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IN THIS ISSUE

INSPIRING BEST PRACTICE IN MEDICAL AESTHETICS

58

SUN SAFETY
Malignant melanoma
education

DISAPPEARING ACT
Do fat-dissolving
injections work?

DREAM BIG DR RAJ THETHI’S NEW SUPER-CLINIC

July/August 2021 | aestheticmed.co.uk

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

Vicky Eldridge, Consultant Editor

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

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

MARKETING
Jennifer Shutter
E: jennifer@aestheticmed.co.uk
T: +44(0)203 841 7361
July/August
PUBLISHER
Mark Moloney
E: mark@aestheticmed.co.uk
T: +44(0) 207 349 4790

DESIGN AND PRODUCTION 6 EDITORIAL BOARD

Alex Charlton-Roberts
alex.c@professionalbeauty.co.uk Meet our editorial advisory board
Daniel Parker 45
daniel@professionalbeauty.co.uk 10 NEWS
Jaqui Palmer The latest news from the industry
Jaqui@professionalbeauty.co.uk
20 WORKPLACE POLICIES
PRINTING Employment lawyer Tina Chander on
Buxton Press
the workplace policies to introduce
buxtonpress.com
post-pandemic
SUBSCRIBE
Annual subscription UK: Print £44, 26 OPERATIONS MANAGEMENT
DD £39.50, Digital £10. Phil Elder shares tips on optimising your
Europe: £59; outside Europe: £67.50. operations management in clinic
To receive your copy of Aesthetic Medicine
every month call 01371 851875 or see 29 ASK ALEX
escosubs.co.uk/aestheticmedicine
Clinic marketing expert Alex Bugg answers
The publisher accepts no responsibility your questions
for any advertiser whose advertisement is
published in Aesthetic Medicine. Anyone 30 CLINIC PROFILE
dealing with advertisers must make their AM editorial board member Dr Raj Thethi
own enquiries. tells us all about his new clinic

Professional Beauty Group

25 Allington House, High Street
Wimbledon Village, SW19 5DX

2 Aesthetic Medicine July/August 2021

 CONTENTS

36 FAT-DISSOLVING INJECTIONS
Dr Maeve Kenningham explores the safety
and efficacy of Aqualyx 26

45 MALIGNANT MELANOMAS
An in-depth educational update on
malignant melanomas by Dr Ana Mansouri

54 SIGNATURE TREATMENTS
Dr Joshua Van der Aa explains how he
created his signature injectable brow lift

58 LIP LIFTS
Mr Naveen Cavale discusses the surgical lip
lift as an alternative to repeated filler

61 TREATMENT REVIEW
We try a new device-based facial at 111SKIN

62 PRODUCT NEWS
The latest product launches
20
68 CASE STUDY
Combining RF microneedling and minimally
invasive liposuction with Dr Judy Todd

73 CASE STUDY
Dr Martin Kinsella shares the results of PLLA
collagen-stimulant Lanluma X for buttocks
enhancement

78 CASE STUDY
Dr Aamer Khan presents an injectable hand
lift on a patient in her 50s

WELCOME TO THE JULY/AUGUST ISSUE OF AESTHETIC MEDICINE

I think this issue really demonstrates achievement and advancement in the field of medical
aesthetics. First, I’m proud to profile Dr Raj Thethi’s exciting new clinic in Leeds (pages 30-33),
having witnessed his star rise in the industry while he has remained humble and truly focused on
caring for his patients. Secondly, Dr Ana Mansouri looks at just how far dermatology has come in
understanding, detecting and preventing malignant melanomas in her in-depth clinical article
on pages 45-51. Lastly, this issue features three impressive case studies that show the incredible
capabilities of our technologies and treatments, spanning non-surgical face lifts (pages 68-69),
a safe, injectable alternative to dangerous BBL surgery (pages 73-74); and hand rejuvenation, an
area in which ageing is difficult to treat (pages 78-80). Here’s to continued brilliance.

Georgia – Editor
georgia@aestheticmed.co.uk

aestheticmed.co.uk Aesthetic Medicine 3

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EDITORIAL ADVISORY BOARD
Meet the
experts
The Aesthetic Medicine editorial board
includes some of the leading names
in aesthetics. Their clinical expertise
and diverse range of specialties
help ensure the magazine meets the
needs of its readers
DR SOPHIE SHOTTER
Dr Sophie Shotter is the founder
and medical director of Illuminate
Skin Clinic in Kent. In 2019, she was
invited to join the Allergan faculty
board, having been mentored by
Dr Mauricio de Maio. She is also
on the board of the International
Association for the Prevention
of Complications in Aesthetic
Medicine (IAPCAM). In 2017, she
won Businesswoman of the Year
at the Kent Women in Business
awards.
MR ALI GHANEM
Mr Ali Ghanem is a consultant
aesthetic plastic surgeon and
clinical senior lecturer in plastic,
reconstructive and aesthetic
surgery at Barts and the London
School of Medicine & Dentistry,
as well as visiting professor and
head of department of Aesthetic
Medicine at the College of Medicine
and Dentistry, Ulster University.
He is qualified in Medical Law
and Ethics, Surgical Science and
Developmental and Stem Cell
Biology.
6 Aesthetic Medicine
DR STEVEN HARRIS
Dr Steven Harris has been
practising aesthetic medicine at
his clinic in North London
since 2004 and has gained
an international reputation
for producing natural looking
results. His original approach
and techniques include Facial
Reshaping with Myomodulation
and the Nonsurgical Lip Lift (NLL).
Dr Harris is also a trainer and
educator.
DIJA AYODELE
Dija Ayodele is an aesthetician and
founder of West Room Aesthetics
in London and the award-winning
educational platform Black Skin
Directory (BSD). Her clinic is a
go-to destination for patients of
colour seeking skin rejuvenation
treatments and advice for their
skincare needs. She speaks
regularly at both industry and
consumer events and in 2019
launched a pioneering sunscreen
campaign for black skin.
DR NICK LOWE
Dr Nick Lowe is a consultant
dermatologist at Cranley Clinic,
London and clinical professor
of Dermatology at UCLA School
of Medicine, Los Angeles. He is
a Fellow of the Royal College of
Physicians, American Academy of
Dermatology and American Society
of Laser Medicine and Surgery.
He has authored more than 450
clinical and research publications,
15 scientific and five educational
books.
DR SHIRIN LAKHANI
Dr Shirin Lakhani has an extensive
background in medicine, having
worked both in general practice
and in a hospital environment. She
is also a trained anaesthetist. In
2013 she founded Elite Aesthetics
in Kent. She also practices from the
renowned Cranley Clinic in London.
She has a specialist expertise
in intimate health and appears
regularly on television and in the
press as well as speaking at medical
conferences worldwide.
EMMA DAVIES
Emma Davies has specialised in
aesthetic medicine since 1998. She
was a committee member on the
RCN Aesthetic Nurses Forum from
2000-2010; founder member and
secretary of the British Association
of Sclerotherapists (2003-2010)
and founder member and past
chair of the British Association of
Cosmetic Nurses (2010-2014).
She is currently clinical director
of Save Face.
DR ULIANA GOUT
Dr Uliana Gout is the founder of
London Aesthetic Medicine Clinic
& LAM Academy. She is president
of the British College of Aesthetic
Medicine (BCAM) and sits on
the Board of Trustees. She also
acts as a BCAM Appraiser for the
GMC. She sits on the Board of
the International Peeling Society.
She has co-authored numerous
medical textbooks.
DR RAJ THETHI
Dr Raj Thethi graduated from Leeds
University Medical School in 2013,
having completed an additional BSc
(Hons) 1st Class Degree in Anatomy.
On completion of his surgical training
in the Yorkshire Deanery he qualified
as a Member of the Royal College
of Surgeons (Edinburgh). He has
completed a Level 7 accredited
course in Aesthetic Medicine.
He is also a trainer for Teoxane and
founder of Yorkshire Skin Centre.
DR YASMIN SHAKARCHY
Dr Yasmin Shakarchy practices
dentistry and facial aesthetics in
Solihull and Birmingham. Having
completed her dentistry training at
the University of Birmingham, she
became a Member of the Faculty
of Dental Surgery (MFDS Ed) and
received a PG certificate in aesthetic
and restorative dentistry. She was
the national dental ambassador for
Jamie Oliver’s Sugar Smart campaign
and won Best Young Dentist 2018
and 2020 for the Midlands at The
Dentistry Awards.
July/August 2021
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NEWS AND ANALYSIS

AM Live going ahead as planned
Following the Government’s
announcement that it is to push back the
easing of remaining coronavirus restrictions
in England, Aesthetic Medicine Live will
continue as planned on 8-9 July 2021. The
show will follow the guidelines for events in
Roadmap Step 3 released on Monday, 17
May 2021. Step 3 allows business events with
1,000 visitors or 50% of a venue’s capacity
to take place. For the first time, Aesthetic
Medicine Live will take place in the National
Hall at Olympia London. This is a fantastic
new venue for the show which will allow for
more space around the exhibition floor,
ensuring a comfortable visit. In addition to a
larger space, there will be much wider aisles
on the exhibition show floor, temperature
checks outside the venue, mandatory
wearing of face masks inside the venue at all
times, and socially distanced seating within
the conference, Business Workshops and
Demo Theatre. We look forward to welcoming
the industry back together under one roof.

German PIP safety body found liable in landmark case, must award victims compensation
A French appeal court has ruled that thousands of victims of the PIP
breast implant scandal are to be compensated.
10 years after the TUV1 case was brought, German safety body
TUV Rheinland, which issued safety certificates for the faulty breast
implants manufactured by French company Poly Implant Prothèse
(PIP), has been found liable and will now have to fully compensate
the victims involved in the case. This includes 540 British women,
some of which still have the implants in place because they can’t
afford to have them removed or replaced. The court also upheld an
earlier judgement of negligence by TUV.
It emerged in 2010 that the faulty implants were filled with
industrial-grade silicone that was not safe or cleared for human
use. PIP was then liquidated, but the faulty
implants had been in manufacture since
2001. Many of the implants ruptured, causing
the silicone to leak into the body and cause
often debilitating side effects and illnesses.
Up to 400,000 women worldwide are
thought to have received the implants.
BAAPS (British Association of Aesthetic
Plastic Surgeons) president Mary O’ Brien
said to the BBC: “The human cost and
distress to many women and their families
following surgery involving PIP implants
is sobering.” The Association supported
the development of the International
Collaboration of Breast Registry Activities
(ICOBRA), which provides guidance for
national registries and which the NHS Breast
and Cosmetic Implant Registry is part of.

10 Aesthetic Medicine July/August 2021


First ready–to–use toxin recieves European approval
Alluzience, a new BoNT-A neuromodulator
from Galderma, has become the first ready-
to-use toxin approved for use in Europe.
National approval processes will now take
place for the product after it received a
positive decision from its European
approval procedure.
Unlike all other BoNT-A wrinkle relaxants
currently approved in Europe that come in
powder form and require reconstitution with
sodium chloride before use, Alluzience is a
ready-to-use formulation. Galderma says
this avoids any calculations and allows for
more precision, meaning that the product
has the potential to improve safety and
dosing accuracy compared with powder-
form BoNT-A preperations.
Alluzience is intended for the treatment of
frown lines. The European authorisation
Younger patients spending more on aesthetic treatments
Patients aged under 40
are contributing more to
aesthetic treatment sales
in 2021 compared to those
aged over 60, found data
from Guidepoint Qsight.
In March and April 2021,
spending by patients
aged under 40 increased
by 70% compared to the
same months in 2019 (as
a pre-pandemic baseline).
Conversely, treatment
sales by patients over 60
decreased by 6%.
The data company has
collected point-of-sale
and survey data from hundreds of clinics in the US since 2007 and gives insight into near-
real-time data. Overall, treatment sales grew 27% in March and 14% in April compared to the
same months in 2019, with non-surgical skin tightening and toxin injections experiencing the
highest increases, at 36% and 32% respectively.
aestheticmed.co.uk
is based on the data
from two trials including
one study in which more
than 50% of patients
demonstrated effects
within two to three
days.1 An effect was
demonstrated for up
to six months.1 One
month after injection,
85.2% of patients were
either “satisfied” or “very
satisfied” compared to
9% for placebo patients.1
“At Galderma we
pride ourselves on developing innovative
products that meet today’s needs, which
is underpinned by our longstanding
knowledge and heritage in dermatology,”
said Alexandre Brennan, head of Galderma’s
global business unit for aesthetics. “We know
how advantageous it is for doctors to have
access to a ready-to-use liquid formulation
in Alluzience. It’s for this reason that [this]
is an important milestone for both patients
and healthcare professionals.”
1. Ascher B, Rzany B, Kestemont
P, et al. Liquid Formulation of
AbobotulinumtoxinA: A 6-Month, Phase
3, Double-Blind, Randomized, Placebo
Controlled Study of a Single Treatment,
Ready-to Use Toxin for Moderate-to-
Severe Glabellar Lines. Aesthet Surg J.
2020;40(1):93–104.
INDUSTRY NEWS
BCAM to launch new logo
and website
The British College of Aesthetic
Medicine (BCAM) will reveal its new
logo and website on 8 July via Zoom.
Members including Dr Rita Rakus will
share memories of the early days of the
College, and president Dr Uliana Gout will
also speak at the virtual event. Following
the logo reveal guests will have a virtual
“tour” of the new website, which BCAM
says will “completely modernise” its
online event booking, payments and
member sign-ups.
Award win for Noon Aesthetics
Clinical skincare brand Noon Aesthetics
has been awarded Most Outstanding
Aesthetic and Skincare Specialist of
the Year in the 2021 Global Excellence
Awards by Global Health and Pharma
Magazine. The brand was commended
for redefining skin treatment efficacy and
safety thanks to its DermShield product
formula. The brand has also developed
an e-learning academy to support
practitioners through webinars, online
courses and digital tools.
iS Clinicial looks for world stars
Harpar Grace, distributor of clinical
skincare brand iS Clinical, has
announced the launch of the iS Clinical
World Star Contest 2021. The contest
will select one account partner from the
UK and one from Ireland based on the
highest growth and revenue achieved
with iS Clinical. There will also be one
Premier Star winner; the account partner
with the highest overall qualifier metrics
globally. Prizes include flights and
accommodation at the awards ceremony
in the US in 2022, VIP education training
and products.
IAPCAM returns for 2021
IAPCAM (International Association
for Prevention of Complications in
Aesthetic Medicine) will return with its
annual conference on 3 September
2021 at Church House in London.
The Association’s global faculty of
KOLs will present and comment on
key topics in the management and
avoidance of classic and current areas of
complications. The event will take place
both in person and online on a new virtual
conference platform, where delegates
will be able to ask questions through the
live chat function. Attendance packages
start at £75 for a virtual pass.
Aesthetic Medicine 11
NEWS AND ANALYSIS
Mesoestetic launches new
website
Aesthetic product and treatment
brand Mesoestetic has launched its
new website, mesoestetic.co.uk. The
website is designed to be faster, easier
to navigate and more user-friendly than
before, giving better access to company
information, case studies, information on
products and treatments and upcoming
launches. “We endeavour to provide our
client partners with the most accurate,
up-to-date information and share our
knowledge and expertise in the field of
medical aesthetics,” said the brand.
Lynton appoints Mr Ali Ghanem
Lynton has announced plastic surgeon
Mr Ali Ghanem as its latest KOL for the
DEKA SmartXide CO2 laser device.
“SmartXide is a device that allows
medical practitioners to perform both
invasive and non-invasive dermatological
procedures alongside surgical
applications,” he said. Lynton has also
created a new Microneedling Masterclass
for its latest microneedling device,
EPN Pen, a combined microneedling
and electroporation device. For more
information: lynton.co.uk/training
Fillmed parent company joins
plastic pollution fight
KRESK Group, parent company of dermal
filler and aesthetic treatment brand
Fillmed, is sponsoring sailor François
Gabart in his work fighting plastic
pollution over the next four years, having
aquired Gabart’s new trimaran boat.
The first joint project, Kresk4Oceans,
will implement awareness-raising and
education operations around plastic
pollution and will finance scientific
projects in the field of recycling and the
development of new eco-responsible
materials.
Cosmeselect adds to portfolio
Aesthetics distribution company
Cosmeselect has been appointed as
exclusive distributor for MCCM Medical
Cosmetics. The pharmaceutical skincare
brand’s product portfolio includes
peels, mesotherapy cocktails and
homecare. “Our selection of products
is used by award-winning doctors...
sourcing the most effective products
that show significant improvements in
the treatment of specific face and body
conditions,” said Cosmeselect founder
Aminah Aboud.
12 Aesthetic Medicine
Sun safety knowledge worryingly lacking in the US
A third of Americans failed a basic
quiz on sun exposure, with young
adults faring the worst. The survey,
from the American Academy of
Dermatology (AAD), was designed
to measure the level of sun-safety
knowledge of the population.
Generation Z (those born after
1996) demonstrated the lowest
level of awareness about the
dangers of sun exposure. 42%
were unaware that tanning can
cause skin cancer, while 41% didn’t know
that ultraviolet rays are reflected by snow,
water and sand. 33% didn’t think they could
get sunburn on a cloudy day.
Millennials (those born between 1981
and 1996) didn’t do much better. 37%
didn’t know that tanning can cause skin
cancer, and 23% didn’t believe that sunburn
increases the risk of developing skin
cancer. More than half of the entire survey
population (1,000 adults) didn’t know that
shade can protect them from the sun’s
harmful rays, 35% believed that tanning
More than half of UK men use partners’ skincare products
More than half of men in the UK admit to
using their partner’s skincare products
without them knowing, revealed a new
study by skincare brand Clarins. In the
recent survey of 1,000 men in the UK, 56%
said they were guilty of “stealing” their
partner’s products to help with their skincare
concerns, while more than one in ten (14%)
owned up to using their other half’s products
every day, and 19% admitted that they use
their partner’s products “often”.
When asked about their own skincare
routines, the survey revealed that men are
most likely to use moisturiser, cleanser, eye
cream and spot treatment. In addition, it was
discovered that 90% of men have at
least one skincare insecurity, with the top
is safe as long as you don’t burn; and 47%
either believed or were unsure as to whether
having a “base tan” prevents burning in
the sun.
“These are striking results when it comes
to younger generations’ knowledge about
basic sun exposure,” said Dr Kenneth
Tomecki, president of AAD. “Gen Z and
Millennials have a lifetime of potential
damaging sun exposure ahead of them, so
now is the time to close the knowledge gap
and ensure they are aware of how easy it is
to practice sun-safe behaviour.”
five biggest concerns dry skin (41%),
dark circles under the eyes (35%),
acne/acne scars (27%), ageing/fine
lines (26%) and blackheads/enlarged
pores (26%).
For the men that regularly use
their own skincare products, almost
50% said the amount of time and
money they spend on their routine
has increased over the past five
years. Four in five men (82%) say
they spend up to £50 a month on
specialist skincare products.
Psychotherapist Sarah Lee, who
worked with Clarins on the survey, said:
“Traditionally, ‘masculinity’ has had a very
narrow, heteronormative definition. For
some men, secretly using their partner’s
moisturiser is a lot easier than recognising,
challenging and deconstructing societal
norms. Men’s ability to express their identity
(or emotions) freely is generally helpful,
however it becomes problematic when it’s
based on unrealistic expectations such
as filtered images or feeling the need to
conform to certain body types or looks. We
need diverse role models, and we need to
practice being less judgmental towards
our bodies.”
July/August 2021
 A NATURAL LOOK IS
AN EXACT
SCIENCE

Patients today want a filler that naturally integrates into their tissue, so that
they can retain their identity and express their emotions with confidence1.

BELOTERO® Balance is indicated for the

correction of moderate lines, such as: nasolabial • Natural Integration1,2
folds, glabellar and perioral lines so patients can
feel empowered with natural-looking results2.
• Natural Movement3

• Your Own Artistry

merz-aesthetics.co.uk Merz Pharma UK Ltd, 2 Ground Floor Suite

B, Breakspear Park, Breakspear Way, Hemel
@merzaesthetics.uki Hempstead, Hertfordshire HP2 4TZ

BALANCE Merz Aesthetics UK & Ireland

MERZ AESTHETICS is a registered trademark
of Merz Pharma GmbH & Co. KGaA.

References
1 Prager W et al. J Drugs Dermatol. 2017; 16(4): 351-357
2 Micheels P et al. J Clin Aesth Derm. 2015; 8(3): 28-34
3 Kerscher M et al. Clin Cosm Inv Dermatol. 2017;10:239-247
Adverse events should be reported. Reporting forms and information for United Kingdom
can be found at www.mhra.gov.uk/yellowcard. Reporting forms and information for
Republic of Ireland can be found at https://www.hpra.ie/homepage/about-us/report-an-
issue/mdiur. Adverse events should also be reported to Merz Pharma UK Ltd at the address
above or by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143.

M-BEL-UKI-1184 Date of Preparation June 2021

NEWS AND ANALYSIS
Aesthetic practitioners send
open response to JCCP
regarding its 10–Point Plan
A group of over 100 doctors, nurses and
dentists from the field of aesthetics have
come together to issue a response to
the JCCP (Joint Council for Cosmetic
Practitioners) in reference to its 10-Point
Plan, released in March. The Plan is a
framework of recommended actions
towards regulation and a monitored, safer
environment for the practise of non-
surgical aesthetic procedures, including
hair restoration. (See infographic opposite
for the 10-Point Plan in brief).
Represented by Dr Steven Land, director
of Novellus Aesthetics, Ness Griffiths,
aesthetic nurse practitioner at Novellus
Aesthetics; and Dr Tapan Patel, director
of Phi Aesthetics, the response addresses
each point individually and summarises
“the general feelings about this plan from
those operating within the sector”. The main
body of the letter reads as follows:
1. Statutory regulation:
“We would start out by pointing out that
those we feel should be injecting – doctors,
dentists and nurses – are already mandated
to be on a statutory register. Entry onto
these registers compels them to ‘follow best
practice guidance’; ‘comply with standards of
proficiency’; ‘provide treatments safely’ and
‘possess (any) insurance cover’. It is our belief
that legislation restricting practice to the
aforementioned groups would solve many of
these problems in one go and thus this point
does not actually go far enough.
“Lobbying and exerting political influence
to this end would be a more useful effort
than trying to set up another compulsory
register when it is not needed and would, in
fact, be a huge leap forward in making the
whole industry safer. Working with these
regulatory bodies – NMC, GMC and GDC – to
encourage them to take aesthetic medicine
more seriously as a speciality and develop
their own guidelines and policies would be
welcomed by everyone in the sector.”
2. Mandatory education and
training standards:
“Much in this point is to be applauded
– working to raise the training and
educational standards within aesthetic
medicine is paramount. We would
point out that restricting the practice of
aesthetic medicine to doctors, dentists
and nurses would solve a lot of the issues
around maintaining competence and
being registered on a PSA register would
add the proposal of working with these
14 Aesthetic Medicine
THE JCCP’S 10
POINT PLAN
The Joint Council For Cosmetic Practitioners is an organisation working
closely with government and national bodies seeking greater regulation
on non-surgical aesthetic treatments and hair restoration surgery in the
UK. Our ultimate aim is to create a safer environment for members of
the public undergoing non-surgical treatments with mandated
qualifications, premises criteria, insurance and many other steps relating
to the sector and industry. Our 10 Point Plan lays out the campaigns we
carry out and the goals we seek.
STATUTORY REGULATION
1 Seek and advise on statutory regulation for the non-
surgical aesthetics and hair restoration surgical sector.
MANDATORY EDUCATION AND TRAINING STANDARDS
2 Government and education/training regulators in the UK to
mandate specific qualifications, education and training
requirements for specific modalities.
CLEAR, TRANSPARENT, INFORMATION
3 Aesthetic service providers to clearly display simple,
informative guides on all services provided including risks,
benefits, costs, qualifications, and insurance to members of
the public.
DEFINITION OF MEDICAL AND COSMETIC TREATMENTS
4 Work with Government agencies to clearly define in law
what constitutes a ‘medical’, a ‘medically-related’ treatment
and what is ‘cosmetic’ only.
SAFE AND ETHICAL PRESCRIBING
5 Implement robust standards and regulation for safe,
ethical and professional prescribing within non-surgical
aesthetics.
MORE REGULATED ADVERTISING AND SOCIAL MEDIA
6 Tighter controls and penalties on exaggerated, inaccurate
and misleading advertising and social media posts in
relation to aesthetic treatments, hair restoration and
training.
NATIONAL COMPLICATIONS REPORTING
7 Introduce enhanced and co-ordinated processes for the
reporting and analysis of adverse incidents at a national
level.
ADEQUATE INSURANCE COVER
8
Legislate all cosmetic non-surgical aesthetics and hair
restoration surgical practitioners to hold robust and
adequate indemnity insurance covering each service
provided.
LICENSING OF PREMISES, TREATMENTS AND
9 PRACTITIONERS
Set nationally agreed standards for licensing and
regulating premises, treatment procedures and
individuals.
RAISING CONSUMER AWARENESS
10 Raise public awareness of the risks and benefits
associated with non-surgical treatments and hair
restoration surgery.
July/August 2021

registers to ban their members from training
those unqualified to undertake medical
procedures.”
3. Clear, transparent information:
“Again, much to be recommended in this
point – and again all of this would be covered
under the duties expected by the relevant
registering bodies of doctors, dentists and
nurses. Restrict practice to these groups, work
with their registering bodies for clear guidance
on aesthetic medicine for their members,
and a regulatory framework to prevent poor
practice already exists.”
4. Definition of medical and
cosmetic treatments:
“This is a point that we have issue with. We
would contest that any procedure using a
prescription-only medicine or a class-three
implantable medical device is medical. It may
also be cosmetic as the two are not mutually
exclusive, and to try and set such distinction
is unfair (as a comparison, we would point
out that the majority of breast augmentation
surgery (using an implantable medical device)
is for cosmetic reasons but is also self-
evidently medical).
“The recently published WHO ICD-11
classifies everything we treat with botulinum
toxin and dermal filler to be a disease.
Aesthetic medicine is considered a medical
speciality in its own right in other countries
and restricted to medical practitioners – and
it should be so in this country, too.”
5. Safe and ethical prescribing:
“Again, much to be commended in this point
– particularly the objectives of publishing
details of practitioners’ prescribers (perhaps
as part of the licensing scheme mentioned in
Point 9) and the proposal that all prescribing
professionals are allowed to obtain stock for
emergency purposes – both of which would
increase safety for our patients.
“We would also add that working with the
GMC, GDC and NMC to adopt the 2019
GPharmC guidance on not prescribing for
non-medical professionals in the field of
aesthetic medicine would be welcomed by
advocates of patient safety.”
6. More regulated advertising and
social media:
“Again, nothing here to argue with, suffice to
say that current rules and regulations need
to be more strictly enforced to ensure a
level playing field. As fillers are considered a
medical treatment by their regulatory bodies,
medical practitioners are not allowed to
do any sort of offer, whereas non-medical
practitioners are free to do what they will
aestheticmed.co.uk
NEWS SPECIAL
(again, restricting aesthetic medicine to
medics would solve this problem).”
7. National complications reporting:
“We agree that making dermal fillers
prescription-only devices should lead to an
increase in complication reporting, especially
if this is made easier with an online reporting
form or app. Pushing for regulation around
medical devices (which have notoriously poor
vigilance) may be easier as it removes the
requirement for reclassification and would
improve the safety of medicine as a whole.”
8. Adequate insurance cover:
“Another laudable aim, entirely covered by
making aesthetic medicine practice-able only
by medics. Membership of our respective
mandatory registers makes us compelled to
have adequate insurance for the fields within
which we practice.”
9. Licensing of premises, treatments
and practitioners:
“This point and its objectives go a long way
toward making the field of aesthetic medicine
more regulated and safer for the patient.
Licensing of premises to ensure they meet
basic requirements, details of the treatments
carried out and the details of the practitioners
working there, and their regulatory bodies,
prescribers and qualifications would seem
so obvious that we suspect most members
of the public would be surprised to find out it
doesn’t already happen.”
10. Raising customer awareness:
“Any proposal to raise public awareness of
aesthetic medicine, its benefits and its risks
is to be applauded. The availability of reliable
information is key to safe decision making
by our patients – knowing what procedures
are available, safe and well-evidenced, and
which practitioners can be relied upon to do
right by them, is paramount to the safety of
our patients and the continued success and
growth of aesthetic medicine as a speciality.”
The authors added: “As general points we
would like to say we have issues with the
impartiality of the APPG for beauty, aesthetics
and wellness. It is funded by the beauty
industry and previous public meetings have
shown they have little understanding of the
medical aesthetics field and the complexities
contained therein. We believe that closer ties
with the current regulatory bodies for doctors,
dentists and nurses are key relationships
for moving the safety of aesthetic medicine
forward – many of the points covered in this
document should be being regulated by these
bodies for their members yet are seemingly
ignored, even when concerns are reported.”
Aesthetic Medicine 15
advancedtechnology,affordableprices,nocompromiseonspecification

– charlotteward,nurseandclinicaldirector,
orchardleaaesthetics
 VISIT US ON
STAND C14

LIVE
OLYMPIA LONDON
8-9 JULY 2021
POLICIES
ith the impact the pandemic
W has had on all businesses,
it’s important to update your
workplace policies to reflect
these changes to working life so staff
know where they stand, and so that you
as an employer have provided necessary
guidance about the new rules you expect
them to adhere to. These policies will also
likely provide a level of comfort to the
workforce who will recognise the business is
responding sensibly and proactively to the
ongoing crisis.
CORONAVIRUS POLICY
This policy will look to address the ways
the business has adapted as a result of
coronavirus in order to reduce the spread
of the virus and ensure the welfare of staff
is maintained during any future outbreaks.
Matters which you may want to include
within this policy are:
• Amendments to the Sickness Absence
Policy (e.g. to comply with Government
guidelines for isolation)
• Amendments to the Flexible Working
Policy (e.g. to comply with working from
home requirements/ to address those
wishing to isolate/ to assist those using
public transport to adapt work hours
• Amendments to the Annual Leave Policy
(e.g. to account for holiday while on furlough
leave/ to allow additional carry-over if staff
need to work due to covid-19.
20 Aesthetic Medicine
Follow the
Employment lawyer Tina Chander breaks
down some workplace policies worth
introducing post–pandemic
FLEXIBLE WORKING POLICY
This policy will look to provide employees
with greater flexibility in their working
arrangements through being able to request
changes to their regular and contractual
work pattern. Matters which should be
included within this policy are as follows:
• Examples of what flexible working changes
can be requested by employees, e.g. changes
to their hours, their days or their location
of work
• Confirmation of who will be eligible to make
a formal flexible working request (i.e. must
have been employed for a period of at least 26
weeks/ cannot have made a flexible working
request in the last 12 months). For those not
eligible, there should be guidance as to how
they can make an informal request
• The process for how an employee should
make a flexible working request
• The factors the business will use to decide
whether to allow the flexible working request,
i.e. the eight business reasons which may lead
to a rejection
• The process for how an employee can appeal
the decision.
HOMEWORKING POLICY
This will set the parameters of when the
business will allow home working and any
specific requirements. Matters which should
be included within this policy are as follows:
• Examples of when working from home may
be preferable/ permitted, including those
rules
roles which cannot work from home, if any
• The arrangements for working from home
• How to apply for home working and the
factors considered in deciding if it
is allowed
• Confirmation of what equipment will be
needed and if this will be supplied by
the business
• A reminder on data protection and
confidentiality
• Links to the flexible working policy for if a
permanent change is desired
• A reminder to comply with the Health
and Safety policy and any additional
considerations when working from home,
e.g. not meeting customers at home,
sticking to working patterns, etc.
TINA CHANDER
Tina Chander is a
partner and head of the
employment law team at
Midlands law firm Wright
Hassall. She deals with
contentious and non-
contentious employment
law issues, acting for
employers of all sizes from
small businesses to large
national and international
businesses, advising on all
aspects of employment
tribunal proceedings
and appeals.
July/August 2021
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 VISIT US ON
STAND D30

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How we deliver Personalisation... OLYMPIA LONDON
8-9 JULY 2021

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Quality Management
OPERATIONS MANAGEMENT
Smooth
operator
How can you make your operations management
more efficient? Phil Elder shares his tips
want to talk about operations
I management in this issue, to
get you thinking about, and if
necessary, implementing, new
ways in which you could streamline your
processes for a smoother overall running
of your clinic. Operations or operational
management is the planning, organising and
supervising that governs your being able to
provide the services you do as a business.
“As such, it is delivery-focused,” says writer
Tim Dhoul, “ensuring that an organisation
successfully turns inputs to outputs in an
efficient manner. The inputs themselves
could represent anything from materials,
equipment and technology to human
resources such as staff or workers.
“Examples of the types of duties or
specialist positions this encompasses are
procurement (acquiring goods or services
from external sources), managing relations
with those involved in processes and
improving a company’s sustainability with
regard to their use of resources”.1
Now, I’m guessing you weren’t exactly
aware you were singing up for all these jobs
when you opened your clinic, and that these
26 Aesthetic Medicine
aspects of running the business can often feel
overwhelming on top of everything else, not to
mention actually treating patients.
Let’s simplify it. Realistically, operations
management involves the planning, strategy
and supervision of three elements: people,
process and technology.
PEOPLE
This covers your staff, patients and suppliers.
We live in a world of very easy access to
information and people via email, social
media channels and instant messaging.
When used correctly, the joy of this hyper-
connectivity is the ability to build relationships
quickly and easily, but are you leveraging it in
the best ways possible?
Immediate action step:
• CRM system – If you don’t have one, get
one. Simple but incredibly useful customer
relationship management (CRM) systems
are now often free. When you meet someone
(be it a new patient or business contact), take
their business card (if a business contact)
and log the person’s telephone number, email
address and social media channels in your
July/August 2021

system. This allows you immediate access
to the individual’s interests, passions and
regularly-updated live feed. Of course, I’m
not in any way suggesting we start stalking
people, but having this information to hand
becomes an incredibly powerful tool to build a
rapport and make it easier to keep patient and
business relationships going strong.
TECHNOLOGY
Thanks to the pandemic, many of you will
have become more in tune – whether you
like it or not – with technology. But there are
some simple technology hacks you may not
have thought about which we can within the
business to modernise the way some lesser-
considered things are done.
Immediate action step:
• Private YouTube channels and cloud-based
drives – I regularly use these for staff training,
instead of or to support written internal
documents. Whenever you are training
someone in any aspect of the business, or
even just performing a task yourself, record
it to then go on to form a digital operations
manual. For visual learners, actually seeing
tasks performed as opposed to reading
instructions is much easier to digest. And,
if you’re inclined to do so, you could even
begin filming learning material for any future
courses should you wish to move into the
training sector.
I can’t emphasise enough how much time
I save from doing this. When new members of
staff start at the clinic, they immediately have
a starting point for training; and your existing
and future staff have a standardised point of
reference for tasks that they may not perform
regularly. This will not only increase staff
efficiency but will also make future training
efforts more effective and save you no end of
time in re-training or answering questions for
task-based processes.
PROCESSES
As aesthetic clinic owners, we input products
and skills to provide the output of services to
our patients or clients. Processes can range in
length and complexity and while we are in an
industry in which automation is not an option
and the delivery of professional, high-quality
care is paramount, don’t overlook the ability
to implement processes into
your clinic.
Immediate action steps:
• Stock control – This can be as simple as a
note to reorder X amount of stock stuck to the
inside of your stock cupboard. Or, it can be a
task reminder on your device or time blocked
out in your calendar to check stock. Is your
aestheticmed.co.uk
BUSINESS
current process working for you? Could it be
more effective? Manual methods of stock
control can include a diary reminder to check
stock levels and re-order on either a weekly or
monthly basis. Or, if you are using bookkeeping
software, these often have built-in capabilities
for tracking stock levels. Most people often
simply associate the feature with use for
shops or e-commerce-style businesses, but
I’d always recommend logging treatment and
product sales too, as this will allow you to track
the most popular treatments in your clinic and
give a greater focus for marketing. The majority
of accounting software (such as Xero, for
example) has the ability to record stock.
If you record how much filler stock you
have, for example, then each time a treatment
is recorded this will automatically reduce
the stock level, and you are able to set up
auto re-orders or alerts when stock reaches
below a certain level. As I mentioned, you will
already have many of these systems in place
within your business, and simply looking into
different ways to make the most of them can
make a big difference to the efficiency of your
operations management.
• Checklists – As a pilot, checklists are at the
heart of my processes when I’m in the cockpit.
Even in an emergency situation, I know that
those set actions are to be followed in a set
pattern to get the best outcome. This is a
simple but very effective process we should
be adopting into our clinics. One very key
point, however, is to make sure that these
are reviewed regularly and that all those
involved are part of an open-door policy
so that these particular processes can be
refined if necessary, as and when changes
occur. Checklists can be used for the most
straightforward to the most complex chain of
events to ensure consistent outcomes.
Operations management is a huge subject,
but the most important message I want to
get across is to encourage you to open your
mind to thinking of ways in which to improve. PHIL ELDER
Whenever possible, think about how you Phil Elder is a multiple
can leverage a resource, system or skill to business owner. His
portfolio includes Neos
allow you to push forward. And do take note
Clinic, an aesthetic clinic
of the suggested immediate action steps – in Ipswich, accountancy
education is a wonderful thing but without practice RSZ Accountancy
implementation it is worthless. and a finance company.
So, as soon as you finish reading this Blogs, videos and other
article, take an immediate step towards resources on business
implementing or at least reviewing something efficiency, structuring a
company, tax savings and
we’ve discussed.
more can be found on
Phil’s website:
philipelder.uk.
REFERENCES Follow him on Instagram:
1. https://www.topmba.com/mba-programs/what- @philipelder
operations-management
Aesthetic Medicine 27
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Ask
Alex
Clinic digital marketing
specialist Alex Bugg answers
your questions
Q: I OFFER A MINOR SURGERY SERVICE
AS WELL AS AESTHETICS, BUT I FIND
THIS IS HARDER TO MARKET. WHAT
SHOULD I DO?
A: Firstly, I’d make sure you have plenty of
information about minor surgery on your
website, so you can rank on Google in your
area – or even nationally – for each concern.
Know who your target patients are – what do
they know already, what are they searching
for answers to, what do they want as a
solution? Then see if there any alignments
with your current patient base. These
databases are usually the quick win.
Then, it’s about creating awareness
campaigns for minor skin lesions; most
Q: HOW DO I MAKE MORE SOCIAL MEDIA CONTENT WHEN I ONLY HAVE A FEW
PATIENTS WHO CONSENT TO THEIR IMAGE BEING USED?
A: Especially when starting out, creating 4. The follow-up – when you follow up with
content for social can zap a lot of time and
energy. This is where repurposing can help.
As well as creating educational posts – be
that words on an image or video – you can
repurpose one client’s consented image
into multiple social media posts which you
can use across the space of weeks or even
months. One well-planned appointment
with image and video can make the
following posts:
1. Before-and-after single image
2. Photos or video showing the
treatment process
3. The products – discuss the products you
used for this case
aestheticmed.co.uk
BUSINESS
people have some sort of concern but generate leads. Don’t write off “traditional”
aren’t exactly sure what it is, or the solution. ads either; print in local media is one
Double down on education through video, option, but who hasn’t wanted to buy an ad
text and audio. Case studies for minor on the back of a bus one day? With such
surgery are usually very visual, so where you visual treatments which are relatable, why
can get consent for anonymised images to not explore this?
be used, do. Share awareness campaigns on Remember, some minor surgery patients
social media and email, contact local press would have zero interest in aesthetic
(remember, print journalism often goes treatments, so you have to go and find
online) and keep local TV and radio in mind, those patients and tell them you’re here
as they can often be underestimated. and offering this (where a GP service might
Once you’ve got your marketing no longer). This is why understanding your
messaging, you could advertise. If you’ve patient and building awareness are the
got a strong landing page with case studies building blocks to successfully marketing
for minor surgery, you can switch on any treatment, be it skin tag removal or
paid ads via Google or other channels to toxin injections.
the patient, show the difference between
post treatment and two or four weeks after ALEX BUGG
(whatever is appropriate) Alex Bugg works for Web
5. In my bag – if they left with skincare Marketing Clinic, a family-
products, ask them to snap what’s inside run digital agency, which
specialises in medical
6. The video testimonial – or the written one
aesthetics. They build
7. The key testimonial quote in an image websites and deliver
8. Any user-generated content posted by marketing campaigns for
the patient doctors, nurses, dentists,
That’s a week’s worth of posts from just distributors and brands.
one patient. These can be posted in order Contact her: alex@
or mixed in with other posts. They don’t just webmarketingclinic.
co.uk or follow her
need to be feed posts either; these can also
on Instagram:
go on stories or be spread across multiple @webmarketingclinic
social channels.
Aesthetic Medicine 29
CLINIC PROFILE

North
star
Dr Raj’s Thethi’s new clinic is exciting, impressive and
somewhat unexpected, finds Georgia Seago

r Raj Thethi says he never “Covid made a lot of opportunities pop up

D expected to have this – a

3,500sq ft, two-floor clinic
with six treatment rooms,
an operating theatre and recovery room,
training centre and offices – at such an early
stage in his career, at the age of just 31. “I
thought this was going to be something I
would have 15-or-so years into the future,
when I was 45, or something,” he says.
for me. Of course, I appreciate how horrible
it is, but there are silver linings to everything.
The day before the PM announced the first
lockdown, I was due to sign a lease for a
much smaller clinic space, but I had this
weird gut feeling. Now, I’m so glad.”
Dr Thethi explains that as restrictions
from the first lockdown started to ease in
July last year, he called back to see if the

30 Aesthetic Medicine July/August 2021


space was still available. It wasn’t, and he was
“kicking myself; so, so gutted”. But then he
came across a much bigger unit online and
suddenly, things took a different turn. The
vision expanded into what is now Yorkshire
Skin Centre, and it’s hard to imagine things
turning out how they were originally intended.
With so much more space than he
expected and having to completely renovate
the whole thing, Dr Thethi had his work cut
out: “Covid meant that throughout the most
recent lockdown I could just focus on it as
a full-time project, because I didn’t have an
architect or a designer, I did everything from
scratch myself; where the walls were going
to be, where the plug sockets were going to
go, down to the taps and treatment couches.
There weren’t even any pipes because it’s
a former car showroom, so the floors were
weighted concrete – no floorboards or
timber, nothing,” he says.
Of course, it’s not entirely true that
Dr Thethi did everything himself. In fact,
his father, a joiner, ended up doing and
overseeing most of the work, including
the plumbing, mounting of the electrics;
essentially everything one would need to
do to create a fully functional super-clinic
out of massive shell. “The hardest bit was
figuring out the logistics of what you need
and where, and how you’re going to achieve
it, so my dad has been instrumental. It was
expensive, but it’s a place I want to grow
into, I don’t want to keep moving around,”
he says.
ON THE MAP
Based in Leeds, Dr Thethi wanted his clinic
to rival those of London in terms of prestige,
but with the space, light, luxury and artistry
that are perhaps harder to achieve in the
capital thanks to the astronomical rents of
Harley Street and the surrounding areas.
“Space and light are so important, and when
you have a little cramped, dingy room, it
takes away from the whole experience for the
patient, especially when you’re squeezing
past them to get a needle or something. I
treat my patients like portraits, and I want to
be able to demonstrate in surroundings that
echo it,” he says.
Having himself visited other clinics for
training in the past, Dr Thethi says he was
always conscious of the spaces in which
practical treatment demonstrations were
carried out. So, suddenly faced with a much
bigger space than he ever anticipated, he
decided to incorporate a training facility.
“Most of the time you’re just stood in the
injector’s room and you’re training in there,”
he explains. “A clinical space is great, but
it’s not really a training environment. When
aestheticmed.co.uk
CLINIC PROFILE
clinics do have a separate space it’s always
an afterthought, but I want training to be the
forefront. When you walk into the training
facility at Yorkshire Skin Centre [which is
within the clinic building] you know that it’s a
space purely for education.”
In his own words, what Dr Thethi really
loves is creating beauty. This is evident in his
approach to his patients’ treatments, but
also in the design of the new space. Before
going into medicine, he says he wanted to
become an architect, so the opportunity to
design and create the clinic of his dreams
was a real gift. “The fact that I could design
a space and take it to the artistic level that
I wanted it to be at, that level of style and
sophistication… I just haven’t seen it that
often. There are very few clinics in the north
that are like that. Often, you find mediocre
design and I’ve worked in many places that
looked like decaying hospitals. I really didn’t
want to bring that vibe,” he says.
The clinic’s luxurious yet tasteful interior
lends a certain sparkle to the patient
journey, reflecting how seriously Dr Thethi
takes his work but on a level that is genuine,
welcoming and comfortable – exactly the
way he makes you feel when you speak to
him, and, presumably, why he has a clientele
large enough to justify such a big space (at
the time of our interview, Dr Thethi had no
availability for two months and patients were
having to be turned away who didn’t want
to wait). “I think it just reflects better when a
place is more beautiful,” he says. “People walk
in and they instantly feel confident that you’ve
Aesthetic Medicine 31
CLINIC PROFILE
invested time, energy and money into their
experience, that I’m confident in helping them
achieve their aesthetic goals.”
ACHIEVING EXCELLENCE
Dr Thethi is in the process of obtaining CQC
registration for the clinic in order to get up
and running with another element that
sets it apart – its operating theatre, where
visiting plastic surgeons will run some of their
consultations and perform minor procedures
such as upper blepharoplasties and mole and
skin lesion removals. Mr Sharif Kaf Al-Ghazal,
consultant plastic surgeon at Bradford
Teaching Hospitals NHS Trust, is one such
surgeon, while Dr Thethi is in contact with
others interested in providing specialisms like
minor vascular surgeries.
He’s also already planning on adding
women’s-health services covering hormones
and vaginal rejuvenation with a focus on the
menopause. “I really want this to be a true
centre of excellence; a place where patients
can come and have the best treatment
no matter their concern,” says Dr Thethi. “I
happily refer patients to other people if I think
they’re better at something than I am. Now, I
can have all these experts under one roof.”
This vision of bringing together expertise
in multiple areas of aesthetics, health and
beauty is the reason behind the name change
from Skin Radiance Clinics – Dr Thethi’s first
clinic which he founded in 2017 – to Yorkshire
Skin Centre. “We needed to rebrand, and I
wanted the new name to be pertinent and
32 Aesthetic Medicine
almost respectful of the space. Skin Radiance
Clinics was when I was a novice injector and
I think I was probably naive in what I wanted;
at that point the long-term plan was to set up
lots of small clinics, hence the plural, ‘clinics’ in
the name,” he says.
Part of the reason behind this shift in
vision is down to how the NHS has evolved to
combine multiple small centres for trauma, for
example, into larger hubs that key specialists
work out of. “I’ve been looking at the way the
NHS is unfolding, and I think it’s important
because they’ve been running a lot longer
than our small clinic models and we can learn
a lot of lessons from that,” says Dr Thethi.
“They discovered that the overall level of
care that people received was less than if
they were taken to a larger tertiary centre
where everyone with those needs is
referred, with a few experts in those certain
procedures. Now, I’d rather people travel
to me at this one location, and I know that
when they come here, I’m going to make their
experience worthwhile.”
TEAM EFFORT
Behind every great doctor is a team of equally
great staff, and Dr Thethi speaks incredibly
highly of his staff members, brought on
board as much for their skills and experience
as their energy and personality. His wife
Sharan, a dentist, is the clinic manager, while
Charlotte Dewhirst and Olivia Horne make
up the admin team. Alongside Dr Thethi,
aesthetic practitioner and semi-permanent
July/August 2021

make-up artist Egle Ambraskaite (known
as Elle) – who, with a Bachelor’s Degree
in Cosmetology and Medicine and more
than 10 years in aesthetics, he describes
as “really, really experienced” – also
performs treatments, providing laser, IPL,
radiofrequency microneedling, cosmetic
tattooing, chemical peels, and more.
“I’m the only cosmetic doctor at the
moment,” says Dr Thethi. But we’ve got all
these empty rooms so potentially we’re
going to rent them out to other medical
aesthetic practitioners. We’ve already had
loads of interest from people who want to
utilise the space because they like the design
and how forward-thinking it is.” However, he’s
understandably cautious about who else
works from Yorkshire Skin Centre, especially
when many of the most skilled and reputable
injectors already have their own clinics. “I
need to make sure that the person I bring in
is very moldable and coachable so I can get
them to a level where they’re independent
but would make the same decisions I would
make. And that’s really, really, really hard to
find,” he says.
Another reason for eventually bringing
other clinicians on board is to free up some
of Dr Thethi’s workload, though he recognises
that the intensity of the early stages of
owning a new clinic won’t last forever: “There
are always going to be teething problems
at the beginning, and at the moment one of
them is that I’m having to stay here so late at
night, working literally until two o’clock in the
morning every day, then back up at six to
work again,” he says. “I think it’s just the initial
phases of figuring out the logistics of a clinic
aestheticmed.co.uk
CLINIC PROFILE
more than anything else, but at the moment,
I’m missing my kids a little bit.”
TRIED AND TESTED
Dr Thethi uses the Teoxane HA dermal-filler
portfolio for injectables alongside Ellansé
from Sinclair Pharma, and is a trainer for
both, while for skin treatments, the clinic
uses ZO Skin Health.
He says his favourite treatment to
perform at the moment though, is InMode’s
Morpheus8 radiofrequency microneedling
(see page 66 for a case study with the
device). “I love it so much,” he says. “If I
can smell what I’m doing [from heating the
skin] that means I’m doing something deep
and I’m doing something serious for the
patient. That’s where I feel very comfortable
in treatments.” The media buzz around
Morpheus8 and the transformations of
patients who have had the treatment
is evident during consultations, says Dr
Thethi. “They walk in already having some
knowledge, which makes our job a lot easier.
They’re informed and half the hard work is
done because that social proof works, there’s
evidence,” he says.
Dr Thethi places much importance on
consultations, spending at least an hour
with each new patient before he agrees to
work on their face. “I don’t care if I spend an
hour and a half with someone and not inject
them,” he says. “It doesn’t matter, because
the amount of time that you put into that
initial consultation, the patient values that,
they’re going to feel more comfortable
taking your opinion, and it builds trust.” If his
most recent award win – Global Health and
Pharma’s 2021 Most Trusted Aesthetic Clinic
– Leeds – is anything to go by, Dr Thethi’s
approach is clearly working.
Aesthetic Medicine 33
 VISIT US ON
STAND E18

LIVE
OLYMPIA LONDON
8-9 JULY 2021
FAT-DISSOLVING INJECTIONS

Top: before, Bottom: after two sessions of Aqualyx. Treatment by Dr Maeve Kenningham

Slimming
down
Dr Maeve Kenningham assess the safety profile
and mechanism of adipocytolysis with
injectable therapy using Aqualyx

DR MAEVE KENNINGHAM
Dr Maeve Kenningham MBChB MRCGP DipDerm DRCOG DFFP is the director of Dr K’s
Clinic in Wrexham, Wales, where she delivers relaxed, bespoke and patient-centred
advanced medical aesthetic services. She also treats patients at NassifMD Medical
Spa in Manchester once a fortnight. Dr Kenningham has been a GP for 20 years and
has trained for the Royal College of General Practitioners. Follow her on Instagram:
@dr_ks_clinic

36 Aesthetic Medicine July/August 2021


everal adipocytolysis injectable
S products are available in the
UK and are modifications of
deoxycholate (DC): Aqualyx,
Desoface and Desobody, Lipostabil and
Lipodissolve. Kybella is FDA-approved in
the US and is known as Belkyra in Europe
but is not yet available in the UK. Although
greatly anticipated here, it appears patients
elsewhere feel underwhelmed by the results.
A recent search of Realself “worth it” ratings
(accessed in May 2021) showed that 57% of
96 patients felt it was worthwhile, while 42%
felt it was not.
Aqualyx has been in clinical use since
2009, mostly for reduction of localised
adiposity, and I have used it in my clinic for
three years. It is deemed a medical device in
Europe and the manufacturer recommends
its use alongside ultrasound for the micro-
cavitation of adipose tissue. So, without
ultrasound, Aqualyx on its own represents
an off-label use of the medical device.
However, its solitary use has been extensively
described in literature.2–4 Kybella and Belkyra,
on the other hand, are recorded as drugs.4
The principal active ingredient of Aqualyx
is deoxycholic acid. This is a secondary bile
acid that is produced by the liver and used to
break up fat for intestinal absorption. When
injected into adipose tissue it disrupts the
cell membranes and the fatty acid contents
are released. The micro-gelatinous delivery
system, which contains buffering agents
and a low concentration of active detergent,
appears to successfully reduce the
inflammation caused by DC.5 Before I began
working with Aqualyx, my insurer Medical
Protection Society would not insure me for
Lipodissolve use and there had been some
controversy with the FDA about the safety
aestheticmed.co.uk
CLINICAL
claims of Lipostabil. However, both appear to
have a good safety profile in the right hands
and are widely used throughout Europe by
the doctor group NETWORK-Lipolysis.
FAT REDUCTION AND SKIN
STRENGTHENING
The marked immune response from Aqualyx
treatment and resulting macrophage
infiltrate appears to serve a two-fold
purpose. First, the macrophages clear the
cell membrane fragments and free lipids,
and second, through fibroblast recruitment,
neocollagenesis is stimulated.6,7 Once
destroyed, the adipocytes cannot store or
accumulate fat, resulting in fat reduction
but also a bonus of tissue tightening.8,9 This
explains why, in my experience, the tissue
sagging that is commonly observed in a rapid
weight-loss process is not seen in those
successfully treated with Aqualyx.
CONTRAINDICATIONS
The contraindications to use are widely
known and common to all the adipocytolysis
injectable treatments. The side effect profile
is what is expected; the transitory effects of
the inflammatory sequalae in the skin are
experienced by almost all and patients need
to be counseled. Nodules are reported and
are in the main reversible; they have been
shown to be a consequence of inappropriate
injection technique and their frequency
was inversely proportional to the treating
physician’s experience.3
Submental fat may re-accumulate
following the procedure as the neighbouring
unaffected fat cells can expand to fill the gap
created by treatment. Like liposuction, there
can be localised areas of depression. Skin
numbness and neuralgia can also be a side
effect. Lab and patient studies have shown
direct injury of the marginal mandibular
nerve (MMN) sheath with DC.10 It is presumed
this occurs because the myelin sheath is
predominantly lipid, so if the MMN is injured
an asymmetric smile is seen (as it supplies
the depressor labii inferioris muscle). In
my research of papers and personal
experience, this complication is transient
and resolves spontaneously.
Dysphagia and beard area alopecia
are also rare complications. There are
rare reports of skin and muscle necrosis.
Scientific studies show that the physiologic
concentrations of albumin or protein-rich
tissues will decrease the ability of DC to lyse
cells but does not make these cells immune
to apoptosis.11
In my three years of experience, I have
only seen two of the rarer complications.
One patient had hyperpigmentation and
Aesthetic Medicine 37
FAT-DISSOLVING INJECTIONS
Top: before, Bottom: after two sessions of Aqualyx. Treatment by Dr Maeve Kenningham
induration of the upper arm area that
persisted for 12 months and the other was
a temporary paralysis of the depressor
labii inferior that lasted seven weeks.
This complication occurred despite the
recommended placement of the product
1.5cm below the inferior border of the
mandible from the gonion to the menton.12
However, it has been described in the
literature that the nerve can be found up
to 4cm below the inferior border of the
mandible.8 In a Kybella trial, MMN paresis was
identified as a possible complication but all
were transitory.13
CASE STUDY
Mr GH is a 39-year-old patient who was
concerned about submental fullness and lack
of jawline definition. He attended the gym four
times a week and his weight had stabilised
at 91kg, making his BMI 27.5. He had a good
diet and lifestyle. Over the years he has had
toxin and both HA and bio-stimulating fillers
(Ellansé). He grappled with insecurities about
his appearance and these treatments gave
him confidence to engage more freely in
social interactions. After a brief assessment,
we discussed all available options including
a targeted 5% weight loss through further
dieting or oral or injectable medication (off-
38 Aesthetic Medicine
license in his case), an attempt to improve
the definition of the jawline through further
treatment with Ellansé or with PDO/ PLLA/
PCL threads, a consideration of surgery
with liposuction and/or neck lift; or some
targeted adipocytolysis by the following
methods: cavitation by high-intensity
ultrasound, thermal damage through ablative
radiofrequency, cryolipolysis, laser diode
therapy or injectable adipocytolysis therapy.
He had been happy with filler in the past,
but he saw that there was heaviness and
hypertrophic adiposity in the submental
area. These changes are frequently the result
of ageing and weight gain but there is also a
genetic component. This jowled appearance
is further exacerbated by ptosis of the
unsupported skin with the downward pull of
the platysma muscle.1 He wanted to pursue
adipocytolysis with injectable therapy. We
could then visit defining the jawline with fillers
or threads at a later date if needed.
Assesment
When assessing patients for adipocytolysis
with injectable therapy, I manipulate the
area to ascertain if it is adipose tissue and
determine the thickness. If the area is thick
there appears to be less risk of unsightly
induration of the skin. I do a medical
July/August 2021

assessment and exclude other causes of
fullness such as thyromegally and cervical
lymphadenopathy. I assess the skin for
abnormal scarring tendencies and other
contraindications and exclude these
patients from treatment. I discuss how many
treatments are most likely to produce good
results. We then go through the consent and
capacity process. I take a series of photos
to include the profile view of the face with
Frankfort plane parallel to the floor. I chart
the patient’s weight.
Treatment and results
I use an ANTT and a sterile dressing pack. I
add 0.2ml 1% lidocaine per vial as this aids my
patient’s comfort, and use three X 3ml luer lok
syringes with a 25G 70mm blunt cannula. The
cannula is inserted in the pre-platysmal fat.
Threads of 0.3-0.5ml per pass of product are
distributed as homogeneously as possible. I
trained in the use of lipolysis sharp cannulas
but found the bruising and haemosiderin
staining an unnecessary draw back. I now use
27/25G 70mm blunt cannulas. This also helps
in keeping my product in the low-resistance
adipose plane.
The procedure itself takes less than 10
minutes to perform and the patient will be
aware of heat and a burning sensation for
the next 12 hours. The adipocytolysis occurs
immediately on injection but the residual
inflammation may take time to settle. The
swelling tends to peak at day two to four
– cold packs are helpful – and can last for
six weeks, at which point I review to assess
whether another treatment is needed. Most
patients require two to four treatments in
the submental area. In this case, after two
sessions of Aqualyx we did not have to
proceed to further jawline sculpting as the
patient was very happy with the results. His
weight remained stable throughout.
aestheticmed.co.uk
RESULTS
The removal of fat cells will be permanent
with adipocytolysis no matter what product
is used. The resulting inflammation appears
to have a skin strengthening fibrosis that
further enhances the results.8,9 However, if
weight is gained the neighbouring untreated
adipocytes enlarge and fill the void left. I
have a few patients who have had another
submental treatment 18 months after their
initial course and their results improve
again without problems.
In my experience Aqualyx is a relatively
safe and efficacious treatment for the
reduction of submental fat. I look forward to
comparing it to Belkyra when it appears on
the UK market.
REFERENCES
1. The Anatomy of the Aging Face: Volume Loss and
Changes in 3-Dimensional Topography. Sydney R.
Coleman, MD, Rajiv Grover, BSc, MB BS, MD, FRCS
(Plast) Author Notes. Aesthetic Surgery Journal,
Volume 26, Issue 1_Supplement, January 2006, Pages
S4–S9, https://doi.org/10.1016/j.asj.2005.09.012
2. Rauso R, Rusciani A, Curinga G. An adipocitolitic
aqueous micro- gelatinous solution for buffalo
hump deformity reduction. J Drugs Dermatol.
2014;13:1282–1284.
3. Pinto H, Hernandez C, Turra C, et al. Evaluation of a
new adipocytolytic solution: adverse effects and
their relation- ship with the number of vials injected. J
Drugs Dermatol. 2014;13:1451–1455.
4. Rauso R, Salti G. A CE-marked drug used for localized
adiposity reduction: a 4-year experience. Aesthet
Surg J. 2015;35:850–857.
5: Comments on “Injection Lipolysis With
Phosphatidylcholine and Deoxycholate” Giovanni
Salti, MD, Raffaele Rauso, MD Aesthetic Surgery
Journal, Volume 34, Issue 4, May 2014, Pages
639–640, https://doi.org/10.1177/1090820X14528506
Published: 01 May 2014
6. Duncan D, Rotunda AM. Injectable therapies for
localized fat loss: state of the art, clinics in plastic
surgery. Clin Plast Surg. 2011;38:489 501.[PubMed]
[Google Scholar]
7. Saedi N, Rotunda AM, Dover JS. Injectable fat-
CLINICAL
reducing therapies: fat reduction. In: Orringer JS,
Murad A, Dover JS, editors. Body Shaping, Skin Fat
and Cellulite: Procedures in Cosmetic Dermatology
Series. Vol. 91 2014. [Google Scholar]
8. Plast Reconstr Surg Glob Open. 2016 Dec; 4(12
Suppl): e1155. Published online 2016 Dec 14.
doi: 10.1097/GOX.0000000000001155 PMCID:
PMC5172481 PMID: 28018773 Ava T. Shamban, MD
9. Pereira JX, Cavalcante Y, Wanzeler de Oliveira R. The
role of inflammation in adipocytolytic nonsurgical
esthetic procedures for body contouring. Clin Cosmet
Investig Dermatol. 2017;10:57-66
https://doi.org/10.2147/CCID.S125580
10. Deoxycholic Acid and the Marginal Mandibular
Nerve: A Cadaver Study June 2018. Aesthetic Plastic
Surgery 42(Suppl 1) DOI:10.1007/s00266-018-
1164-4
11. Thuangtong R…Tissue selective effects of injected
deoxycholate Dermatol Surg. 2010; 366: 899 - 908
12. Novel Expanded Safe Zone for Reduction of
Submental Fullness with ATX-101 Injection.
Shridharani, Sachin M. M.D.; Chandawarkar, Akash A.
M.D. Author Information . Plastic and Reconstructive
Surgery: December 2019 - Volume 144 - Issue 6 - p
995e-1001e doi: 10.1097/PRS.0000000000006299
13. Kythera Biopharmaceuticals, Inc. Dermatologic
and ophthalmic drugs advisory committee briefing
document: ATX-101 (deoxycholic acid) injection.
Aesthetic Medicine 39
8-9 JULY 2021

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EXHIBITION | CONFERENCES | BUSINESS WORKSHOPS | DEMO THEATRE

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Entrance policy: The show is open to doctors, dentists, nurses, medical professionals and qualified aesthetic practitioners.
Face masks will be mandatory inside the venue at all times. Entry without a face mask or covering will not be permitted.
Strictly no persons under the ages of 18 will be admitted. Event helpline: +44 (0) 344 443 4413.
8-9 JULY 2021

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Entrance policy: The show is open to doctors, dentists, nurses, medical professionals and qualified aesthetic practitioners.
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 BELIEVE IN THE
POWER OF SEEING.
Ultherapy® is the only FDA cleared microfocused ultrasound technology
that has real time visualisation (MFU-V).1,2
Real-time visualisation, enabling For more information
treatment customisation, precision targeting of tissues,
and optimised patient outcomes 3 visit Ultherapy.co.uk
FDA-cleared and CE-marked so you can be @merzaesthetics.uki
confident of Ultherapy®’s good safety profile1
Merz Aesthetics UK & Ireland
The Gold Standard for non-surgical lifting
and skin tightening, as determined by
an expert consensus panel3

REAL-TIME VISUALISATION
1

REFERENCES:
1. www.accessdata.fda.gov/cdrh_docs/pdf13/k134032.pdf Accessed September 2019 2. Ulthera release:
Ultherapy® décolletage treatment now FDA-cleared. BioSpace website. https://www.biospace.com/
article/releases/ulthera-release-ultherapy-and-0174-d%C3%A9colletage-treatment-now-fda-cleared-/.
Accessed January 21, 2020. 3. Fabi SG, Joseph J, Sevi J, Green JB, Peterson JD. Optimizing patient
outcomes by customizing treatment with microfocused ultrasound with visualization: gold standard
consensus guidelines from an expert panel. J Drugs Dermatol. 2019;18(5):426-432
Adverse events should be reported. Reporting forms and information for United Kingdom
can be found at www.mhra.gov.uk/yellowcard. Reporting forms and information for
Republic of Ireland can be found at https://www.hpra.ie/homepage/about-us/report-an-
issue/mdiur. Adverse events should also be reported to Merz Pharma UK Ltd at the address
above or by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143.

Refer to the Instructions for Use (IFU) for complete instructions on operating the Ultherapy® System
The non-invasive Ultherapy® procedure is U.S. FDA-cleared to lift skin on the neck, on the eyebrow and under the chin as well as to improve lines and wrinkles on the décolleté.
The CE Mark indications for use for the Ulthera® System include non-invasive dermatological sculpting and lifting of the dermis on the upper face, lower face, neck and décolleté.
Reported adverse events from postmarketing surveillance are available in the Instructions for Use (IFU ). Please see the available IFU in your country for product and safety
information, including a full list of these events. © 2018 Ulthera, Inc. The Merz Aesthetics logo is a registered trademark of Merz Pharma GmbH & Co. Ulthera, Ultherapy, DeepSEE, SEE
THE BEAUTY OF SOUND and the Ultherapy logo are trademarks or registered trademarks of Ulthera, Inc., in the U .S. and /or certain foreign countries.

Merz Pharma UK Ltd. Ground Floor Suite B, Breakspear Park, Hemel Hempstead, Hertfordshire HP2 4TZ Tel: +44 (0) 333 200 4140
M-ULT-UKI-0988 Date of Preparation June 2021
 CLINICAL

Warning
signs
Aesthetic doctor Dr Ana Mansouri examines the
epidemiology, risk factors, diagnosis, treatment
and prevention of malignant melanoma

DR ANA MANSOURI
Dr Ana Mansouri is an aesthetic doctor at Kat & Co in Birmingham. She has a Bachelor
of Medicine & Bachelor of Surgery from Newcastle University Medical School and
has completed a postgraduate diploma in Clinical Dermatology with Queen Mary
University London. She is a member of the British Association of Dermatology (BAD),
British Society for Dermatological Surgery (BSDS) and British Society of Aesthetic
Examiners and Assessors (BSAEA). Follow her on Instagram: @doctor__ana

aestheticmed.co.uk Aesthetic Medicine 45

MALIGNANT MELANOMA

rimary cutaneous melanoma or malignant melanoma Greatly increased High risk Low risk

P (MM) is an increasingly common malignant tumour

arising from cutaneous melanocytes. MM is an
uncommon cancer in the UK (≈4% of all new cancer
risk (over 10-fold):
Presence of giant
(≈8-10-fold):
Above average mole
(≈2-3-fold):
Any family history
diagnoses).1 It has extremely high mortality, with over 2,000 deaths congenital pigmented count (>100) of MM
across the UK in 20111 and subsequently, a significant impact on the hairy neavus*
years of life lost in view of its occurrence in young people.2 Personal history ≥2 Atypical moles** High density freckles
of MM
EPIDEMIOLOGY
MM occurs most frequently in fair-skinned individuals and is more Family history of MM Immunosuppression Red hair or blonde
common in women. Mean age of onset is 50 but ≈20% of patients are (≥2 cases in first such as organ hair, blue eyes,
young adults.2 The lifetime risk was estimated 1:120 for women and degree relatives) transplant recipients sun-sensitive skin
1:150 for men in 2010 in the UK.2 The incidence varies greatly among Table 1. Phenotypic risk factors for malignant melanoma.2,4,3
countries; MM is the 15th most common cancer worldwide.3 *diameter of 20 cm and 5% of body surface area
**2% of the UK population have this phenotype
RISK FACTORS
The incidence of MM correlates closely with latitude and the
causation of sun exposure in the development of MM is well MAPK pathway Gene alterations in MM:
documented.2 UV light is the main environmental risk factor. Intense signaling molecules:
and intermittent UV exposure is associated with higher risks in
contrast to chronic sun exposure. Exposure to over five episodes •RAS • CDKN2A
of sunburn during childhood or adolescence leads to a two-fold • RAF • CDK4
increased risk of developing MM. This also applies to sunbed users
and psoriasis patients receiving UVA phototherapy.3 • MEK • MC1R
• ERK • BRAF
AETIOLOGY
The majority of precursor melanocytes which develop into a benign • p16/ARF
nevus and subsequently into an atypical nevus will regress, however Table 2. Examples of signalling molecules and gene alternation involved in the
some undergo malignant transformation into MM.2 malignant transformation of melanocytes.3
The pathway where normal melanocytes undergo melanogenesis
is not yet fully understood.3 Major advances in the past decade have
identified new predisposing gene alterations. The process is believed
to rely on a complex interaction between environmental UV-exposure
in combination with endogenous triggers (tumour-intrinsic and
immune-mediated factors).3 37-50% of MM carry a mutation in the
BRAF gene, the majority is the V600E type. BRAF mutation leads to Figure 1. The malignant transformation of MM; only 20-50% of MM develop
unregulated activation of the mitogen-activated protein kinase (MAPK) on a pre-existing nevus, a significant number of MM develop de novo.2,3
pathway which is exhibited in up to 90% of MM cases. Activation of
MAPK and thus RAS protein activation stimulates RAF (including BRAF)
and subsequently MEK and ERK kinase phosphorylation. This process
leads to cell cycle deregulation and inhibition of apoptosis.3
Xeroderma pigmentosum is a genetic disease where the DNA
excision system is dysfunctional hence leading to a predisposition to
MM. The familial atypical multiple mole-melanoma syndrome and its
variant, the melanoma-astrocytoma syndrome has been associated
with germline mutations in the high-penetrance melanoma genes
CDKN2A or p16 and mutations in CDK4.3

DIAGNOSIS
Early diagnosis is essential due to MM’s typically slow early growth rate,
as this may allow for detection and removal of curable lesions, hence a
reduction in likeliness of mortality.2,4
Figure 2. Malignant transformation of the melanocyte through the two
Clinical features processes of mutations affecting proto-oncogene/tumor suppressor genes
Most cases of MM are asymptomatic, however some patients (TP53, NF1, PTEN) and the BRAFV600E mutation which may undergo further
experience pruritus, tingling or bleeding. These features are rarely UV mediated mutation (TERT and CDKN2A).3

46 Aesthetic Medicine July/August 2021

 CLINICAL

Type of MM: Clinical features:

Superficial spreading melanoma (SSMM)
Nodular melanoma
Lentigo maligna melanoma (LMM)
Acral lentiginous melanomas (ALM)
• Most common type – approximately 70% of cases
• Initially slow growing and develop horizontally (curable stage)
• Later acquire potential for invasion
• Up to 50% demonstrate BRAF mutations.
• Most common on sun-exposed areas (head and neck) and in older patients
• Presents as a rapidly enlarging lump typically over weeks to months
• Vertical growth phase
• One third are amelanotic
• May be ulcerated.
• Commonly presents on skin with a history of chronic sun exposure and in individuals over 60 years of age
• Precursor pigmented macule - in situ lentigo maligna (LM) or Hutchinson’s freckle.
• Initially slow growing lesion or changing patch of discoloured skin
• Later rapidly becomes invasive.
• Rarest subtype, approximately 2% of cases
• Seen in patients with African American skin types
• Aetiologically unrelated to sun exposure
• Occur on soles, palms as initially slowly enlarging flat patch of smooth discoloured skin
• Later becomes thicker with an irregular surface
• Subungual lesions often present as narrow pigmented band in the nail, which slowly widens and ultimately
produces a mass.

Table 3. Clinical subtypes of Malignant Melanoma.1,2,5

helpful in diagnosis as they commonly occur in benign moles.2 Major features (2 points): Minor features (1 point):
The majority of MM in the UK occur in the lower legs in women and on
the back in men. Head and neck lesions commonly occur in people Change in size of lesion Inflammation
with chronic sun exposure.2 Irregular pigmentation Pruritus or altered sensation
MM can be classified into the four most commonly occurring
clinical subtypes as per Table 3. Irregular border/contour Lesion larger than others or
Atypical moles and melanoma in situ are considered pre-malignant diameter >7mm
lesions and often show marked variation in shape and colour and may Oozing or crusting lesion
have an inflamed appearance.1,2 It is important to note that MM can
rarely arise from any melanocytic origin including gastrointestinal tract, Table 4. The Glasgow 7-Point Checklist system. Referral to secondary care is
ears and eyes, oral and genital mucosa as well as leptomeninges.1 recommended for a lesion with the presence of any major feature or a lesion
scoring at least three points. The presence of minor features should
Clinical assessment tools increase suspicion.1,6
A number of assessment tools are used to identify high-risk lesions.
The Glasgow 7-Point Checklist outlines minor and major
clinical features as per Table 4. The ABCDE rule is another commonly A Geometrical ASSYMETRY in two areas
used tool for early detection of MM as per Table 5.
These tools are considered more sensitive than specific; however, B Irregular BORDER
they may be less accurate in identifying nodular and amenlanocytic C At least two different COLOURS in lesion
subtypes.4 The “ugly duckling” sign may be more useful in these cases
whereby the melanoma can be recognised as an “outlier”. It is also D Maximum DIAMETER >6mm
important to note the majority of MM cases develop de novo.1,6 It is E EVOLUTION/change in lesion
well documented that some melanomas will have no major features,
the cue in identifying MM may therefore lie only in the history.2,6 Table 5. The ABCDE rule of diagnosing melanoma. The presence of any feature
is an indicator for referral.1,2,4,6
Referral
Any suspicious lesion should be referred for local specialist MDT
input, in particular any individual classed at high risk (see Table
1).1,2,4 A moley patient should be referred for a 13-week specialist

aestheticmed.co.uk Aesthetic Medicine 47

MALIGNANT MELANOMA

assessment including risk estimation and Clinical features of suspected MM:

patient education.2
Dermatoscopy
Dermatoscopy is a useful tool in
assessment and monitoring of atypical
melanocytic lesions as well as in
improving early detection of MM as it can
increase diagnostic accuracy in the use
of trained clinicians.4
Differential diagnosis
The differentials of the MM diagnosis
include a wide range of conditions as per
Table 8. Subungual MM may in particular
be misdiagnosed as a fungal infection or
pyogenic granuloma.1
• A new mole which is growing quickly over the age of puberty
• A long-standing mole which is changing progressively in shape, size or
colour at any age
• Any mole which has three or more colours or has lost its symmetry
• Any new nodule which is growing and is pigmented or vascular
in appearance
• A new pigmented line in a nail
• Something growing under a nail
• A mole which has changed in appearance and which is also itching
or bleeding
• Any new persistent skin lesion especially if growing, pigmented or
vascular in appearance, and if the diagnosis is not clear.
Table 6. Indications for urgent two-week referral to local specialist
MDT assessment.1,2,4

Histopathology SSMM: Lentigo Nodular Acral Amelanocytic

Histological classification and risk maligna melanoma: lentiginous melanoma:
calculation determine subsequent melanoma: melanoma:
treatment options.
• Irregular • Asymmetrical • Isolated • Irregular • Low level focal,
Staging pigment shape globules structures peripheral
Breslow thickness is measured as network • Irregular • Blue-grey veil and pigment and irregular
millimeters of depth from the granular layer rhomboidal • White streaks network pigmentation,
of the epidermis to the deepest part of • Radiating structures • Irregular linear/ • Assymtrical • Linear, dotted,
the tumour. This describes the anatomical peripheral • Pigmented dotted vessels shape corkscrew or
streaks follicular • Broad parallel polymorphous
level of invasion and makes part of the
openings ridge pattern vessels
AJCC staging system (as per Table 11) as it
• Slate grey dots
correlates strongly with survival.4
and globules
Pre-operative staging CT is
recommended for stages IIC and III in Table 7. Classical dermatoscopical features of MM subtypes.1,5
view of the higher likelihood of distant
metastases, whereas stage IV disease
should be imaged based on SSMDT SMM LMM NM ALM
outcome.4,6 Once melanoma has spread it
typically becomes life-threatening rapidly
and prognosis is therefore poor.4

TREATMENT
Local skin cancer MDTs should identify • Diffuse pagetoid • RGP pattern with • The RGP pattern •Similar pattern of
patients who would benefit from specialist pattern of RGP with epithelioid, spindle is absent RGP as LMM with
skin cancer MDT (SSMDT) evaluation such dominant type and uncommonly • The dominant cell the exception of
as advanced or metastatic MM and rare • Epithelioid cells dendritic cells. type in the VGP is hyperplastic RGP and
subtypes of MM.4,6 and dermis ranging Typically, atrophic epithelioid the variable frequency
from normal to epidermis • Desmoplasia, of regression
Surgical excision of primary melanoma hyperplastic • VGP with dominant neurotropism, • Lentiginous,
Suspected MM should undergo excision • Dominant type spindle and and regression are spindle, epithelioid
biopsy with a 2mm margin of normal skin to Epithelioid cells epithelioid cells uncommon or dendritic cells
confirm the diagnosis.4 Surgery is the only in the VGP, rarely • Desmoplasia, are found in RGP
curative treatment; wide local excision with with desmoplasia neurotropism and and spindle and
recommended margins (Table 13) is the and neurotropism. regression are epithelioid cells
mainstay of treatment to reduce the risk of Partial regression is common in VGP
loco-regional recurrence. The decision of common
appropriate margin will be determined in Table 10. The four main histological subtypes and their histological patterns.5

48 Aesthetic Medicine July/August 2021

 CLINICAL

STAGE PRIMARY TUMOUR LYMPH NODES (N) METASTASES (M)

(PT)
IA < 1 mm, no ulceration,
mitoses
< 1 mm)-2

IB < 1 mm, with ulceration

or mitoses ≥ 1 mm) -2
1.01–2 mm, no ulceration

IIA 1.01–2 mm, with

ulceration
2.01–4 mm, no
ulceration

IIB 2.01–4 mm, with

ulceration
> 4 mm, no ulceration

IIC > 4 mm, with ulceration

IIIA Any Breslow thickness, Micrometastases

no ulceration one to three nodes Figure 4. Therapeutic approaches for the
IIIB Any Breslow thickness, Micrometastases medical treatments for MM.3 Monoclonal
with ulceration one to three nodes antibodies improve the efficacy of the immune
system to identify and destroy malignant cells.
Any Breslow thickness, One to three Dabrafenib/vemurafenib: selective RAF inhibitors;
no ulceration palpable metastatic Cobimetinib/rametinib: selective MEK inhibitors;
nodes Ipilimumab: monoclonal antibody IgG1k anti-
Any Breslow thickness, CTLA-4; Nivolumab/pembrolizumab are PD-1
No nodes, but
no ulceration monoclonal antibodies IgG4 and IgG4k anti-PD-1.
in-transit or satellite
metastasis ⁄es
IIIC Any Breslow thickness, Up to three palpable
with ulceration lymph nodes
Any Breslow thickness, Four or more nodes
with or without or matted nodes or
ulceration
in-transit disease +
lymph nodes
Any Breslow thickness, No nodes, but
with ulceration in-transit or satellite
metastasis ⁄es
IV, Skin, subcutaneous
M1A or distant nodal
disease
IV, Lung metastases
M1B
IV, All other sites or
M1C any other sites of
metastases with
raised lactate
dehydrogenase
Table 11. The 2009 American Joint Committee (AJCC) Cancer staging system for MM expressed as TNM.
Thickness measured using the Breslow system.4

aestheticmed.co.uk Aesthetic Medicine 49

MALIGNANT MELANOMA

MDT with consideration of functional and Benign: Pre-malignant or malignant:

cosmetic. The histology should be reviewed
again following WLE to ensure adequacy • Seborrhoeic keratosis • Dysplastic naevi
of excision.4,6 • Benign melanocytic naevi • Squamous cell carcinoma
• Blue naevi • Pigmented basal cell carcinoma
Lymph node management • Vascular lesions such as • Pigmented actinic keratosis
The presence of nodal involvement is spider angiomas and pyogenic
the most important clinical predictor of granulomas
prognosis. Patients with primary melanoma Table 8. Differential diagnoses of MM.1
of stage IB-IIC with Breslow thickness
>1mm should be referred to SSMDT if this
provides a SLNB service for the purpose Poor prognostic markers Favourable markers
of contributing to the staging process.4,6
Radical dissection of the entire lymph • Increased tumour depth (Breslow thickness) • Purely desmoplastic
node basin is now only indicated where • Presence of ulceration
metastases is confirmed. Patients needs • Vertical growth phase
to be counselled carefully on the risks and • Increased mitotic count
benefits of this in view of a lack in good • Vascular or lymphatic infiltration
quality evidence for its effect on survival.6 • Perineural infiltration
• Microsatellites
Advanced and unresectable melanoma Table 12. Prognostic histological markers for MM.4
Treatment for all advanced cases of MM
or loco-regional recurrence should be
evaluated by SSMDT. Options are generally Breslow thickness Excision margin
palliative in nature and include surgical
excision, CO2 laser or isolated limb infusion In situ 5mm (complete histological
or perfusion.4 excision)
The benefits for radio and chemotherapy <1mm 1cm
are limited. Radiotherapy may be
considered in cases of doubt of the 1.01-2mm 1-2cm
adequacy of surgery following recurrence 2.1-4mm 2-3cm
or concerns regarding the feasibility of
salvage surgery.4 Chemotherapy may be >4mm 3cm
indicated for patients otherwise unsuitable Table 13. Recommended margins for wide local excision as recommended by
for targeted treatments, metastatic cases the BAD guidelines 2010.4 Thickness measured using the Breslow system.4
or disease progression despite surgery
or laser. Adjuvant chemotherapy lacks
evidence in regard to survival benefit.4 Therapy: Mode of action Description Candidates Examples

New treatments Targeted BRAF inhibitors Inhibit mutated patients with Vemurafenib
Significant progress in the biological therapy RAF protein V600E mutation Dabrefenib
understanding of MM during the last decade
has contributed to the development of new MEK inhibitors Inhibit in BRAF mutation Trametinib
targeted treatment options for advanced upregulated MEK
MM. This includes BRAF inhibitors as Immunotherapy CTLA-4 inhibitors Inhibition of Patients with no Ipilimumab
single agents, or in combination with a other aspects of BRAF mutation
MEK inhibitor as well as novel single or the carcinogenic or failed BRAF
combinational agent immunotherapies.6 pathway which in inhibition
These recent advances have improved turns increases
outcomes for advanced stage MM patients the likelihood of
significantly although the immunotherapies cancer cells T-cell
are associated with severe complications targeting
such as autoimmune toxicity. All patients
with advanced MM should therefore be PD-1 inhibitors Pembrolizumab,
tested for BRAF mutations and discussed Nivolumab
in SMDT.6 Table 14. New treatment modalities for MM3,4,6

50 Aesthetic Medicine July/August 2021


Alternative treatments
A number of complementary and
alternative medicine treatments are
available for MM including nutrition therapy,
neuropathic medicine, herbal medications,
acupuncture and acupressure,
hydrotherapy and meditation.7 The
evidence base to support their use
is sparse.
PREVENTION AND FOLLOW-UP
The general public – in particular, children
– should be advised to avoid sunburn.
Patients identified at risk of MM are advised
of life-long sun avoidance. This should be
targeted to patients particularly at risk (see
Table 1) in view of the suggested role of
vitamin D deficiency in the prevention of
other types of cancer as well as for general
health. At-risk patients should be advised
to supplement Vitamin D.2,4 Patients at high
risk should be referred for risk assessment
and education including monthly self-
examination1,2 but regular follow up is
not required.4
Patients at greatly increased risk should
receive life-long follow-ups by a specialist
due to the risk of malignant change.4
Psychosocial factors
The psychosocial implications of MM often
significantly affect patients’ and families’
quality of life. The prevalence of anxiety and
depression in skin cancer patients
has been reported at between 11-
23%. A holistic needs assessment is
recommended at each point in the journey
to identify particularly vulnerable patient
groups. The specialist MDT can be a useful
resource in identifying vulnerable patients
as well as facilitating referral to local
support services.8
MM is an important condition with
increasing incidence and high burden on
years of life lost. The importance of
patient education, prevention of risk factors
and early recognition of suspicious lesions
is therefore great. Recent breakthroughs
of MM’s complex molecular aetiology has
thankfully lead to the development of new
therapies which have improved the outlook
for advanced MM. Mapping of further
genotypes is under investigation which is
promising for the future of MM.
aestheticmed.co.uk
CLINICAL
STAGE FOLLOW UP PATIENT IMAGING
IN SITU MELANOMA None required
IA 3-4 monthly for a year Self-examination
IB - IIIA 3-4 monthly for three
years  6 monthly
for two years
IIIB AND ABOVE 3-4 monthly for three
years  6 monthly
for two years 12
monthly for five years
IIC AND ABOVE Pet CT 6 monthly for
three years and 12
monthly for two
further years
Table 15. BAD guidelines for follow-up of MM patients.4
Psycho-social implications of MM:
• Distressing emotions at time of diagnosis
• Sun exposure anxiety
• Concerns regarding change in appearance disfigurement
• Negative beliefs about skin cancer
• Passive/avoidant coping style,
• Lack of social support
• Concerns about implications on self and others
• Concerns about ability to detect recurrence or anxiety
around recurrence
• Mental health problems pre-existing the cancer diagnosis
• Inability to resume to previous activities, roles and responsibilities
• Anxiety around being discharged from a specialist service
• Hopelessness, sadness and concerns about the future and uncertainty
• Initiation of palliative care, death and bereavement
• Reduction in emotional functioning and quality of life
Table 16. Psychosocial factors to consider when assessing patients with MM.8
REFERENCES
1. McCourt C, Dolan O, Gormley G. Malignant 5. www.dermnetnz.org (Accessed on 10th February
melanoma: a pictorial review. Ulster Med J. 2019 and 19th February 2019).
2014;83(2):103-10. 6. Brown ESR, Fraser SJ, Quaba O, Simms A, Stein A.
2. Royal College of Physicians and British Association Clinical Cutaneous melanoma: an updated SIGN
of Dermatologists. The prevention, diagnosis, referral guideline. Journal of the Royal College of Physicians
and management of melanoma of the skin: concise of Edinburgh. 2017;47(3); 214-217.
guidelines. Concise guidance to good practice series, 7. https://www.healthline.com/health/melanoma-
No 7. London: RCP, 2007. alternative-treatments#alternative-treatments
3. Leonardi GC, Falzone L, Salemi R, et al. Cutaneous (Accessed 1st February 2019).
melanoma: From pathogenesis to therapy (Review). 8. Hansen E. London Cancer North and East:
Int J Oncol. 2018;52(4):1071-1080. Psychosocial support for adult skin cancer patients.
4. Marsden JR, Newton-Bishop JA, Burrows L et al. 2013. www.londoncancer.org/media/76385/london-
BAD Revised U.K. guidelines for the management of cancer-skin-psychosocial-support-guidelines-2013-
cutaneous melanoma 2010. Br J British Journal of v1.0.pdf
Dermatology. 2010; 238–56.
Aesthetic Medicine 51
COMMERCIAL FEATURE
Turn down
the
volume
Emma Chan shares how her lip treatments have
evolved in her 14 years in practice
ike many of the patients I see
L in my practice today, I was
first attracted to what could
be achieved with aesthetic
treatments when I started researching
them for myself back in 2007, ahead of my
upcoming wedding.
At the time, I was working as an advanced
nurse practitioner in A&E, having just done
my Master’s in Advanced Practice, and the
parts of my role which I enjoyed the most
were the practical parts. In A&E there were
plenty of opportunities for me to work with my
hands, suturing and putting drains in, etc. My
husband was an NHS hospital consultant and
I knew that two of us working shifts wouldn‘t
work if we were to have a family. Aesthetics
brought together all my interests and it felt like
the right time to look at training.
THE CHANGING FACE OF LIPS
Back when I first started in aesthetics, we
didn’t have the conferences and the journals
that we have today. We didn’t even have a
rep for the major brands for the whole of the
North West of England, so you were only really
introduced to and guided towards products
through your basic training. Dermal fillers
are one of the main stays of any aesthetic
practice, and lip treatments have continued
to grow in popularity since I first started.
Product selection is absolutely key, not
only for natural outcomes but also for safety
and efficacy. It was always important to me
to stick to products from the market leaders
that had plenty of clinical data. As my practice
grew along with the industry, there was more
opportunity for me to look at other products
that I became aware of through going
to conferences.
I was already using some of the Merz
Aesthetics portfolio but the big game changer
for me was the introduction of BELOTERO®
Lips Shape1 and BELOTERO® Lips Contour2
52 Aesthetic Medicine
into my practice. They really revolutionised
the way I market to and treat patients
presenting for lip enhancement.
In the past, across most brands, products
were only available in 0.5ml or 1ml syringes.
This undoubtedly influenced the industry and
our patients. Demands and pricing became
focused on volume treatments rather than
the individual need of the patient. Patients
even started requesting a 0.5ml or 1ml lip
treatment, rather than presenting with a
desire for a particular improvement or result.
The BELOTERO® Lips Shape1 and Lips
Contour2 products are presented in a 0.6ml
syringe. BELOTERO® Lips Shape1 is perfect for
volume enhancement or correcting volume
loss in the ageing lip, while BELOTERO® Lips
Contour2 is a much more cohesive product,
ideal for treatment of the vermillion border
and perioral lines.
Over the past couple of years, I have
witnessed changing trends – a move away
from the over-enhanced lip, an increased
desire and demand for natural enhancement
and correction of overfilled lips. This
pattern has been seen across all age groups,
with younger patients seeking a natural
enhancement and older patients seeking
restoration. This observation, along with
the timely launch of the BELOTERO® Lips
products, prompted me to change the way
I market and deliver lip treatments in my
practice, and gave me an opportunity to move
away from volume-focused treatments and
offer something different.
The Lip Duo treatment was created as an
alternative to the 0.5ml or 1ml treatment.
Utilising the BELOTERO® Lips Shape1 and
Contour2 0.6ml products, I was able to
combine the properties of fine line and
volumising fillers. This gave me flexibility
to treat a range of deficiencies as well as
to beautify the central lower face and lips.
Treatments are priced accordingly, slightly
more than a 1ml treatment, but also deliver far
superior results. Both Lips products benefit
from the use of Cohesive Polydensified
Matrix® (CPM) technology3, a combination
of high and low-density zones that allows
BELOTERO® products to “mimic”
tissue behaviour.
The low density features of BELOTERO®
Lips Contour2 ensures optimal dermal
integration4, which makes it ideal for the
vermillion border and perioral wrinkles. The
cohesivity helps prevent the undesirable
migration of product from the vermillion
border into the white lip. In contrast, Lips
Shape is highly elastic to support tissue with
an amazing ability to resist shear stress and
return to its original shape. These rheological
properties are ideal in a highly dynamic area.
A common presentation to an aesthetic
clinic is the desire to enhance lip volume and
create and improve the lip outline and Cupid’s
bow. In addition, in ageing lips, refining perioral
wrinkles is also a common request. To treat
the presenting concerns, products with varied
rheology are required to achieve optimal
results. This could be costly for patients and
for the clinic, especially if only a small amount
of a specific product was required. There has
certainly been a temptation to try to make a
single product fit the patient’s needs in order
to come in on budget, and I have seen the
undesirable results of this first hand.
A CASE STUDY WITH BELOTERO® LIPS
SHAPE1 AND CONTOUR2
The patient presented to clinic requesting
enhancement of the lips. No previous dermal
filler treatment had been performed. On
assessment, it was clear that enhancing the
lips in isolation would not achieve best results.
In fact, it was felt that it may even further
highlight areas of deficiency. Following a
consultation and analysis with the patient, a
tailored approach was delivered.
July/August 2021

Top: before, Bottom: after
ASSESSMENT
There was volume loss to the upper white lip
marionette region and the development of
nasolabial folds was creating shadows and
uneven transitions. There was also loss of
volume and proportion, in particular in
the lower lateral lip as well as dynamic
perioral lines.
TREATMENT PLAN
1. To restore volume to the white upper
lip and improve contours on the lateral
aspects as well as the commonly seen
vertical lines of tissue weakness from the oral
commissures.
2. To define the lip border, creating a sharp
lip outline and Cupid’s bow.
3. To improve lip proportion by volumising
the lip body, with particular attention to the
lower lip.
4. To improve the nasolabial and
marionette region.
TREATMENT
BELOTERO® Lips Contour2 was used in the
upper white lip, vermillion border, upper lip
body and oral commissures, with a total of
0.6ml used. BELOTERO® Lips Shape1 was
used in the lower lip, inferior nasolabial lines
and marionette region, with a total of 0.6ml.
RESULTS
Using a combination of products enabled
me to achieve improvement in multiple
areas of the central lower face. The lips
have now become a feature of the lower
aestheticmed.co.uk
Top: before, Bottom: after
face, with very little product used within
them. The treatment of the surrounding
areas of deficiency has removed shadows,
lifted the tissues and improved contours
and transitions, overall, delivering much
more than a “lip enhancement” with great
economy of product and a reasonable price
point for clients.
Additional benefits are the fantastic
before and afters achieved. This provides
great content to market the Lip Duo
Treatment with that is not comparable to a
traditional volume lip treatment. Educating
patients is also important to understand the
potentially undesirable results often seen
from using the wrong product in the wrong
place. For example, product migration and
distortion of the lip outline from the use of a
volumising lip filler into the vermillion border.
CONCLUSION
Product selection plays a key role in
providing natural-looking lip- filler
treatments. We must start to move away
from lip treatments which look unnatural and
overdone and towards those that enhance
our patients’ features, not overpower them.
Educating your patients about the safety,
tolerability, clinical evidence and efficacy
M-BEL-UKI-0963 Date of Preparation January 2021
This advertorial is sponsored by Merz Aesthetics UK & Ireland
For more information visit merz-aesthetics.co.uk, @merzaesthetics.uki on
Instagram or Merz Aesthetics UK & Ireland on Facebook
COMMERCIAL FEATURE
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of what is being injected into their lips is
paramount. The BELOTERO® Lip Duo
treatment offers us as nurse practitioners
an opportunity to re-educate our patients
and to put an end to the culture of them
requesting lip fillers by the ml. By using a
blend of products, lip filler treatments can
be tailored to individual patients for more
natural-looking results.
Those looking to gain more knowledge
of the products and techniques used
to achieve great results in the lip area
should take a look at the BELOTERO® Lips
Masterclass webinar from The Merz Medical
Institute. You can access the webinars at
merzwebinars.com.
REFERENCES
1. IFU – BELOTERO Lips Shape.
2. IFU – BELOTERO Lips Contour.
3. Sundaram & Fagien 2015 Cohesive
Polydensified Matirs Hyaluronic Acid for Fine
Lines. Plast Recon Surg. 136:149S, 2015
4. Micheels, P. et al. Effect of Different Crosslinking
Technologies on Hyaluronic Acid Behavior:
A Visual and Microscopic Study of Seven
Hyaluronic Acid Gels. J Drugs Dermatol. 2016
May 1;15(5):600-6
Aesthetic Medicine 53
SIGNATURE TREATMENTS

Personal

Top: before, Bottom: immediately after InclinEyes treatment

best
Dr Joshua Van der Aa gives an insight into the process
of creating a signature injectable treatment, and tells
us the story behind his own

DR JOSHUA VAN DER AA

Dr Joshua Van der Aa is an injection-focused cosmetic practitioner specialising in
rejuvenation of the peri-orbital area. He is a graduate of Leuven University’s Medical
School in Belgium. Before opening Dr Joshua Harley Street Aesthetics in 2020, he
worked in some of the best-known, award-winning clinics in London and Europe.
Follow him on Instagram: @drjoshualondon

eneration Z model and it-girl Bella Hadid has never visited my clinic, but her name

G is ever-present inside these four walls. For the past two years at least, the way her
eyes look has triggered more patient enquiries (both in person and via my inbox)
than perhaps any other external influence. She’s not the reason I set out to create
a new treatment technique, but on some subconscious level, her sway at the outset
is undeniable.

54 Aesthetic Medicine July/August 2021


Top: before, Bottom: immediately after InclinEyes+ treatment (addition of tear trough filler)
I launched my first signature treatment, InclinEyes, in May. It uses
dermal filler to achieve lifted brows, enhanced symmetry and subtly
elongated eyes. It was born out of a mix of concern from first-hand
observations in my clinic, and a fixation and determination to solve
a “puzzle”. It was becoming perplexing and troubling to be routinely
met with as many young female patients asking for “eyes like Bella”
as the number I had to counsel who had undergone unsuccessful
or unsightly “Bella” treatments elsewhere. “Can I undo it without
surgery?”, they would ask. I felt strongly there was a big need for a
safe, predictable and reproducible treatment to improve eye shape
and brow position. So, my task became to do this convincingly and
minus the surgical sutures.
THE FOX EYE TRAP
One of the biggest beauty misconceptions in circulation right now
is the belief that Bella Hadid has had a “fox-eye” thread lift. She’s
publicly denied it and I share in the opinion that her covetable eye
shape most likely results from a specific surgical brow lift and perhaps
a canthopexy, further emphasised at times by the application of
accentuating make-up. Nonetheless, the increasing popularity of
fox-eye thread lifts to achieve, non-surgically, the look that has social
media buzzing, means there is a large demand in the market for
treatments that can elevate the eyebrow position and elongate eyes.
Unfortunately, in my opinion, fox-eye threads not only over-
promise and under-deliver on results, but they can also come with
substantial risks. Personally, I don’t condone the fox-eyes thread lift
treatment; it can cause significant swelling and downtime and carries
risks such as scarring, visible threads, dimples, puckering of the skin
and long-lasting pain. From what I’ve seen, this type of threads rarely
last longer than two weeks to two months. Where brow thread lifting
is concerned, the risks far outweigh the rewards. Add to that, often,
aestheticmed.co.uk
CLINICAL
the treatment is overdone, sometimes giving the patient an alien-like
appearance, albeit very temporarily.
ANOTHER WAY
My starting point was literally to ponder whether there could be a way
to achieve that more open and winged-eye effect without any need
for forcibly hoisting the brow tail into unnatural angles. I began by
deconstructing the eye region to its natural anatomy and assessing
which parts needed to be augmented in which patients to achieve
optimal results. I studied the minimally invasive work of great plastic
surgeons and set about comparing this to the relevant local anatomy. It
made me believe that a certain improvement in the shape of the brow
and eye is achievable.
I’ve had a long-held fascination with treating the temples and
upper eyelids from a rejuvenation point of view, and over more than
12 months, I found a duplicable way that gently raises the brow tail by
adding volume, while also improving the appearance of the canthal
tilt, or inclination, of the eye, resulting in a more feminine, almond-
eye shape and a youthful, lifted brow. For this treatment, I found, it’s
a combination of addressing both bony volume deficit as well as
strategically optimising fullness in certain fat pads in the brow and
eyelid area.
It was at this point that InclinEyes was born and also when I realised
that I had to take my medical hat off and put on the business one. I’d
done the hard work, even given it a name, and now I had to promote it
and protect it if I was going to get it out there, which meant registering
the trademark. That’s not something that came naturally to me but,
for the benefit of fellow clinicians yet to attempt it, I can say I found it
relatively straightforward, albeit occasionally nail-biting. I began with
a search to confirm nobody else in our industry grouping was using
it. Then it was just a case of working my way, step-by-step, through
Aesthetic Medicine 55
SIGNATURE TREATMENTS
Top: before, Bottom: immediately after InclinEyes+ treatment (addition of tear trough filler)
the application process, a final review, and with nervous excitement,
clicking “submit”. Be prepared for a wait of about three months for the
trademark to be filed, during which time it can also be challenged. That
was the nerve-racking part.
EYES WIDE OPEN
As with most treatments, the InclinEyes process begins with careful
and considered selection of the patients; arriving at mutually agreeable
outcomes is always key, with the proviso from me that the end result
can only ever look natural, of course. The ideal candidates are patients
with generally sad, droopy or tired-looking eyes, with a heavy or hollow
appearance and minimal excess eyelid skin. Essentially though,
anyone who goes into this with the right expectations will benefit from
the treatment. I find that in older patients, with skin draped over the
eyelashes, a surgical intervention, such as upper eyelid correction, is
advisable first.
Using a cannula, I gently administer a soft, light hyaluronic-acid
product that integrates well in the delicate tissue around the eye area.
Teosyal by Teoxane is a good choice but I’m also trialling a couple more.
There are no toxins, threads or other devices used. – the treatment
consists entirely of filler. In a nutshell, what InclinEyes involves is
strategic volume optimisation of the periorbital bone and fatty tissue to
improve the appearance of the inclination of the brow and the canthal
tilt (the apparent tilt of the eye itself). To what extent this happens
is dependent on factors that vary from patient to patient, unique to
each face. The outcome is always a more youthful and lifted, open
and sensual look, which is arguably more credible and natural looking
because it’s less extreme than fox-eye threads. I couldn’t be more
delighted with the results so far and with patients’ reactions to them.
Unlike a brow lift with botulinum toxin that lasts three to four months,
InclinEyes lasts for 12. And unlike existing upper eyelid fillers, this – quite
56 Aesthetic Medicine
distinctly – repositions the brow tail and creates that more desirable
outer-eye slope. Crucially, it’s also safer because it’s fully reversible,
and this was a key motivator for me given that I see so many patients
stuck with tension and rippling from threads. Downtime is minimal;
often there’s none but in some cases it’s no more than a mild swelling
for about 10 days at most, which is so slight it wouldn’t be noticeable
to others. What’s more, because the treatment uses fillers exclusively,
and no toxin or threads, a safe, predictable and long-lasting effect
is achieved. In some cases, patients can also have a second or third
treatment, and after these additional treatments it’s not unusual to
have results that last for up to two years.
Alongside InclinEyes, I’ve introduced InclinEyes+, which includes
bespoke options adaptable to each face. In essence, this adds
affordable treatments for people who are suffering from volume loss in
the surrounding areas that act as scaffold to the eye area. If this is the
case, it’s important to address these at the same time to ensure optimal
results of the InclinEyes treatment itself. Usually, this is either in the
temple or tear trough regions.
LOOKING AHEAD
So, is InclinEyes the new “fox eyes”? In short, no. And neither would I
want it to be. I’d rather it was considered the elegant, safer and more
natural-looking alternative. After all, this procedure’s effect will work
somewhat differently with each individual face, and that’s the key. Like
many of my colleagues, I believe our role is not to promote a single
beauty ideal, encourage trends, or change or distort a face to look a
certain, prescribed way. It’s not about giving my patients eyes like Bella
Hadid’s, it’s about introducing them to a new opportunity to appear
refreshed, brighter and wider-eyed, if that’s what they want. I think less in
terms of lifting brows because I believe the most important thing I can
lift with my work as an aesthetic doctor is someone’s spirit.
July/August 2021
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LIP LIFTS

Lifelong
lift
Plastic and reconstructive surgeon
Mr Naveen Cavale on a permanent alternative
to lip filler – the lip lift

MR NAVEEN CAVALE
Mr Naveen Cavale is a plastic and reconstructive surgeon, currently a consultant at
King’s College Hospital London. He also operates privately from the Cadogan Clinic in
Sloane Square. He is the UK representative for the International Society of Aesthetic
Plastic Surgery (ISAPS) and president of the plastic surgery section of the Royal
Society of Medicine. He frequently visits Gaza to provide surgery to those affected by
blast and gunshot injuries. Follow him on Instagram: @realplastics

58 Aesthetic Medicine July/August 2021


he lip lift – a surgical procedure
T that involves shortening
the amount of skin on show
between the nose and the
mouth to make the upper lip look fuller and
lifted – is not a new procedure, but demand
has increased among my clients within the
last two years or so. [At the time of writing,
the hashtag “lip lift” has 14.6 million views
on TikTok]. It’s not one of my “signature”
procedures, yet I have definitely seen an
uplift in patients enquiring about it. I believe
the reasons for this are the same as to
why rhinoplasties have massively risen in
popularity over the last year, too. With us
spending a lot of time staring at a mirror
image of ourselves on video conferencing
calls and webinars, people may have noticed
things about themselves that previously
they wouldn’t have done. I think a secondary
reason for the lip lift’s rise in popularity is
that many people now want a more natural
enhancement for their lips, which the lip
lift procedure does very well. Lastly, it’s
permanent, so for someone who spends a lot
of money on fillers, and providing they’re the
right candidate for treatment, it can be a
great, cost-saving alternative in the long
run, as long as they get it done for the right
reasons. You’re also much more likely to get
a more natural-looking result with a lip lift
compared to injectables as the skin is pulled
up rather than pushed out.
It’s somewhat obvious but important to
point out that unlike injectables, this is a
permanent treatment. In select cases, a lip
lift can be performed on patients who have
previously received filler. Therefore, those
that have fillers regularly seem to be the
most interested in the procedure as this is
a permanent way to achieve a fuller-looking
upper lip, negating the need for further
regular injectables. If desired, patients are
able to receive filler after a lip lift, but I’d
always refer them to a specialist in lip filler,
as it would obviously be a more complex
treatment than usual.
SCULPTING SHAPE
My approach to this procedure is not about
volume, especially in the upper lip. Rather,
it is all about shape and proportions –
the lower lip is naturally larger than the
upper. Bad filler to the upper lip swaps this
relationship and can make things look quite
fake. Lip lifts are fantastic at improving
shape, proportion and perception; however,
careful patient selection is key. An example
of someone who wouldn’t be suitable is
a patient with a long upper lip where the
aestheticmed.co.uk
CLINICAL
mouth has a natural gape. This gape is very
attractive and tends to be desirable to
patients, but if it is already there, doing a
lip lift can increase it and make closing the
mouth difficult, making things look unnatural.
The lip lift is potentially suitable for a patient
with lax skin around the mouth, but as above,
patients suitable for this procedure have to
be very carefully selected. It won’t be right
for everyone.
During the procedure, a “bullhorn”-shaped
piece of skin is removed from just under
the nose. This can be done as skin only, and
it can also be combined with moving the
underlying muscle upwards as well (a “deep
plane” lip lift). A lip lift can be done under
local anaesthetic (unless the patient has real
objection to this, in which case it can be done
under general). The area to be removed will
be drawn up on the skin and we can pinch
the area to show the effect. The marked-up
skin is then removed. The operation takes
roughly 45 minutes to 1 hour.
LIFT OFF
The trickiest part of this operation is stitching
everything back together. We have to do this
in layers so it looks natural and use certain
techniques so it doesn’t pull down on the
nose. We almost never use just one layer
to close after surgery. Instead, we close the
different layers – muscle, fascial, deep skin,
and the outside skin layer. With a lip lift it will
be most common to close in two or three
layers. The outside layer will be closed with
non-dissolving stitches; everything inside
will tend to be dissolvable sutures. As this
procedure is most commonly performed
under local anaesthetic, patients can be out
of the operating room once the procedure
is finished. Stitches will need to be removed
after a week. I advise patients that they may
wish to take 10 days to two weeks off work as
downtime. Once the stitches are out and the
area is dry, the scar can be hidden
with concealer.
The main side effects seem to be mild
scabbing and swelling as the incision settles
down. Patients often recall the sensation
as a bit like having a thick lip – a similar
sensation as following dental work. Swelling
is usually completely gone after three weeks
and there is a risk of bruising following the
procedure. Again, it’ll usually disappear after
a couple of weeks. I normally advise patients
to drink from a straw for a couple of weeks
post-surgery, but other than that, it’s a fairly
straightforward procedure with minimal
downtime or impact on everyday life
during recovery.
Aesthetic Medicine 59
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60 Aesthetic Medicine
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July/August 2021

All
in one
Georgia Seago reviews the HydroFacial Plus
at 111 Harley Street
THE LOWDOWN
Cosmeceutical skincare brand 111SKIN gets its name from the
location of founder Dr Yannis Alexandrides’s plastic-surgery practice
in central London. Alongside face and body surgical procedures,
injectables, PRP, IV therapy, laser and more, clients can now
also visit for an advanced non-invasive, no-downtime facial with
HydroFacial Plus (not to be confused with HydraFacial).
Combining multiple modalities into one platform, the device uses
water-based hydrodynamic vortex technology to cleanse, exfoliate
and brighten the skin as a basic treatment, extracting deeply-lodged
impurities and hydrating the dermis. The suction created can also
be used to reduce water retention for mild lymphatic drainage, for
a temporarily more sculpted face. However, the device has several
add-on handpieces that allow aesthetic therapists to take the
treatment and its benefits for clients’ skin further. These include
oxygen infusion, cryo-heat, Bohr, ultrasound and multi-polar
radiofrequency. The treatment also allows multiple opportunities
for 111SKIN products to be layered and/or infused into the skin.
THE EXPERIENCE
I had my treatment with aesthetician Samia Vazir. We were also
doing some IPL for pigmentation at the same appointment, but
we started with the HydroFacial Plus. After talking about my skin
concerns (mainly dullness and blackheads) she first double-
cleansed with an exfoliating cleanser. Samia decided we’d do a
deep cleanse with the aqua vortex handpiece followed by Bohr
exfoliation with CO2 bubbles (which fizzes and foams on contact
aestheticmed.co.uk
TREATMENT REVIEW
with the skin) to bring oxygen-rich blood to the surface. Next, she
used the aqua vortex handpiece again to perform an aqua peel to
address my pores and blackheads, followed by the infusion action
to push a blend of topical growth factors into my skin to support its
repair, maintain protective functions and promote elasticity.
Samia then applied her favourite 111SKIN product, Celestial Black
Diamond Serum – formulated to improve firmness and elasticity,
address hyperpigmentation and brighten the skin – and passed over
my skin with the radiofrequency handpiece to increase penetration
and plump the skin. The last tech stage was a gentle massage
with the de-puffing cryo handpiece over the top of Y Theorem Bio
Cellulose full-face sheet mask and Celestial Black Diamond Eye
Mask, which sit under the eyes.
Finally, Samia applied Antioxidant Energising Essence followed by
Celestial Black Diamond Day Cream Light and Eye Cream, then
sun protection.
THE VERDICT
Even though my HydroFacial Plus treatment was completely
relaxing throughout, it’s a hardworking treatment that left my skin
plump, glowing and lifted. The ability to mix and match modalities
depending on what the client needs on that day sets this apart from
other similar platforms and negates the need for multiple different
devices in clinic. The treatment (or elements of it) can also be done
in combination with other more advanced skin procedures such
as laser, IPL and needling. It’s a great all-rounder for rough texture,
blackheads, dryness, dehydration and dullness.
Aesthetic Medicine 61
NEW PRODUCTS
111SKIN
The luxury cosmeceutical
skincare brand has reformulated
its Celestial Black Diamond
Neck & Décolletage Serum. Now
containing 111SKIN’s signature
diamond delivery system to
penetrate and treat the thin skin
on the neck and décolletage, the
serum is formulated to address sun
damage, dryness and dehydration.
It contains a peptide complex
to lift, firm and tone; lactic acid
to smooth skin texture and help
fade stubborn discolouration;
a moisture complex with
humectants and polysaccharides
to draw water to the dermal layer;
and NAC Y2, a blend of amino acids,
antioxidants and vasoprotectors
to help skin work at an optimised
function, neutralising free radicals
and brightening the area.
62 Aesthetic Medicine
Revision Skincare
DEJ Eye Cream from Revision
Skincare is billed as an all-in-
one eye treatment to combat
visible signs of ageing in the area.
Fomulated to address the upper
eyelid and create the appearance
of more lifted, firmer and smoother
skin, the cream utilises the brand’s
pathway technology and prebiotic
innovation. Key ingredients include
alpha-glucan oligosaccharide,
amino acid copper complex,
goji fruit extract, THD ascorbate
and palmitoyl tripeptide-38. The
cream also works to target sagging,
hooding and redness around the
eye area and shields against
free radicals.
Institute BCN
Spanish mesotherapy laboratory Institute BCN has
developed a skincare line called BCN Prebiotics.
The line comprises four products developed to
help restore the skin’s microbiome and maintain
the balance of the microbiota. Ideal for patients
who have recently undergone medical aesthetic
treatments, the products contain prebiotic active
ingredients along with highly moisturising, antioxidant
and anti-ageing ingredients such as hyaluronic acid,
sugars and natural moisturising factors, aloe vera and
avenanthramide. The products are: Balance Serum,
Shield Cream, Intense Repair Concentrate and
Scrub Exfoliator.
July/August 2021
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NEW PRODUCTS

Swissline
Swiss skincare brand Swissline has
launched in the UK with Skinbrands,
distributor of brands including
Medik8, Priori and Revitalash.
Swissline takes a biotech approach
to its products and formulations,
drawing on DNA research and natural
actives. Products include the Cell
Shock line of anti-ageing formulas
with bio-mimetic growth factors,
marine collagen, silk, gold and the
brand’s signature cellactel 2 complex.
The line comprises Luxe-lift Rich
Cream, 360° Anti-Wrinkle Serum,
Face Lifting Complex II, Facial
Boosting-Essence, Overnight Balm,
and more.

iS Clinical
New from iS Clinical is Liperfection Trio and Extreme Protect Duo. The
Liperfection Trio comprises three lip products to exfoliate, hydrate,
soften and plump the lips: Lip Polish, with sucrose, vitamin C and
cocoa butter; Youth Lip Elixir, containing antioxidant extremozymes,
vitamin C and cocoa butter; and Liprotect SPF 35, with transparent
zinc oxide dispersion, transparent titanium dioxide dispersion and
coconut oil. Meanwhile, the Extreme Protect Duo pairs Extreme
Protect SPF 40 – a tinted, water-resistant sunscreen with antioxidant
extremozyme technology – with Liprotect SPF 35.

Croma
Austrian pharma company Croma-Pharma
is introducing a new skincare brand to its
portfolio. Croma Farewell (“farewell to ageing
skin”, for example) will initially launch with five
hyaluronic acid-based serums, all containing
both high and low-molecular weight HA.
Irritated Skin is for sensitive skin and contains
madecassoside, niacinamide and D-panthenol
to soothe, reduce redness and strengthen
the skin’s barrier; and Puffy Eyes helps fight
the appearance of puffiness, dark circles and
crow’s feet with ash tree bark extract, organic
silicon and vitamin B3. Also available are Dry
Skin, Aging Skin and Oily Skin.

64 Aesthetic Medicine July/August 2021

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NEW PRODUCTS

HydraFacial
HydraFacial’s latest skincare partnership is
with cosmeceutical skincare brand Murad on
the Murad Retinol Booster. Designed for use
with the HydraFacial device to personalise the
treatment, the Booster helps accelerate skin
surface renewal, plumping to visibly reduce
the appearance of fine lines and wrinkles while
treating uneven skin tone and dullness. It
contains a patented retinol tri-active technology
for rapid action while being gentle on the skin,
making it suitable for all skin types
including sensitive.

Noon Aesthetics
There are two new cleansers in the
Noon Aesthetics cosmeceutical
skincare range, distributed by
Advanced Esthetics Solutions.
CosmoClear Cleanser is a
purifying and moisturising
cleanser that removes excess
oil and impurities from the skin.
It includes active ingredients
glycolic, lactic and salicylic
acids, along with moisturising
compounds and chamomile
Pollogen extract. Meanwhile, Micro-Soft
A new Oxypod treatment capsule is available for the Pollogen Cleanser is a microemulsion
Geneo+ device for advanced aesthetic facial treatments. The formula that is ideal for make-
Hydrate Oxypod with blue spirulina, niacinamide and lactobionic up removal. It contains organic
acid is formulated to revive dry, dull and dehydrated skin. The macadamia oil, rich in palmitoleic
active ingredients work together to hydrate skin and replenish its acid to contribute to healthy
moisture-retention abilities. They are stored in their suspended skin function. Other ingredients
state within the Oxypod and are activated only in reaction with include lavender floral water
Geneo+’s primer gel. and squalene.

Vivacy
French aesthetics brand Laboratories Vivacy has
launched the Vivacy Beauty clinical skincare range
to sit alongside its Stylage HA dermal fillers. The
products contain the brand’s vivasôme anti-ageing
complex, based on active encapsulation through
liposomes. These liposomes create a pathway
through the skin’s outer layers for optimal ingredient
penetration (sorbitol, stabilised vitamin C, hyaluronic
acid and mineral water from Treignac in France.
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66 Aesthetic Medicine July/August 2021

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FACETITE AND MORPHEUS8

Double
win
Dr Judy Todd tells us how she combined minimally
invasive liposuction with RF microneedling for
ultimate results with little downtime

DR JUDY TODD
Dr Judy Todd runs Synergy Clinic in Glasgow. She graduated from the University of
Glasgow Faculty of Medicine in 1995 and started her career in aesthetic medicine
in 2005. She is also a consultant anaesthetist with the NHS and a Fellow of the
Royal College of Anaesthetists. Follow her on Instagram: @dr_judy_todd

CONSULTATION
My patient was 45-year-old Lauren Simon, who appears on reality TV show The Real
Housewives of Cheshire. She came to me wanting to rejuvenate her appearance following her
divorce, specifically concerned with redefining her jawline, reducing submental fat under the
chin and generally improving her skin texture.
From my initial consultation I could see that Lauren was a good candidate for FaceTite. She
had moderate amounts of loose skin and excess fat on the face and neck. The deposits of
fat were located under the jawline, which gave her a double chin, and there was a moderate
degree of skin laxity. Due to her olive skin, she didn’t suffer from fine lines but there were
enlarged pores and a pronounced nasolabial fold, both of which could be significantly
improved with Morpheus8 radiofrequency microneedling and FaceTite non-surgical advanced
contouring, both treatments from InMode. For the loose skin and excess fat, we opted for a
combined treatment of FaceTite and NeckTite. This combined therapy of the three procedures
is known as Refine RF in the US.
FaceTite is a minimally invasive advanced contouring system that uses a cannula inserted
below the skin to “burn away” fatty tissue, employing a directional radiofrequency thermal field
which reduces fat coagulation and provides tissue remodelling. There is a dual-temperature
system which provides greater safety and control, focusing the energy concentration in the
treatment zone. NeckTite works in a similar way but focuses on the fatty tissue under the
jawline and chin. The system automatically shuts off when it reaches a maximum temperature
and issues an alert noise to the aesthetician, and there is also a guide on the exterior which
shows the exact position of the cannula tip.
All treatments were to be conducted at the clinic on the same day, with the total treatment
time projected at just a little over two hours.

68 Aesthetic Medicine July/August 2021


Left: before, Right: three months after treatment
TREATMENT PLAN
Lauren was given tumescent anaesthesia
under the jawline and around the cheeks
to prepare her for the NeckTite and
FaceTite procedures. This also provided
hydrodissection for the cannula to navigate
through the subcutaneous fat layer. The
treatment is minimally invasive and is, in my
opinion, the next best alternative to facelifts
without the invasive surgery. First, I performed
NeckTite to the fatty tissue under the jawline
and chin. Then, moving onto FaceTite, the
cannula went in close to the ear and was then
moved across towards the nose within the
fat layer above the SMAS. Between four and
five movements were applied in a fan-like
shape so that the whole of the cheek area was
covered, and this was repeated on both sides
of the face. Total treatment time was around
an hour including the anaesthesia. At all times
Lauren was conscious and comfortable; she
was aware of the procedure but not in any
pain. Approximately 15-20ml of fatty tissue
was extracted from the jawline and cheeks
with some gentle liposuction. Aspirating
some of this reduces downtime and post-
operative swelling.
The Morpheus8 treatment followed
immediately afterwards. The tumescent
anaesthesia provided adequate pain relief in
the lower face, but Lauren’s upper face was
prepped with an anaesthetic cream an hour
prior to treatment. The treatment itself lasted
around 45 minutes with the microneedling
aestheticmed.co.uk
CASE STUDY
conducted at two depths, at 0.4mm for
fat contraction and at 0.2mm for skin
rejuvenation and contraction of pores. For me,
one of the great advantages of the Morpheus8
treatment is that I can provide skin tightening
right into the delicate eye area, and Lauren
had the treatment on the lower lids and to
reduce crow’s feet at the sides of her eyes.
RESULTS
After the treatment, Lauren was given a
compression bandage for her face which she
was told to wear for the next few days. She was
concerned how long the downtime would be
as she leads a very active social life, but it was
only a little over 24 hours in her case; she had
the treatment on Friday afternoon and was
able to enjoy a Sunday lunch out with friends
the same weekend.
Lauren is thrilled with the results of
her treatment; her jawline is much more
pronounced, her skin texture and pores are
hugely improved, and the double chin has
been almost entirely irradicated. The time for
the results of the procedures to fully develop
was just under three months. There is some
initial swelling from FaceTite post-procedure,
but this goes down quickly and then the
contraction takes a couple of months to
finish. The treatments have given Lauren so
much more confidence to get back out again
socially after a difficult divorce and have truly
given her a new lease of life. She is so grateful
for everything we’ve done for her.
Aesthetic Medicine 69
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 CASE STUDY

Left: before, Right: immediately after one treatment

Body
beautiful
Dr Martin Kinsella shares one of his first case
studies using new PLLA collagen–stimulant
Lanluma X for buttock enhancement

DR MARTIN KINSELLA
Dr Martin Kinsella MBChB BDS BACD has practised for over 16 years as an
anti-ageing cosmetic doctor, primarily from his lead clinic Re-enhance in Hale,
Cheshire. He also has clinics in Yorkshire and London and makes frequent trips to
Mallorca to see patients and worldwide to train other cosmetic doctors.

aestheticmed.co.uk Aesthetic Medicine 73

INJECTABLE BUTTOCK ENHANCEMENT
Left: before, Right: immediately after one treatment
espite causing death in one in 3,000 cases1, the number
D of people opting for buttock enhancement by fat transfer
(commonly referred to as a Brazilian Butt Lift or BBL) has
more than doubled in the last five years.1 The procedure
involves taking fat from areas of the body where it’s not wanted and
transplanting it into the glutes to enlarge them. However, injecting fat
into the buttock can easily lead to serious problems if done incorrectly.
Complications can include a fat embolism, when fat enters the
bloodstream and blocks a blood vessel. In the lungs, for example, it
blocks oxygen from entering the bloodstream, while in the brain it can
cause a stroke.
While many patients opt for a buttock enhancement for aesthetic
reasons, other patients look to treat the area after losing a significant
amount of weight, to address serious disfigurement after pelvic
trauma, or if they are experiencing practical problems, such as holding
up trousers. However, in all cases the aim of treatment should be to
enhance the shape of the buttock and texture of the skin as opposed to
completely changing and distorting the patient’s natural shape.
Now, we have a non-surgical, safe alternative to a BBL in the form of
Lanluma X, an injectable poly-L-Lactic acid (PLLA) collagen stimulant
for the body. The treatment adds volume and re-shapes the buttock
area to enhance the curve and shape of the buttocks without surgery
or indeed, a high risk of complications. Lanluma works very differently
than other kinds of dermal fillers. Instead of simply adding volume in
the way that hyaluronic acid ingredients would, Lanluma’s ingredients
kick-start the body’s natural collagen production mechanism. Since
collagen is the protein that gives the skin its structure and shape,
Lanluma injections perfectly create a curved shape that looks natural
and, importantly, fits with the patient’s body type.
CONSULTATION
Sarah, 44, presented as a patient who was concerned about the shape
of her buttocks having exercised regularly over a number of years
and for a considerable amount of time. She explained that she would
work out up to seven days a week with endless squats but struggled
to achieve the desired look in increasing the size of the buttocks. As a
patient who was very focused on reversing the signs of ageing, Sarah felt
that her buttocks did not necessarily reflect her age and the rest of her
body. Lanluma was suggested to enhance the shape and fullness of
the buttocks.
74 Aesthetic Medicine
TREATMENT PLAN
After marking and sterilising the area, sterile water is drawn into the
Lanluma syringe and slowly added to the vial containing the product
(in a dry powder format). The vial has to be shaken for ten minutes
for optimal injectability and then left to stand for one hour to ensure
complete hydration. The product should then be strongly agitated
immediately prior to use for one minute.
I made one entry point per side with a cannula. An instant result
was visible on Sarah on the day of treatment, but as the building of
collagen takes several weeks to months, patients will likely need several
injections to see improvement in volume and shape, depending on
their needs. Sarah received one injection to each side of the buttocks
and is due to return in four weeks’ time [at the time of writing] for a
second session. I used one vial per side and will use one or two per side
for the second treatment. The number of vials used should be based on
the patient’s response to the product during the first session and the
intended outcome of treatment. For older patients with an “A-shape”
buttocks, two vials per side may be recommened for the first session.
Downtime is minimal, and Sarah was provided with an aftercare
guide to follow for the next few days following treatment.Advice includes
massaging the area vigorously for a few seconds every day for at least
two weeks to reduce the risk of nodules and/or granulomas; and the use
of bandaging or compressive underwear following treatment to hold the
shape of the buttocks.
RESULTS
The results of the treatment are visible and yet incredibly in keeping
with Sarah’s natural shape. The improvements are three-fold. Firstly,
there is an improvement in volume. This in turn achieves lifting of each
buttock, and thirdly, we see an improvement in skin texture which
reduces the appearance of cellulite and skin dimpling, and this will only
improve over time. Sarah is delighted with her results and told me her
confidence sky-rocketed. We are both looking forward to seeing how
the results develop following her second treatment.
REFERENCES
1. https://pubmed.ncbi.nlm.nih.gov/28369293/
July/August 2021

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dedicated to breakthrough research and clinical science, with a
team of experts bringing 50years of experience in HA science and
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Claire Williams, chief executive of global distributor Circa Skin, says:
“Kysense represents an exciting innovation and step forward in what
clinical practitioners can offer their patients and we are delighted with
the positive feedback we have had from our existing customers.
In addition, we are revolutionising the business aspect for our
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Aesthetic Medicine 75
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INJECTABLE HAND LIFT

Tell-tale
signs
The hands are often the first place to show signs of
ageing. Dr Aamer Khan shares a hand–rejuvenation
treatment using a collagen–stimulating injectable

DR AAMER KHAN
Dr Aamer Khan is co-founder of Harley Street Skin and has dedicated the past
16 years to performing cosmetic and non-surgical procedures for thousands
of patients. He has knowledge in diverse areas including human psychology,
psychiatry, surgery and dermatology. Follow him on Instagram: @dr.aamerkhan

Before the Harley Street Hand Lift

78 Aesthetic Medicine July/August 2021


he skin on the hands ages
T much quicker than skin
on other areas of the body
because it is constantly
exposed to the environment (including
sunlight), has fewer oil glands, and is
continuously stressed by the movements of
the hands and regular washing.
Post-menopausal women find that
there is an accelerated deterioration in
the collagen in their skin (from 1% per year
to 1.5% per year) due to lack of oestrogen.
As the years go by, crêpey skin, prominent
veins and volume loss on the hands reveal
our true age faster than any other part
of the body. Using injectables can visibly
minimise the effects of ageing in the hands.
Traditional dermal fillers only address
lines, wrinkles and folds, but Ellansé – a
collagen-stimulating injectable made from
carboxymethyl cellulose (a gel carrier and
short-term volumiser), and microspheres
of bio-stimulator polycaprolactone – works
beneath the surface of the skin to activate
cellular regeneration and stimulate type I
collagen production. Ellansé can be injected
into the sub-dermal tissues, down to
the periosteum.
At my clinic Harley Street Skin, we have
created a treatment using Ellansé called
the Harley Street Hand Lift. The treatment
involves up to 20 micro-injections into the
After the Harley Street Hand Lift
aestheticmed.co.uk
CASE STUDY
subcutaneous layer of the skin on the backs
of the hands. The results are immediate
– volume is restored, dilated and bulging
veins diminish, and ageing hands look
years younger. In the weeks that follow, as
fibroblasts and newer collagen are formed,
skin quality improves with tighter looking,
more youthful skin. Fibroblasts are also
found in the subcutaneous fat, and their
stimulation also serves to increase the
thickness of this layer. The results can last up
to three years.1
CONSULTATION
When treating the hands, it is incumbent upon
us as practitioners to consider any differential
diagnoses and exclude any other significant
pathology, which the patient’s concern
may be a presenting complaint for, such
as multiple system atrophy, carpal tunnel
syndrome, muscular atrophies or dystrophy,
other motor nerve problems, inflammatory
conditions, such as arthritis, collagen disorder;
and fat strophic disorders. Though these
conditions are rare, and would have other
signs and symptoms, we should be aware of
them and be able to refer the patient back to
their GP for further assessment if necessary,
before treating them. As ever, a lot of clues
will be in the patient’s medical history, so it
is important to take the time to establish a
comprehensive history from them.
Aesthetic Medicine 79
INJECTABLE HAND LIFT
I initiate a conversation about the
ageing process and explain to the patient
what impact that has on their hands, and
what they can do to slow the process
down, improve and preserve things for
themselves. This serves to empower
the patient. With better knowledge and
understanding, it engages them with the
whole process of rejuvenation, and allows
them to take personal responsibility for
part of the treatment and the outcomes.
We then discuss the options available,
including doing nothing, explaining that
any action or treatment carries a risk and
outcomes cannot be guaranteed. It is
important to discuss not only the benefits
but also the limitations of each of the
options, including the contraindications.
June, 58, presented with thin, veiny
and blotchy hands which looked much
older than her face. She hoped to not
only improve them but to avoid the
psychological discomfort when holding
hands with her younger boyfriend. She
wanted to rejuvenate her hands as much as
possible to reverse the signs of ageing. After
the initial consultation and assessment, it
was felt that June had been unhappy about
her hands ageing since the menopause.
This had affected her confidence; she
would avoid showing her hands, especially
in pictures. Her sense of psychological
discomfort was heightened when she met
her younger partner, and this was her trigger
to seeking help and advice.
TREATMENT PLAN
Examination revealed loss of skin elasticity,
with dyschromia due to photodamage
with early keratoses. There was loss
of subcutaneous fat, with increased
prominence of the appearance of the veins.
There was no other significant medical or
psychiatric history, and there were no
other conditions that we would be
concerned about.
We discussed the options along with their
risks, limitations, and benefits, and decided
upon a comprehensive regenerative
approach treatment including skincare and
sun protection for the hands and Ellansé
injected sub-dermally to rejuvenate the
skin and sub-cutaneous fat layer.
Consideration of peels or IPL for
rejuvenation of photo-ageing was
considered for a later date if necessary.
80 Aesthetic Medicine
A numbing cream was applied to
the backs of June’s hands and 15 to 20
injections were administered which
covered an area from just above her wrists
to the bottom of her fingers.
RESULTS
We saw instant results in June. Her hands
looked plumper, more rejuvenated and less
wrinkled and her veins were less noticeable.
In following up after the treatment, we
offered advice on how to maintain the
results for longer. Washing our hands all
the time and the constant exposure to
oil-stripping soap and hot water, along
with application of alcohol-based hand
sanitisers can make even the sturdiest
of hands dry, red and irritated. June was
advised to watch her water temperature
as hot water can strip the skin of its natural
oils, leading to dry, chapped, and cracked
skin. I reminded her to opt for washing her
hands with soap wherever possible instead
of using a hand-sanitiser gel as it is much
kinder to the skin and more effective at
actually cleaning the hands, too.
A gentle, unscented soap with hydrating
ingredients like glycerine which pulls
moisture into the skin is best, as well as
ceramides, shea butter and coconut
oil. Soothing ingredients such as aloe
vera, chamomile and green tea can also
decrease any inflammation and irritation.
June was also advised to always use a hand
cream after washing as it will act as a barrier
and help seal in hydration. The skin can
absorb the most moisture during the first
few minutes after washing your hands. I told
her to choose a thick, creamy formula with
ingredients like oatmeal (good for soothing
itchy skin and eczema) emollients and
hydrators. Again, these include glycerin,
ceramides, vitamin E and shea butter or
hyaluronic acid and help the skin barrier
retain its natural moisture. She can also
use an intensive hand mask once a week to
intensely hydrate the skin.
REFERENCES
1. Moers-Carpi M, Sherwood S., Polycaprolatcone
for the correction of nasolabial folds: 24 month,
prospective randomized, controlled clinical trial.
Dermatol Surg 2013;39:457-463
July/August 2021
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