I was ready to escalate my aesthetics business to where I wanted to be, with my own clinics in different locations throughout Scotland.

What is it like working with your partner in an aesthetic clinic?

Roy & Sylvia: It’s wonderful! For us, it works well as a partnership. Although we both have separate roles within the clinic, we still work closely together.

Kerry & Barry: We find it’s both challenging and gratifying. It’s important to recognise our individual skillset and nurture that, while offering support in other areas. We find that it’s a balancing act that once you get right, can be extremely rewarding. We’re lucky in the fact that we completely understand each other, what drives us, our goals and unique skill sets, so we reap the benefits of a good working relationship.

Frances & John: It’s fantastic and great fun.

John is process driven, much more task orientated and strives to get things right, so has made our business so efficient, effective and a joy to work in. Frances is much more people orientated, with a ‘let’s do this, let’s do this now’ attitude. Overall we find that it’s a perfect combination.

What positives come from working with your spouse/partner?

Kerry & Barry: Because we share a working schedule, we get to really balance our at-

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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home life. We can easily coordinate time off together, which makes us a more effective duo at-home so we never miss any of the important family moments. The combination of my (Kerry) clinical expertise and Barry’s business expertise has really helped the clinic to grow substantially. Where I (Kerry) feel like I’m lacking in business acumen, Barry has helped to educate me on this side of the business as he has more experience in this area, and vice versa.

Roy & Sylvia: It’s great that we manage to understand each other so well, respect each other’s advice and opinion and work harmoniously. For example, sometimes the purchase of expensive equipment should not only be based on medical grounds.

Roy sometimes gets enthusiastic about new innovations and I (Sylvia) have to be the practical one who looks for a return on investment.

Frances & John: We are complete opposites.

However, this really works for us and our business. John is the thinker, gets all the processes in place to make conceptual visions perfect. Frances is the clinical lead, supporting, mentoring and developing our staff, whereas John has much more of a background role with purchasing, accountancy, and strategic thinking. Although our roles are different, we do share the same vision for our clinic.

What are the biggest challenges?

Kerry & Barry: One of the biggest challenges we face is taking conflict home with us.

Working in our industry we face many challenges, some of which we don’t always agree on. This is something that crops up from time to time and if not managed properly can end up putting a strain on us both.

Frances & John: Your business is your passion and it can sometimes consume your whole life.

It’s easier for it to seep into your personal life when you live with the people you work with.

Roy & Sylvia: We don’t always agree, which can be a challenge, but we always manage to discuss any issues. We often bring work home with us – it’s definitely not a nine to five job, and being available 24/7 to discuss clinical matters can sometimes take over our personal time.

How do you overcome these challenges?

Roy & Sylvia: We make sure that we are always aware of time management in order to have some down time. For example, Roy is just so passionate about his work that he would never take time off. I (Sylvia) have to plan the

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diary well in advance in order for us to take holidays. We also try and create boundaries in order for us to have our own personal life outside the clinic. This is not always easy!

Kerry & Barry: We always try to acknowledge any disagreements as they arise. What we’ve learnt is that settling conflicts as soon as possible stops any conflict being brought home and interrupting that important hometime together. We’ve learnt to communicate very well so that any spheres of conflict are left behind when we leave the clinic. We know when to turn off work mode and just be partners; we always make time in the week to unwind with a glass of wine and talk about non-work related topics.

Frances & John: We take days off together away from the clinic much more now as we found we needed that break, and ensure we have a fabulous team that respects this. We have a chat after a day in the clinic about work for a short while each day, and then that’s it.

We make sure there is no more work chat until the next day.

Do you have any interesting stories about working together?

Frances & John: We went to an Allergan business development meeting and a group participation exercise was carried out to find out our personality profile and how this could be applied to our business. We found out we were officially the exact opposite from each other in personality types! The group leader laughed and said our profiles were absolutely perfect for working together in a medical aesthetics business.

Kerry & Barry: Earlier this year our clinic featured in a TV show on our national broadcast channel, RTE One that followed different sides of the beauty industry. After the show aired we had garnered a lot of attention from the public and now whenever we go for dinner or drinks we have people come up to us to introduce themselves. It’s always an unusual experience, but always gives us a laugh!

What are your top tips/advice for other couples who might be in a similar position or thinking about getting into business together?

Roy & Sylvia: First and foremost, you both have to be capable of working in a partnership together or you might find that you clash, which won’t be good for your business or relationship. You also have to understand the other partner’s needs and also put up with idiosyncrasies. Patience is a virtue!

Kerry & Barry: Find the balance of both your

strengths and weaknesses so that you can help each other learn and grow. Try to maintain your own identity by factoring in time just for you. Barry sails and I (Kerry) travel regularly, so it never feels like we’re spending too much time together. Define your roles from the outset so you have a clear understanding of each other and what is expected of you.

Frances & John: Think about each of your strengths and weaknesses, to figure out where you will complement each other. We often have totally different viewpoints, but rather than being the cause of an argument, it’s a huge benefit if you can listen to both sides as it’s never the case that one is right and the other is wrong. Two heads are definitely better than one. We have different experiences, backgrounds and education to bring to the table as well as having our collective best interests at heart. Don’t micromanage each other, let your roles develop as you grow, always encourage and support one another.

Summary As highlighted, working and living with your partner does have its challenges, but can also result in a wonderfully successful business. Sylvia Saleh highlights that because long hours are often required to uphold a successful aesthetic business, commitment and understanding your partner is vital.

Dr Saleh adds, “I believe that trust is the biggest factor of working with your partner successfully.”

Kerry and Barry summarise by saying, “Something you don’t expect to happen when you begin to work alongside your partner is the respect and admiration that you develop for one another when you witness your partner’s skills put to use. You become each other’s biggest cheerleaders, and that brings another level of desire to be successful.”

Do you work with your partner?

Or perhaps you work with your family members or best friend? Tell us about your experiences by tagging us on social media or commenting on the online article!

REFERENCES 1. Susie Mesure, For richer, for poorer: the couples in business together, Financial Times, 2019. <https://www. ft.com/content/a244e496-41c1-11e9-9499-290979c9807a>

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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“My success all comes down to the staff working for me” Consultant plastic surgeon Mr Taimur Shoaib shares his career highlights and talks about his passion for teamwork “Growing up I had two main interests; computer science and medicine,” shares consultant plastic surgeon Mr Taimur Shoaib. He adds, “From an early age I concluded that if I became a surgeon, I could always use computers as a hobby, but if I became a computer scientist, I couldn’t operate on people as a hobby!” And that’s where it all began for this Scottish-based plastic surgeon and successful multiple clinic owner. Mr Shoaib graduated from the University of Glasgow in 1992 with a degree in medicine before training in general surgery as part of the Oxford Surgical Rotation. In 1997, he attained the Fellowship of the Royal Colleges of Surgeons (FRCS) qualification in surgery from the Royal College of Surgeons of Edinburgh and, following this, undertook a higher doctorate in Head and Neck Cancer Plastic Surgery at Canniesburn Hospital in Glasgow. Later, he also achieved a diploma in medical informatics, aptly linking back to his passion for computing.

His doctorate saw him lead research on ways to determine the spread of mouth cancer.

He explains, “Before I did my research, the most accurate way of determining whether a mouth cancer had spread was only about 60-70% accurate. The team and I developed a method where it became 95% accurate. We wrote around 30 papers on the subject and I got a grant of £150,000 from the Scottish Government to continue the research. This was a huge achievement of mine.”

Mr Shoaib worked within the NHS for 14 years, and in 2006 he decided to work as a sole practitioner within the aesthetics field alongside this. It seemed like a natural step for Mr Shoaib, who states, “I worked with a medical student a few years ago and we looked into the likelihood of surgical patients going on to have non-surgical treatments and vice versa. The study found that 89% of patients who have had surgery subsequently go on to have repeated non-surgical treatments and wait around four months post-procedure. It was a no brainer for me to develop my work into this field. I worked alone for a while but in 2009 I felt it was

time to expand. And so, La Belle Forme was born.” Now, La Belle Forme has five clinics across the UK, employs more than 30 people and has won a number of industry awards.

Mr Shoaib believes one of the factors to his success is ensuring that his staff are well looked after. He says, “Sir Richard Branson has a great quote – train people well enough they can leave, treat them well enough so that they don’t want to. My success all comes down to the staff working for me, I am simply the figurehead.” When quizzed about potential challenges, Mr Shoaib refers to himself as “time poor” and wishes he could spend more time with each individual staff member in his clinic. He also recognises that for many, a common challenge is staff recruitment. “Recruitment has definitely changed in aesthetics. When I first began, it was a case of chatting to your peers and colleagues to see if they knew anyone interested. Whilst there is still an element of that today, a formalised HR procedure ensures everything is well-documented and consistent across the board and it’s something all clinic owners must adopt,” explains Mr Shoaib.

When discussing recruitment tips, Mr Shoaib says, “What I think works really well within interviews is to ask your interviewee scenario-based questions. For example, for a receptionist role, you could ask them what they would do if a patient phones

up multiple times daily with concerns over a treatment. It encourages them to think on their feet and you can tell a lot about a person from their answers.”

Education is something that is also of upmost importance to Mr Shoaib, so much so that he is now a honorary senior clinical lecturer in the faculty of medicine at the University of Glasgow, faculty member of the Allergan Medical Institute and founder of Inspired Cosmetic Training, with the aim to inspire upcoming medical professionals.

He also has a practice in medicolegal aspects of aesthetics, giving opinions on whether patient management has been negligent. “No matter what stage you are at in your career, you should always be a student,” shares Mr Shoaib, adding, “I think it is inconceivable that any healthcare professional would continue working in a subspecialty branch of medicine without a professional development plan in place. This should be multi-faceted. Everyone should attend at least one conference a year and read CPD-accredited articles every month.

They should also learn through both small and large group teaching.” Mr Shoaib’s advice on success is simple. “I have seen so many fall from a place of excellence because of arrogance or discontinuing their learning. I think it’s really important to always remember your roots and always have a degree of humility,” he shares.

What are your hobbies?

I like to go car racing. I have a car that is exclusively made for track driving so I like to go as fast as I can. I guess you could call me a bit of a thrill seeker!

Do you think aesthetics is a tough industry to work in?

Like many others, I feel passionately about regulation and I believe that Scotland is leading the way. If we are able to stop non-medics from performing injectable treatments, then I think the other countries in the UK may follow suit. I can’t see it being the other way around.

What are your thoughts on the use of social media in aesthetics?

For an advertising point of view, I think a strong online presence is going to be fundamental for practitioners. I also think social media will continue to influence treatments and ultimately become a research resource. We must all stay up to date with this evolving platform but it is of upmost importance to use it appropriately.

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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expectations of what natural ageing looks like, the lack of endorsement can stop others from exploring aesthetic medicine safely and effectively, leaving them exposed to potential risks and complications.

So, how can we, as responsible aesthetic practitioners, contribute to a cultural shift where a celebrity’s choice to invest in a service that we offer is public, normalised or perhaps even praiseworthy?

The problem

The Last Word Dr Hennah Bashir argues why she believes celebrities should be more transparent about their aesthetic treatments In today’s society, the chance that your patients, and indeed yourself, are or have been influenced by images you see on social media and in glossy magazines is pretty high. In fact, it was reported that 23% of UK consumers have clicked through to buy a product after seeing it featured by a social or celebrity influencer.1 There’s no denying that the popularity of Chrissy Teigen’s ‘mum bod’ pictures and Selena Gomez’s no makeup Instagram posts show that the public appreciates the celebrities who ‘keep it real’. In regards to aesthetic procedures specifically, the likes of Kylie Jenner, Cindy Crawford, Sofia Vergara

and Kim Kardashian have all been open and honest about what they have had done which, in turn, may have helped to popularise procedures like botulinum toxin, lip fillers, and ‘vampire’ platelet-rich plasma facials amongst the general public.2,3 However, so many celebrities remain silent or deny undergoing any aesthetic treatment at all.

In my opinion, celebrities who do not reveal that they have had any aesthetic procedures are arguably doing their fans a disservice.

This secrecy can mislead the general public in terms of their expectations of what is or isn’t realistic as part of the normal ageing process.

Beyond giving the general public unrealistic

We all know that bad aesthetic work is highly publicised. The best is often not reported on. This is generally because ageing A-listers choose to be very discrete, which of course they are perfectly entitled to be

Some might say that there is a moral imperative on public figures to be body positive, based on their responsibility and the volume of people, of all ages and backgrounds, they are influencing.

Based on this, celebrities who claim their gorgeous skin and sculpted faces are purely a product of nature and good living can be perceived as contributing to the narrative that we live in a world where we are all victims of a ‘genetic lottery’; that you can never improve on aspects of your appearance that make you unhappy, thus making the ‘normal’ person ‘hopeless’ with no acceptable path to embrace their wishes for aesthetic self-improvement.

This is where body dysmorphic disorder (BDD) can come into play. The disorder is thought to affect around 2% of the British population; however, prevalence of those dissatisfied with their bodies and suffering the psychosocial consequences is far higher.4 Patients with common skin problems for example, often suffer substantial psychosocial comorbidity and reduced quality of life,4 yet many are put off seeking help by negative impressions of private cosmetic doctors, long NHS waiting lists and simply being unaware of what is available to them.

If celebrities were more forthcoming about how they also suffer issues with their appearance and choose to have aesthetic treatments to improve them, our collective journey to self-acceptance would surely make the world a happier, more understanding place.

A stigma for practitioners We all know that bad aesthetic work is highly publicised. The best is often not reported on.

This is generally because ageing A-listers choose to be very discrete, which of course they are perfectly entitled to be.

However, this leaves me questioning whether there is a stigma attached to the treating practitioner. For example, when celebrities with great aesthetic work deny they have had any procedures, this causes a negative media

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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Celebrity aesthetic practitioners I believe that celebrity aesthetic practitioners are perhaps the ultimate solution to this quandary.

Those who boast a huge social media following, represent leading pharmaceutical companies and regularly speak at some of the most respected conferences could be the solution to the reluctance of their famous patients to be transparent. These practitioners are able to explain procedures and lend some glamour to the idea of having them, whilst still portraying it with the upmost respect, without trivialising the procedures. Their personal touch and fame has the potential to rehabilitate the image of the medical aesthetics specialty. Many celebrity practitioners are often featured in magazine and newspaper articles, as well as appearing on TV, and they use this exposure for the good of us all by breaking down the pros and cons of aesthetic work, while being a friendly face for the world of aesthetics.

Whilst it’s unrealistic to expect celebrities to give full impartial disclosures on aesthetic work done, ‘celebrity practitioners’ are in an ideal position to promote best aesthetic practice and dispel myths and fears in a suitable way.

bias where stories of major complications can paint the industry as dangerous. In my opinion, the practitioner who has assisted in creating a natural aesthetic should be praised and recognised for their good work and skills.

People forget that many aesthetic practitioners have years of clinical experience and are qualified medical professionals, sometimes with specialisms in other areas as well, meaning that patients are more often than not, in the best hands.

In an ideal world, people would find admitting visits to an aesthetic practitioner as simple as telling people about visiting their dentist.

In my opinion, we should collectively regard caring for the face and body as part of good overall health.

Unfortunately, as red top papers and gossip magazines love to focus on the minority of unsafe practitioners, this taints all of us who always put the safety and best interests of our patients first. Practitioners and their celebrity patients who can voluntarily offer an alternative story, could shape the narrative to be more realistic.

The counterargument No matter how valuable celebrity endorsement is, a touchstone of medical professionalism is confidentiality, as well as treating all patients equally. No one can or should be pressured or feel obliged to disclose work that they have had done. We live in an age where talented artists can be ruined by fake news or unfair opinion pieces, and so can we really blame celebrities who want to keep their insecurities or flaws and subsequent treatments private?

Clinics with celebrity patients often think long and hard about how the treatment process

can be made easier and better tailored for celebrity concerns about privacy. For example, privacy glass, offering appointments before or after normal business hours, using separate waiting areas or even alias names on appointment paperwork are useful tips when treating the VIP patient. In my clinic, staff are informed well ahead of VIP appointments, with a well-rehearsed VIP protocol enacted, which helps prevent celebrity patients being made uncomfortable by ‘starstruck’ devotees amongst staff or other patients. For those who want to be open with their followers, a carefully constructed plan of how and what information can be released, as well as a signed consent form for a media release should be used, for the sake of clarity and protection of all parties.

This is a personal decision and something that celebrities’ publicists and management will want to analyse very carefully. It should not be pushed upon by the practitioner.

The way forward Most aesthetic practitioners don’t want public acknowledgement for their individual work but do want better public understanding and reporting on their specialism. I personally believe that celebrities can popularise and change narratives in all areas of healthcare and if they speak about choosing a well-qualified aesthetic practitioner or how to use aesthetic medicine responsibly, it could save so many people from bad outcomes.

Beauty bloggers and vloggers seem to be less shy of talking about aesthetic procedures. Many post pictures and videos of their procedures and experiences to stop others being fearful, explaining how to relax

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in the event of minor complications such as bruising, which is something that I think celebrities can learn from.5 Practitioners could simply reassure celebrity patients who are in two minds about being open by pointing out the huge public engagement and awareness of having a procedure with a safe practitioner. I would also say that the celebrities who do reveal that they have had aesthetic procedures in an attempt to educate their fans should be appreciated and rewarded by the aesthetic industry. You could offer gratis procedures or a complimentary treatment as a thank you or include VIP rewards in the form of priority bookings or home visits (when appropriate) and gifted goody bags. These are just some of the ways a practitioner can show appreciation to their celebrity patients. Reciprocal publicity and recommendations are a common exchange in the world of social media and this can even be done without referencing any relationship with the celebrity if a patient preferred. Acknowledging that we all suffer the same wrinkles and sagging skin is only rational and may well be as good for a celebrity’s profile and popularity, as it is for the aesthetic practitioners who treat them. Asking celebrities to reveal treatments sensitively and with the upmost respect is vital. Having suitable documents in place will also reinforce that their privacy will be respected.

Overall, for a number of reasons, it’s unlikely that all celebrities will start to be fully open about what treatments they have had in the near future and practitioners should not push anyone into doing so if they don’t feel comfortable. It’s great to see beauty bloggers, vloggers, reality TV stars and celebrity aesthetic doctors already stepping in to fill the publicity gap, so I would certainly encourage the continuum of this in the future.

Dr Hennah Bashir graduated from St George’s Medical School in 2005. She is a medical author and has been published in the Student BMJ, BMJ and Oxford University Press. Dr Bashir has been working in aesthetics since 2017.

REFERENCES 1. Gooneratne M, Working With Influencers, Aesthetics journal, June 2019 2. Wright R, ‘You bet I have Botox. Everybody does’, Telegraph, Feb 20143.

3. Sharpe M, Beauty clinics cash in on ‘Love Island’ jabs by hijacking branding, The Mirror, June 2019 4. Dalgard F et al., Stigmatisation and body image impairment in dermatological patients: protocol for an observational multicentre study in 16 European countries, Dermatology, July 20185.

5. Duprie J, My no bullshit story on botox, 2018 <https://damselindior. com/my-no-bullshit-story-on-botox/>

Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019

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