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BODY AND SKIN TIGHTENING May 2025 | VOLUME 12 - ISSUE 6

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CPD: Analysing Cryolipolysis Dr Emmaline Ashley examines the use of cryolipolysis for non-surgical fat reduction

Special Feature: Exploring Approaches to Treating Cellulite Examining Vaginal Tightening for Post-Cancer Patients

ALSO IN THIS ISSUE

Mr George Christopoulos explains the science behind LED therapy Liz McKeon explores clinic pricing strategies and how to boost profits

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This content is intended for UK and Irish HCPs only.

The Allergan Aesthetics Portfolio 1–10

A valuable partner Help address some of your patients’ skin quality concerns with a multimodal treatment approach.1,10-14*†

Produced and funded by Allergan Aesthetics, an AbbVie company.

UK-AGNA-240171 | May 2024

References: * Such treatment decisions must be assessed and discussed as part of the healthcare professional–patient consultation prior to any treatment being administered. † Multimodal aesthetics treatment describes the use of more than one type of treatment modality that are administered as part of a patient’s treatment plan.

By scanning the QR code, you are being directed to a third party website on which Allergan Aesthetics, an Abbvie company are only responsible for the references for this article.

Dr Edward Robinson explores the literature around polynucleotide use for hair loss

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Adverse events should be reported. UK reporting forms and information can be found at https://yellowcard.mhra.gov.uk or via the MHRA Yellow Card app, available at Google Play or Apple App stores. Adverse events should also be reported to AbbVie on ProductSurveillance_EAME@allergan.com. Irish HCPs are asked to report any suspected adverse reactions via HPRA Pharmacovigilance; website: www.hpra.ie.

CPD: Polynucleotides for Hair Loss

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Models have been treated with Allergan Aesthetics product. Individual results may vary. The safety and efficacy of HArmonyCa™ has not been evaluated in patients treated with other filling implants.10 There is no data available regarding the safety of injecting a greater amount than 20mL of ALLERGAN dermal fillers per 60kg body mass per year.4 HArmonyCa™ Lidocaine is referred to as HArmonyCa™.

Special Feature: Examining Treatment Approaches to Manage Scars Treating Melasma: Discussing Various Treatment Modalities for Melasma

ALSO IN THIS ISSUE

Dr Nicole Chiang provides an overview of common facial dermatoses CCR 2024 marks its return with the latest advancements in medical aesthetics

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Education that inspires

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Discover expert-led courses and injection techniques on MAX. Start your learning journey today.

FOR HEALTHCARE PROFESSIONALS ONLY Merz Aesthetics Exchange (MAX) is a promotional website produced and funded by Merz Aesthetics UK & Ireland. M-MA-UKI-3879 Date of Preparation April 2025

Contents • May 2025 08 News The latest product and specialty news

16 The Future of Aesthetics with Aesthetica Solutions Aesthetica Solutions unveils cutting edge treatments and prescription services

17 News Special: The Impact of US Trade Tariffs in Aesthetics Aesthetics reports on the implications of recent US trade tariffs

18 Shape Your Future in Medical Aesthetics CCR returns this year for learning, networking and connecting

News Special: The Impact of US Trade Tariffs in Aesthetics Page 17

CLINICAL PRACTICE 21 Special Feature: Approaches to Treating Cellulite

Practitioners share their strategies for improving the appearance of cellulite

27 CPD: Analysing Cryolipolysis Dr Emmaline Ashley explores cryolipolysis for non-surgical fat reduction

32 Treating Periocular Xanthelasma Three practitioners outline treatment options for periocular xanthelasma

35 Introducing the New Generation Tranexamic Acid Peel

Special Feature: Approaches to Treating Cellulite Page 21

AlumierMD showcases the latest peel to tackle stubborn pigmentation

36 Case Study: Addressing Upper Arm Skin Yuliya Culley discusses treating arm skin laxity with poly-L-lactic acid

38 High-End and Multi-Functional Aesthetic Devices Pure Tone Aesthetics brings affordable, high-performance aesthetic machines

40 Utilising LED Therapy in Medical Aesthetics Mr George Christopoulos analyses LED photobiomodulation

42 Examining Post-Cancer Vaginal Rejuvenation Dr Ioannis Liakas explores treating vaginal health in post-cancer patients

45 Assessing Candidacy for Jaw-Slimming Injections Dr Mariam Al-Ani discusses masseter toxin injections

48 Exploring Innovative Skincare Solutions Mr Dalvi Humzah outlines innovative products to enhance clinic returns

49 Abstracts The latest research highlights from Professor Sebastian Cotofana

IN PRACTICE 50 Protecting Your Clinic from Counterfeit Threats Sian Keane examines the rise of counterfeit machines in aesthetics

52 Evaluating Profitable Clinic Pricing Liz McKeon discusses clinic pricing strategies and boosting profitability

54 Assessing Patient Psychological Needs Julie Scott shares why it is crucial to assess the psychological needs of patients

57 In Profile: Sara Cheeney Sara Cheeney reflects on the defining moments of her aesthetics journey

58 The Last Word: Evaluating the Fitzpatrick Scale Dr Derrick Phillips argues for the use of an alternative to the Fitzpatrick scale

NEXT MONTH: MID AND UPPER FACE • Treating the Upper Eyelid • Addressing Rosacea with Toxin

Clinical Contributors Dr Emmaline Ashley is the academic head of education at Acquisition Aesthetics. She holds a degree in biology and postgraduate qualifications in surgery, dermatology and aesthetics. She has worked as a clinician in London and Edinburgh, and currently splits her time between the UK and Cayman Islands. Ms Aoife Naughton is a consultant ophthalmic and oculoplastic surgeon, based at The Clinic Holland Park and at Portsmouth University Hospitals. She specialises in cosmetic and reconstructive oculoplastic surgery, including blepharoplasty and ptosis surgery and lacrimal surgery. Mr Richard Scawn is a consultant ophthalmologist and oculoplastic surgeon based at The Clinic at Holland Park, Harley Street and Chelsea & Westminster NHS Trust. He specialises in blepharoplasty, ptosis, eyelid reconstructions for cancer, burns and trauma. He is the founder and surgical lead for The Clinic Holland Park. Miss Jennifer Doyle is a consultant oculoplastic surgeon based at The Clinic at Holland Park and at Milton Keynes University Hospital. She is head of aesthetics and chief operating officer at the Clinic at Holland Park, and a key opinion leader for companies including Sciton, Sofwave and Ameela. Yulia Culley has been a registered general nurse since 1998, with experience in emergency, cardiology and dermatology nursing. She started practising aesthetics in 2009 and was a Finalist in the Aesthetic Nurse Practitioner of the Year Award at The Aesthetics Awards 2022 and 2025. Mr George Christopoulos is a plastic surgeon and aesthetic practitioner, who specialises in body-contouring operations and regenerative medicine. Mr Christopoulos has a clinical background in reconstructive plastic surgery, and holds a PhD title on skin cancer management. Dr Ioannis Liakas is the lead clinician and medical director at Vie Aesthetics. He studied medicine at Aristotle University, Greece and a Masters in the physiology of ageing at University College London (UCL). Dr Liakas is a Fellow of the Royal College of Physicians, member of BCAM and honorary lecturer at Queen Mary Medical School. Dr Mariam Al-Ani is the co-founder of a private dental and facial aesthetic clinic in Birmingham. She is a general dental surgeon and gained her qualification to the Membership of the Faculty of Dental Surgery (MFDS). She went on to complete a postgraduate certificate in aesthetic and restorative dentistry.

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References: a) The aesthetic effect after initial injection of the viscoelastic implant lasts up to 16 weeks for lateral canthal lines and up to 24 weeks for perioral rhytids.1 1) Instructions for use 2) Sulovsky M, Müller D, Prinz V, Moellhoff N, Cajkovsky M, Duschek N, Frank K. A prospective open-label, multicentre study evaluating a non-cross-linked hyaluronic acid based softtissue filler in the correction of lateral canthal and perioral lines. J Cosmet Dermatol. 2022 Jan;21(1):191-198. doi: 10.1111/jocd.14460. Epub 2021 Sep 24. PMID: 34559948 3) Succi, I. B., Da Silva, R. T. & Orofino-Costa, R. 2012. Rejuvenation of periorbital area: treatment with an injectable nonanimal noncrosslinked glycerol added hyaluronic acid preparation. Dermatol Surg, 38, 192-8. 4) Data on file 5) Arora G, Arora S, Sadoughifar R, Batra N. Biorevitalization of the skin with skin boosters: Concepts, variables, and limitations. J Cosmet Dermatol. 2021 Aug;20(8):2458-2462. doi: 10.1111/jocd.13871 The healthcare professional confirms having informed the consumer of a likely risk associated with the use of the device in line with its intended use. For risks and adverse events associated with the use of the device consult the instructions of use. CE 0123

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Editor’s letter Well, it’s been an exciting month. Our social media has been inundated with wonderful highlights and learnings following ACE, as well as inspirational posts after the announcement of the Aesthetics Awards Winners. Oh, and to add to the excitement this month, my partner of Shannon Kilgariff 10 years got down on one knee in a beautiful Editor & Event woodland bluebell forest and asked me to marry Manager him! Thank you to those of you who have sent @shannonkilgariff such lovely, heart-warming messages – it truly is fantastic to be in a community with so many friends and I feel so lucky to be a part of this incredible, supportive, aesthetics field! Turning our attention to the May issue of the Aesthetics Journal, we’re focusing on one of the most in-demand topics in clinics right now; body and skin tightening. In this issue, you’ll find a Special Feature on treating cellulite (p.21), offering a practical look at how different techniques can be combined to improve skin texture and tone. We’ve also included a CPD-accredited article on cryolipolysis (p.27), helping you refresh your

knowledge and refine your practice in body contouring. A particularly interesting case study this month (p.42) explores a vaginal tightening treatment for a cancer survivor – a moving reminder of the positive impact medical aesthetics can have in supporting confidence, healing and quality of life post-recovery. In our business section on p.50, we’re turning your attention to an important topic; counterfeit devices. With innovation booming, it’s crucial to know what to look out for and how to protect your clinic from unregulated and potentially dangerous equipment. Looking ahead, we’re already planning for our next major event – the Clinical Cosmetic Regenerative (CCR) Congress, returning this September 25-26. Our CCR preview in this issue gives you a first look at what’s in store. Thanks for reading this issue of the Aesthetics Journal and being part of the Aesthetics community. Do let us know what you’d like to read about next! Whether you’re discovering new techniques or looking ahead to you next new product for your practice, I hope this issue brings you both inspiration and practical knowledge to carry into clinic.

Clinical Advisory Board

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

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

If you are interested in contributing to the journal, get in touch... Email: editorial@aestheticsjournal.com

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

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

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

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

Jackie Partridge is an independent nurse prescriber. She is the clinical director and owner of Dermal Clinic in Edinburgh and a KOL for Galderma. She holds an MSc in Non-surgical Aesthetic Practice and a BSc in Dermatology. Partridge is a stakeholder group member with Scottish Government/HIS, Honorary BACN member and JCCP Fitness to Practice Nurse.

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

Mr Adrian Richards is a plastic and cosmetic surgeon with over 30 years’ experience. He is the clinical director of the aesthetic training provider Cosmetic Courses and surgeon at The Private Clinic. He is also a member of the British Association of Plastic and Reconstructive and Aesthetic Surgeons and the British Association of Aesthetic Plastic Surgeons.

Dr Souphi Samizadeh is a dental surgeon with a Master’s degree in Aesthetic Medicine and a PGCert in Clinical Education. She is the founder of the Great British Academy of Medicine and Revivify London Clinic. Dr Samizadeh is a Visiting Teaching Fellow at University College London and King’s College London.

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

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Advertising

ASA releases rulings on liquid BBL adverts

Talk #Aesthetics

The Advertising Standards Authority (ASA) has released a batch of rulings on adverts for liquid Brazilian Butt Lift (BBL) procedures.

The ASA utilised its Active Ad Monitoring system, using artificial intelligence (AI) to search for online advertisements that trivialise the risks of non-surgical BBL procedures, or exploit women’s insecurities surrounding body image. The ASA shares that these rulings form part of a wider task to tackle advertisement surrounding liquid BBLs.

#AMWC2025 Miss Jennifer Doyle @drjennydoyle Kicking off a sunny Friday in Monaco at the AMWC Conference, speaking alongside my fellow Sofwave KOLs at the Grimaldi Forum.

#Empowerment Michelle McLean @aestheticallyyou I had the pleasure of leading Galderma’s ‘One Product, Many Possibilities’ training event – a day filled with learning, meaningful conversations and incredible women supporting one another!

The ASA emphasised that none of the ads must appear again in the form complained about, telling clinics to ensure future advertising does not pressure consumers into booking, or trivialise the risks of cosmetic procedures.

Cancer Screening

#Connection Dr Mayoni Gooneratne @dr.mayoni Meeting one of my women’s health heroes was a true gift. I loved catching up with Dr Felice Gersh over breakfast on all things women’s healthcare!

The other advertisements echoed parallel issues of time pressure, alongside exploiting women’s insecurities around body image, with one advertisement stating, “Get the curves and contours you’ve always wanted.” The ASA stated, “Marketers should not play on consumers’ insecurities, and must not suggest that happiness or wellbeing depends on conforming to a particular body shape.”

Jess Tye, regulatory projects manager at the ASA, commented, “Last October, we conducted a targeted sweep of UK-based advertisers of cosmetic surgery and non-surgical cosmetic interventions, leading us to launch six investigations into ads for liquid BBLs. We plan to continue this work through follow-up monitoring and compliance action to ensure the cosmetic surgery and non-surgical cosmetic intervention specialties are advertising responsibly.”

#Conference Inspired Cosmetic Training @inspired_cosmetic_training What an unforgettable day at the Scottish Aesthetic Conference! The atmosphere was electric, filled with incredible networking and learning opportunities.

#Workshop Inspire To Outstand @inspiretooutstand A sneak peak from our recent client workshop. Thank you to those who attended the beautiful headquarters, and to Lutronic for supporting our event!

The ASA has released six cases of aesthetic clinics dangerously advertising the liquid BBL procedure, with one advertisement stating, “Black Friday Liquid BBL and hip filler…0% infection rate. Sterile clinic…adds curves…minimal pain.” This was accompanied by the caption, “Black Friday deals so good, they won’t last long! Get your appointments before the price increase on the 30th November 2024!” The ASA challenged the advertisement because the time limit pressured consumers into booking a cosmetic procedure, and the claim ‘minimal pain’ trivialised the risks of cosmetic procedures.

London hospital debuts AI skin cancer screenings Chelsea and Westminster Hospital NHS Foundation Trust has become the first in the world to use artificial intelligence (AI) to discharge patients with non-cancerous skin lesions. The Trust shares that the technology called DERM – provided by Skin Analytics – works by using dermoscopic imaging to identify cancerous, pre-cancerous and benign moles and lesions on the skin. DERM has a 97% effectiveness for detecting skin cancer and 99.96% for ruling out melanoma, which the Trust says is comparable to a dermatologist’s personal accuracy. The aim is to be able to discharge patients with benign legions on the same day as their consultation, supposedly freeing up more than 30% of suspected skin cancer appointments on the urgent cancer pathway at Chelsea & Westminster Hospital. Consultant dermatologist at the hospital Dr Louise Fearfield said, “We wouldn’t be able to keep up with the numbers of patients that are coming through as urgent skin cancer referrals without the technology. Patients would be missed, left waiting and wouldn’t receive their diagnosis in a timely manner.”

Aesthetics | May 2025

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CCR Registration

Vital Statistics

CCR 2025 registration set to open this month

The British Beauty Council reports that while 80% of consumers prioritise sustainability, only 23.4% choose refillable skincare

Registration for the Clinical Cosmetic Regenerative (CCR) Congress 2025 will open this month. Hosted at Excel, London on September 25-26, CCR will welcome 4,000+ professionals from the world of aesthetics to experience 140 leading exhibitors, and five advanced educational stages. CCR’s clinical agendas are renowned for hosting the UK’s most in-demand practitioners, bringing with them a wealth of knowledge on the most groundbreaking research and advanced treatment techniques. The business stream on the In Practice stage is also set to provide two days of practical advice from top business specialists and associations.

(The British Beauty Council, 2025)

Out of 1,500 UK participants surveyed, almost 50% labelled fine lines and wrinkles as their top skin concern (Cynosure Lutronic, 2025)

Returning to CCR for the third time will be the Medical Longevity Summit, showcasing the very latest cutting-edge advancements in functional wellness and regenerative medicine.

Amongst 2,081 individuals, 45% do not apply SPF daily and 69% say SPF is more important to them now than when they were younger

Shannon Kilgariff, editor and event manager of Aesthetics, said, “The countdown is well and truly on for CCR once more! The biggest aesthetics event in the whole of the UK, it really is the place to be to form new connections, see the best speakers and explore a plethora of aesthetic brands. We’re so proud of the education we have on show, and we can’t wait to share it with you.”

(Face the Future, 2025)

Turn to p.18 to register your interest for CCR 2025 now. Aesthetic Trends

BAAPS audit reveals rise in cosmetic surgery The British Association of Aesthetic Plastic Surgeons (BAAPS) has released its annual audit for 2023-2024, revealing a 5% rise in cosmetic surgical procedures, with 27,462 surgeries performed in 2024.

51% of female professionals in the UK experience a lack of inspirational female leaders within their company (Robert Walters, 2025)

Breast augmentation remained the most popular procedure, with 5,202 surgeries performed (+6%). Eyelid surgery (blepharoplasty) saw a 13% increase, rising to become the third most common surgery, surpassing abdominoplasty. Face and neck lifts increased by 8%, while brow lifts saw a significant rise of 20%.

Out of 2,189 UK participants, 78% feel it’s extremely important that skincare products and treatments make them look natural

Body contouring procedures also grew, with liposuction up 8%, abdominoplasty rising 6% and thigh lifts surging by 24%. However, male cosmetic surgery saw a slight decline, down 1.5% overall, with rhinoplasty (-14%) and liposuction (-7%) experiencing the largest drops. Non-surgical treatments also rose, with botulinum toxin performed by surgeons increasing by 5%, and dermal fillers seeing a substantial 27% growth. Consultant plastic surgeon and BAAPS president Ms Nora Nugent commented, “Breast augmentation remains limited to two primary methods – breast implants or fat transfer – but these approaches yield different results. Fat transfer offers a more subtle enhancement, which may explain the continued demand for implants, as there is no true alternative for many women. Implant removal rates have also declined, possibly for similar reasons. Additionally, new research is helping to reshape previous misconceptions about the long-term safety of breast implants.”

(Teoxane, 2025)

The aesthetics market is set to expand in 2025 after an 8.4% growth in 2024, with 892,000 procedures performed in the UK (PolicyBee, 2025)

Aesthetics | May 2025

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Events diary 20th May 2025 BAS Sclerotherapy Conference

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Botulinum Toxin

Relfydess from Galderma launches in the UK this month

5th-7th June 2025 BMLA Annual Conference

Aesthetic pharmaceutical company Galderma will release its liquid neuromodulator RelabotulinumtoxinA (Relfydess) in the UK this month.

18th-19th September 2025 BAMAN Autumn Conference

Galderma explains Relfydess is designed to deliver fast and sustained results for glabellar and lateral canthal lines, and the liquid neuromodulator is optimised for simple volumetric dosing to increase ease-of-use and help ensure consistent dose/volume. Relfydess was launched in European markets in December, and Galderma has confirmed the neuromodulator will be available from May 2025 in the UK.

25th-26th September 2025 CCR 2025 11th October 2025 BCAM Conference IN T H E M E D I A What’s trending in the consumer press

Eleanor Hartley joins Wednesdays podcast to discuss wellness In episode 79 of the Wednesdays podcast, ‘Revealing Our Skincare Treatments’, television personalities Sophie Habboo and Melissa Tattam welcomed nurse practitioner Eleanor Hartley from Hart Medical. Hartley shared how she shifted Habboo and Tattam’s focus from quick fixes to long-term skin health, revealing her internal age is 15 years younger than her actual age. Joking that they visit her clinic twice a week, she described her approach as regenerative and integrative. “I want to create a quiet space in a noisy specialty where there’s so much false information, unlicensed practitioners and not enough regulations,” she said. Chloe Brockett discusses her filler reaction and TOWIE look TV personality Chloe Brockett has explained that she joined The Only Way is Essex (TOWIE) at 18 years old and quickly turned to cosmetic procedures. She recalled, “When I saw my first TOWIE episode, I hated how I looked. The next day I went to a clinic and had filler in my cheeks, chin and nose.” Brockett continued, “I’ve tried to have some filler dissolved, but I had a severe allergic reaction and I could have died.” Brockett’s lips swelled during the dissolving procedure, prompting a ‘special drip’ from her doctor. Unable to dissolve the filler, she said, “Whatever’s in my face now will have to stay.”

René Wipperich, general manager of Galderma UK & Ireland, commented, “Our commitment to innovation in biologics has positioned us uniquely as the only company offering a comprehensive portfolio of three distinct neuromodulators. By leveraging our leadership in the UK through cutting-edge scientific research, the launch of Relfydess proves our dedication to delivering advanced solutions that address the needs of both patients and healthcare professionals.” National Health Service

NHS Scotland continues roll out of Digital Dermatology Pathway National Health Service (NHS) Scotland will roll out its Digital Dermatology Pathway to all GP practices and health boards in Spring 2025. The dermatology pathway aims to prioritise a digital-first approach, with remote monitoring to further harness the benefits of digital technology, the NHS explains. The pathway, already in use across six health boards and in more than 400 GP practices, enables GPs to photograph skin conditions and upload them with referral information via a dedicated digital service. The plan cites evidence suggesting that this pathway will allow around 50% of patients to be returned to their GP “without having an in-person appointment with a consultant.” This Digital Dermatology Pathway is part of NHS Scotland’s Operational Improvement Plan, which aims to enhance key areas of the healthcare system by leveraging digital and technological innovation. Injectables

mesoestetic introduces mesofiller nexha injectable range in the UK Aesthetic manufacturer mesoestetic has announced its new filler range mesofiller nexha is now available in the UK. The company explains that its new launch comprises mesofiller nexha volume and mesofiller nexha lips, with rheologies tailored for different areas. The fillers combine hyaluronic acid with succinic acid – a biostiumulator with antioxidant and regenerative properties. The products contain dual release technology to release active ingredients in two phases, with mesoestetic saying this means their action can be extended for up to seven months. Stephen Schofield, commercial director for mesoestetic UK and Ireland, shared, “This exciting and innovative launch comes in a very special year for mesoestetic, as in 2025 the company celebrates its 40th year, and four decades of innovation and excellence at the service of the aesthetics field.” Aesthetics | May 2025

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Misconduct

Physiotherapist struck off for toxin use without prescription A physiotherapist has been struck off by the Health and Care Professions Council (HCPC) after injecting unprescribed toxin for more than a decade. The HCPC found that between 2008 and 2020, Adrian Paul Harding had provided botulinum toxin treatments without a prescription or written consent through the neuro rehabilitation facility where he worked. His wrongdoing was first discovered when an NHS colleague was seen supplying him with two boxes of botulinum toxin products. The tribunal said Harding’s records had been laid out in a way as to “cover up any wrongdoing by him,” and were “so poor it was serious enough to be classed as misconduct,” with “many” records either missing or incomplete. They went on to say that he had “acted as he pleased” despite knowing a prescription was needed, and “acted with a sense of entitlement.” The HCPC concluded that “Harding’s blatant disregard for the rules over such an extended period of time exhibited a high-handedness with both patients and colleagues which was tantamount to arrogance.” Education

Leading aesthetic brands announce training days Aesthetic manufacturers Alma Lasers, AlumierMD and Dermalux have unveiled a new collaboration on training days across the UK. The companies explain that the workshops will offer hands-on training for a multi-modality approach using the brands’ laser, light therapy and skincare portfolios. Delegates will be guided through treatment planning with real-life scenarios, accompanied by practical demonstrations. AlumierMD head of education Gemma Rabbetts said, “These workshops will deliver a dynamic insight into the advantages of introducing multi-modality protocols in practice. Medical-grade skincare is an effective adjunct to LED phototherapy and laser treatments, helping enhance in-clinic results and commercial gains.” Training will be held in Leeds on May 8, July 3, August 28 and October 23; Evesham on May 14, September 10 and November 12; London on May 29, July 23, September 17 and November 19; and Belfast on June 12. UK Launch

Nordberg Medical UK debuts collagen stimulating range Aesthetic manufacturer Nordberg Medical has officially launched in the UK. The brand, originally from Sweden, has introduced biocompatible, biodegradable, PLLA-based collagen stimulator JULÄINE to UK aesthetic clinics. The company explains that the product uses LaSynPro (lactic-acid induced synthesis of collagen protein) biomaterial-microsphere technology to boost collagen in the skin. Hannah Nolan, Nordberg UK commercial director, commented, “It’s an exciting time for the Nordberg team as we continue our global expansion into the UK. I believe that in JULÄINE we have a product that really meets the market demands for more natural collagen regenerative aesthetic solutions, while providing a strong safety profile and long-lasting results.”

BAMAN UPDATES A round-up of the latest news and events from the British Association of Medical Aesthetic Nurses

BAMAN SPRING SYMPOSIUM 2025: THANK YOU FOR ATTENDING! Our fourth annual symposium took place on April 4, at the beautiful King’s Fund, London. The venue’s sunlit orangery was the perfect backdrop for our exhibition, which showcased a dozen leading brands in the sector and welcomed more than 160 BAMAN nurses. The event marked a significant moment of transition for BAMAN, as the newly established board of directors attended their first event in post. During the day’s welcome, board members extended their thanks to the outgoing committee for their years of leadership and service. It was a special handover with shared recognition of how far BAMAN has come, and a clear commitment to its future. Later in the day it was announced that tickets for this year’s Autumn Aesthetic Conference are now on sale! The conference will take place this September 18-19 at The Eastside Rooms, Birmingham, and will offer two days of high-quality education and networking.

BOARD OF DIRECTORS STRATEGY DAY AT HEAD OFFICE The new Board of Directors met for a strategic planning session at BAMAN’s Bristol office on April 28. The meeting focused on evaluating BAMAN’s current offerings and identifying where further value can be added for members in the year ahead. Key priorities for 2025 will include strengthening BAMAN’s position as the leading voice for medical aesthetic nurses, expanding our educational resources and improving how we support nurses across all levels of experience. The board also reviewed core membership benefits such as regional events, digital learning, local networking, access to BLS training, the BAMAN Practitioner Finder and the bursary scheme, with a commitment to developing each of these areas further. Stay connected and explore all upcoming events to make the most of these opportunities! Become a BAMAN member today at www.baman.org.uk or scan the QR code below.

This column is written and supported by BAMAN

Nolan has been joined at Nordberg UK by sales manager Blair Pizzuti and marketing manager Sandy Ortanca, with the team set to expand in the coming months. Aesthetics | May 2025

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Skincare

Eden Aesthetics to provide Neova SmartSkincare Aesthetic distributor Eden Aesthetics is now supplying Neova SmartSkincare to UK clinics.

Event Spotlight: Experience Live Demonstrations with Galderma

The company shares that Neova aims to address the DNA damage that is associated with premature skin ageing. The brand features copper peptide GHK which has wound healing and cell growth properties, as well as DNA CoFactor – the patented DNA repair and copper peptide technology combination.

Dr Munir Somji explains what you can expect from our CCR Headline Sponsor

Neova’s skincare portfolio incorporates cleansing washes, serums, eye serums, body products and more. According to the company, the Neova Cu3 range utilises Copper Peptide Complex for skin balancing and nourishing, including in the new post-procedure Cu3 Tissue Repair cream. Lindsay Gray, managing director of Eden Aesthetics, commented, “There has been more of a focus around biotech-driven advancements in skincare, as people look for innovations revolving around cell rejuvenation and healthy skin at the molecular level. Neova is spearheading the way with their scientific research into DNA repair, and in particular the supporting clinical studies.”

What will you be doing at CCR this year with Galderma? I will be performing a live injection on stage on a rapid weight loss case, showcasing Sculptra and Restylane to replace lost collagen and elasticity as well as volume.

Evolution

What can delegates learn? Delegates can learn how to use the Galderma portfolio to meet the needs of patients who are suffering from rapid weight loss. We will be talking about the science of ageing and weight loss, as well as strategies I personally use in my clinic, using a combination of hyaluronic acid fillers and collagen stimulators. What are you most looking forward to about CCR? Specialty conferences like this are so important because they provide a break from clinical practice. It is a chance for a period of reflection with colleagues, as well as an opportunity to develop new skills to take back to clinic. Personally, I am looking forward to the regenerative medicine lecture series. This is a facet of CCR which is unique and becomes more insightful each year. I always make a point of bringing one positive change back to my practice each conference. Register your interest! More information about Galderma’s content will be revealed soon. To find out more about the upcoming CCR congress, turn to p.18. Registrations open this month – to be the first to be notified, register your interest now by scanning the QR code below!

Crown Laboratories to operate under Revance name Aesthetic manufacturer Crown Aesthetics will now operate under the name Revance. The company explains that this shift is coming into force following Crown’s acquisition of Revance Therapeutics in recent months. The name change was decided upon due to the brands’ shared vision for revolutionising the aesthetics and skincare fields, according to the company. Jeff Bedard, CEO of Revance, said, “The transition to the Revance name marks an exciting new chapter, representing the future of our combined portfolio of advanced, science-driven brands that are designed to address the ever-changing needs of patients, clinicians and consumers worldwide. By uniting our complementary products and incredibly talented teams under one powerful brand, we are strengthening our unique position in the marketplace.” Education

Endolift International Academy launches in LA Aesthetic device company Endolift has officially launched the training facility Endolift International Academy in Los Angeles (LA). The company states that its new academy provides a dedicated space for advanced training, offering hands-on experience with the device under specialist guidance. The academy hosts regular masterclasses, with previous sessions including Endolift theory, ultrasound demonstrations and live treatment demonstrations. Aesthetic practitioner and US key opinion leader for Endolift Dr Gayane Arutunian, commented, “The positive feedback we receive fills us with pride and confirms that we’re on the right path, delivering valuable education and raising the standard of Endolift practice worldwide.” Aesthetics | May 2025

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Unregulated Products

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Trainers

GPhC highlights Lemon Bottle concerns The General Pharmaceutical Council (GPhC) has issued a statement around unregulated products, including the fat dissolving injectable ‘Lemon Bottle’. The GPhC’s chief pharmacy officer, Roz Gittins, has written to pharmacists, pharmacy technicians and pharmacy owners to raise awareness of the potential risks around the substance ‘Lemon Bottle’, which claims to dissolve fat. The statement also raises concerns about pharmacies dispensing medicines from unregulated online platforms and reminds them to avoid providers that bypass UK regulations. Gittins wrote, “We have received concerns relating to non-medicinal, unregulated and unlicensed products, including ‘Lemon Bottle’, being supplied by community pharmacies, or being administered by pharmacists via injection in other settings. It is the responsibility of the pharmacy owner to ensure that if they decide to stock unlicensed, unregulated products of this nature, there are no medicinal claims made on the packaging or promotional material for those products.” Oleg Seo, global director of SIF Medicos, the brand owner of Lemon Bottle, commented, “Lemon Bottle is currently registered with the Submit Cosmetic Product Notification (SCPN) portal, and is insured for injectable use by reputable UK-based insurance providers. We believe it is essential to frame the UK’s regulatory debate within the broader context of non-medicinal injectables, rather than targeting a single brand that is taking proactive steps in safety, compliance and global standardisation.”

AestheticSource announces new SuneKOS faculty Aesthetic distribution company AestheticSource has unveiled a new training faculty for injectable company SuneKOS. Aesthetic practitioner Dr Jessica Halliley, and nurse prescribers Julia Ogilvie and Lisa Feliz, will now be offering training on the collagen boosting SuneKOS range: SuneKOS Performa, SuneKOS 1200, SuneKOS Body and SuneKOS Cell 15. An initial series of training events have been announced to kick off the partnerships: Dr Halliley will be providing training in Nottingham on May 14; Feliz will be training in Bournemouth on May 19; and Ogilvie’s first session will be in Stirling on May 20. Lorna Bowes, CEO of AestheticSource, said, “Since its launch, SuneKOS has disrupted the aesthetics market with its innovative, science-driven approach to skin regeneration. The addition of Dr Halliley, Ogilvie and Feliz to our expert team further strengthens our commitment to education and excellence in the specialty. Their clinical expertise and passion for aesthetics will be invaluable in supporting practitioners and driving awareness of the SuneKOS brand.”

Research & Development

Aesthetics gains pharmaceutical insights at ACRE HQ Aesthetics visited the headquarters of ACRE last month to gain insight into the company’s processes, and the role it plays in protecting the integrity of aesthetic pharmaceutical products. Aesthetics geared up in high-vis before being guided through the warehouse by co-founder and director Robert Melville, who explained the importance of safeguarding the supply chain from manufacturer to clinical setting. He said, “The qualification process begins with where we buy the stock from. Is that entity correctly qualified to be able to source and supply the products?” The tour began at the goods-in area, where Melville pointed out the designated bays used to receive deliveries. From there, Aesthetics was shown where products are offloaded and logged, with temperature-monitored storage areas clearly marked. “We follow a process which ultimately protects the integrity of the product,” Melville explained. “That starts with the vehicle it’s delivered in, the temperature control of that vehicle and proof that the products have been transported in the manner they should have been, based on the labelled conditions.” On entering the facility, products undergo a thorough verification process. “This is to ensure the product is as expected and we haven’t received something we shouldn’t be happy with,” Melville explained.

ACRE sees its role as a crucial link in the regulated wholesale chain. “Our function is to be the gatekeeper – to manage the correct handling and distribution of the product until it reaches a setting where the next phase is the patient.” He adds, “The safety of the patient is paramount. Our job is to protect the integrity of the product as long as it lives in that space.” Since entering the aesthetics world in 2018 as a subsidiary of CST Pharma, the business has applied pharmaceutical standards to the distribution of aesthetic products. Melville commented, “We’ve maintained and improved standards over time, qualifying both suppliers and customers.” He noted that ACRE’s Medicines and Healthcare products Regulatory Agency (MHRA) licence, gained as part of the group’s longstanding regulatory framework, has supported further growth, including preferred distributor status with Galderma. “We wouldn’t enter aesthetics without implementing the same governance we apply elsewhere,” he added. Looking to the future, Melville shared his view that, “It’s clear regulation is still some way off. But we passionately believe that if everyone follows best practice, you don’t need regulation, because you self-regulate. Our system supports that principle by helping to ensure compliance from all parties involved.” He added that the platform is constantly updated in line with guidance from professional bodies such as the General Pharmaceutical Council (GPhC) and the Joint Council for Cosmetic Practitioners (JCCP).

Aesthetics | May 2025

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Key Opinion Leader

Michelle McLean appointed new BTL Aesthetics KOL

Revision Skincare launches barrier defence moisturiser

Aesthetic nurse prescriber Michelle McLean has been named as the latest key opinion leader (KOL) for aesthetic device company BTL Aesthetics.

Skincare company Revision Skincare, distributed in the UK by AestheticSource, has unveiled its new DermProtect Barrier Defense. The company explains that the product is an intensive moisturiser targeted specifically for patients with dry to very dry and/or sensitive skin. This can be caused by ageing, hormonal fluctuations, harsh climates or skin ingredients known to cause dryness. The product aims to regulate the skin’s 24-hour cycle to maximise daytime defence and overnight regeneration to strengthen the skin barrier, according to the company. Lorna Bowes, CEO of AestheticSource, said, “I’m thrilled to introduce DermProtect Barrier Defense. This formula goes beyond protection – it strengthens the skin barrier while delivering deep hydration, keeping skin resilient and healthy. Developed with the same scientific expertise that defines Revision Skincare, it’s a product I love using in my own routine.”

The company explains that McLean will be contributing to thought leadership, brand advocacy and clinical credibility. She will be doing this especially through her work with EMFACE to treat facial asymmetry. Her role will support ongoing marketing and educational efforts, helping elevate BTL’s presence within aesthetics, the brand explains. James Carr, national sales manager at BTL Aesthetics UK, said, “We’re delighted to welcome McLean to our KOL partnerships. McLean’s results with EMFACE, particularly in treating facial asymmetry, have been outstanding. Her commitment to delivering exceptional patient outcomes perfectly aligns with our values, and we’re excited to collaborate as we continue to lead in non-invasive aesthetic innovation.”

Skincare

ZO Skin Health introduces new Soothing Hydro Mist Skincare company ZO Skin Health, distributed in the UK by Wigmore Medical, has debuted the new Soothing Hydro Mist. The company shares that the product is designed to restore hydration, sooth sensitivity, support the skin barrier and protect against environmental aggressors, even over makeup. The product is also designed to sooth and reduce redness by up to 68% through the use of active ingredient piperonyl glucoside, ZO Skin Health explains. Brett Vye, general manager for ZO Skin Health UK & Ireland, commented, “The launch of our new Soothing Hydro Mist is an exciting addition to our advanced skin health portfolio. This innovative formula is clinically shown to deliver deep, sustained hydration through our Multi-Weight Hyaluronic Acid Complex. Powered by skin-soothing ingredients like piperonyl glucoside and our exclusive ZPOLY complex, Soothing Hydro Mist not only calms and refreshes sensitised skin, but also reinforces the skin’s barrier to help defend against daily environmental stressors.”

This month’s newest clinic openings A round-up of the latest aesthetic clinics opening across the UK Aesthetic practitioner Dr Ahmed El Muntasar has officially opened his new clinic in the heart of Mayfair, located at 71 Duke Street, London. The launch is supported by a carefully selected team of specialists. Clinic and operations manager Angel Joel

has played a key role in ensuring a seamless opening, overseeing the day-to-day running with a strong focus on organisation and patient experience, according to Dr El Muntasar. Senior laser therapist Morgan brings expertise in advanced aesthetic technologies and will be offering Alma Harmony and EmSculpt treatments, alongside microneedling and tailored skincare consultations.

The clinic will offer a range of non-surgical cosmetic treatments. Dr Robinson said, “It’s about improving people’s confidence, in a safe, efficacious way, in order to deliver results that make people feel better.”

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

Discover the Journal Archive Catch up on news, case studies, features and CPD articles www.aestheticsjournal.com/archives

Aesthetic practitioner Dr Ed Robinson has announced the opening of his new clinic, situated at 283 Ashley Road, Hale in Cheshire.

Aesthetics | May 2025

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Symposium Report

BAMAN Spring Symposium provides advanced learning On April 4, the British Association of Medical Aesthetic Nurses (BAMAN) returned to The King’s Fund London to provide 166 delegates with advanced aesthetic education. The day began with a welcome address from BAMAN’s new chair nurse prescriber Amy Bird, in which she welcomed the enthusiastic nurses, and thanked them for their contribution to the specialty over the last 15 years. Aesthetic nurse prescribers Sharon Bennett, Sharon Brown and Sharon King were then presented with honorary memberships, along with a standing ovation. The event continued with advanced nurse practitioner Emmanual Toni speaking on the psychological impact of psoriasis and eczema; nurse prescriber Elaine Williams discussing the links between toxin, mood and perimenopause; and plastic surgeon Mr Tunc Tiryaki diving into the science behind exosomes. Bird commented, “Whether you’ve travelled far or you’re local, whether this is your first BAMAN event or one of many, you are incredibly welcome. You’re part of something bigger – a national network of medical aesthetic nurses dedicated to safe, ethical and progressive practice. Our strength as an association lies not just in what we do, but how we support one another.” On The Scene

Zenoti throws Innergize summit Patient booking software company Zenoti hosted the annual Innergize summit at The Gherkin on April 8. The afternoon centred on business strategy and the evolving expectations of patients within the wellness sector, featuring a series of insightful presentations. A keynote speech was delivered by Sudheer Koneru, CEO of Zenoti, alongside a panel discussion featuring leading figures in the field, including aesthetic practitioner Dr Bryony Elder and aesthetic surgeon Miss Priya Chadha, alongside Richard Gibbons, founder of the Facebook advertising agency Boost My Customers. Miss Chadha commented, “Innergize 2025 was an inspiring opportunity to connect with forward-thinking professionals and gain deeper insight into the distinct capabilities of Zenoti as a comprehensive patient management system. Events like this are essential for both personal and professional growth, and I’m proud to be part of a community so dedicated to excellence, collaboration and compassionate service.” Conference Report

ExoCoBio hosts Summit at RSM The Royal Society of Medicine (RSM) welcomed aesthetic professionals to the 15th UK Regenerative Aesthetic ExoCoBio Summit on March 17. The event brought together clinicians and researchers to discuss advancements in exosome-based treatments and their growing role in regenerative aesthetics. On the day, Dr Munir Somji outlined clinical applications of exosome therapies in aesthetic practice, drawing from case experience. Dr Apul Parikh later detailed the manufacturing standards and purity of the ExoCoBio exosome product in focus, alongside an overview of its mechanism of action and supporting clinical imagery. Dr Ayah Siddiqi later presented on recent developments in skin health, highlighting exosomes as a promising modality in dermatological care. Aesthetics | May 2025

News in Brief Phorest introduces enhanced notetaking technology Software solution company Phorest has released its new Dot Phrasing technology. The company explains that the technology enables practitioners to take faster, more accurate and consistent patient notes during and after consultations. Órla Phelan, global director of medspa operations at Phorest, said, “By automating repetitive notetaking, this feature ensures practitioners spend less time typing and more time focused on their patients.” Cynosure Lutronic releases Skinsights report Aesthetic device manufacturer Cynosure Lutronic has published its patient-focused Skinsights report. The report surveyed 1,500 UK participants, with 66% females and 34% males. The survey highlighted that ‘improving confidence’ was the most popular reason for undergoing an aesthetic treatment, outweighing special offers and peer recommendations. 90% of respondents said they suffered from at least one skin condition, and women were mostly focused on traditional antiageing treatments while men focused on medical skin conditions. Nearly 50% of participants listed fine lines and wrinkles as their top problem. W-Wellness launches Academy UK e-commerce platform W-Wellness has announced the launch of educational platform the W-Wellness Academy. The focus is on providing training designed to help practitioners effectively utilise the platform and its associated products, with the aim of improving patient health and treatment outcomes. Chief operating officer and co-founder Sally Lefever-Bell explains, “The new W-Wellness Academy will run regular events to mentor, coach, educate, empower and support practitioners so they can do what they love best.” Croma-Pharma debuts Croma Revitalis skin booster Pharmaceutical company Croma-Pharma has launched new hyaluronic acid skin booster, Croma Revitalis. The booster, available to wholesalers by mid May, is designed to improve elasticity and hydration to revitalise the skin. Alexandra Mills, nurse prescriber and BAMAN vice-chair, said, “As we age, our skin loses vital components such as hyaluronic acid and collagen, resulting in sagging and creases. Revitalis remedies this by delivering intense hydration into the skin, smoothing out superficial wrinkles.”

Advertorial Aesthetica Solutions

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· Post-treatment NAD+ injections may

help counteract oxidative stress and inflammation, prolonging the effects of aesthetic treatments.

Hair restoration therapy

· NAD+ has been linked to improved

mitochondrial function in hair follicle cells, potentially enhancing the effects of PRP or exosome therapy for hair growth. · By reducing inflammation and oxidative stress, NAD+ can support a healthier scalp environment, optimising hair restoration outcomes.

InstaScript: Revolutionising ordering One of the key recent initiatives to make life easier for clients was to create a bespoke online prescription generation platform. InstaScript lets practitioners create and generate prescriptions online, streamlining their administration and saving significant time. As an additional incentive, clients are able to access 1% cashback on all orders placed above £250.

The role of NAD+ injections in antiageing and skin rejuvenation In the ever-evolving field of medical aesthetics, innovative therapies that promote skin health, longevity and overall wellness are in high demand. Nicotinamide adenine dinucleotide (NAD+) injections have gained traction for their role in cellular repair, energy metabolism and antiageing benefits. While traditionally associated with functional and regenerative medicine, NAD+ therapy is now making its way into aesthetic practices as a complementary treatment alongside conventional cosmetic procedures. This article explores how NAD+ injections can enhance aesthetic outcomes, support skin rejuvenation and integrate seamlessly with other popular treatments.

NAD+ and its role in medical aesthetics NAD+ is a coenzyme essential for cellular function, DNA repair and mitochondrial health. As we age, NAD+ levels naturally decline, leading to reduced cellular efficiency, increased oxidative stress and accelerated ageing. In aesthetics, the goal is not just to improve surface-level appearance, but to support skin health at a deeper, cellular level. 16

Figure 1: NAD+ IM

NAD+ injections have been shown to:1-7

· Boost cellular energy production:

Enhancing ATP production in cells helps improve skin vitality and resilience. · Promote DNA repair: Reducing oxidative stress and supporting cellular longevity can slow the visible signs of ageing. · Improve skin hydration and elasticity: By supporting fibroblast function, NAD+ may enhance collagen production, leading to firmer, more youthful skin. · Accelerate healing and recovery: Post-procedure inflammation and downtime can be minimised with NAD+’s regenerative properties.

Integrating NAD+ therapy with aesthetic treatments NAD+ injections can be a valuable adjunct to various aesthetic procedures, enhancing both their efficacy and recovery time. Skin rejuvenation and antiageing treatments

· When combined with microneedling,

laser therapy or chemical peels, NAD+ may accelerate healing and optimise collagen synthesis. · Patients undergoing platelet-rich plasma (PRP) therapy for skin rejuvenation may benefit from NAD+’s ability to improve cellular repair and function. Injectable aesthetics

· While neuromodulators and fillers

address wrinkles and volume loss, NAD+ therapy supports skin quality from within, providing a more comprehensive antiageing approach. Aesthetics | May 2025

Figure 2: NAD+ IV

The future of NAD+ in aesthetic practices With a growing focus on longevity and regenerative aesthetics, NAD+ therapy presents an exciting opportunity for aesthetic professionals. By incorporating NAD+ injections into treatment protocols, clinics can offer patients not only enhanced aesthetic outcomes, but also improved energy, mental clarity and overall wellbeing. As research continues to uncover the full potential of NAD+, its role in medical aesthetics will likely expand, further bridging the gap between cosmetic enhancement and cellular rejuvenation. Forward-thinking aesthetic practitioners who adopt NAD+ therapy now may, in future, find themselves at the forefront of a new era in beauty and wellness. This advertorial was written and supplied by

If you’d like to know more about NAD+ injections or other high grade aesthetic products, please visit aestheticasolutions.co.uk

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The Impact of US Trade Tariffs on UK Aesthetics Aesthetics reports on the potential implications for UK aesthetics following recent US trade tariffs On April 2, US President Donald Trump announced the introduction of new trade tariffs, significantly increasing import duties on goods from multiple countries.1 This policy shift signalled a broader realignment in American trade strategy, reflecting a move towards protectionism with global economic implications.1 As of April 2025, the UK faces a 10% tariff on most exports to the US, with higher rates particularly on steel and automotive products.2 While the UK is not subject to the steep tariffs imposed on Chinese imports, for example, the 10% tariff is still set to have a significant economic effect. Analysts at the Centre for Economics and Business Research (CEBR) estimate that these tariffs could reduce UK gross domestic product (GDP) by 0.9% by the end of Trump’s term, equating to a potential £20-24 billion impact on the UK economy.3 UK Prime Minister Keir Starmer labelled the imposed tariffs as “a new era,” stating, “This is not just a short-term tactical exercise. We have to understand the changing world when it comes to trade and the economy.”4

What are tariffs? Tariffs are taxes imposed on imported goods, typically calculated as a percentage of the product’s value.5 They are used to regulate international trade by increasing the cost of foreign products, thereby influencing domestic consumption and supposedly promoting local industries.5 Financial specialist Martin Lewis simplifies the concept, saying, “When other countries send goods to the US, there’s now a tariff – a tax levied on them when they’re imported.”6

News Special Trade Tariffs

clinics, regardless of whether these are directly attributed to tariffs. She says, “During this challenging time, maintaining open and transparent communication with suppliers, adopting more strategic procurement practices and clearly articulating value propositions to patients, beyond price alone, will be essential for effective clinic management.” From a UK distribution perspective, nurse prescriber and CEO of AestheticSource Lorna Bowes shares, “We can expect multiple effects from the tariff situation, but many of the negative ones will be seen in the mid to long term. In the short term, a stronger pound has slightly eased US import costs; however, COVID-19-related disruptions to manufacturing and shipping had already driven prices up, largely counteracting this benefit. In the longer term, increased tariffs on key regions could raise costs for US manufacturers sourcing components and raw materials, driving up prices across skincare, injectables and energy-based devices.”

Mitigating risk in clinical practice While trade tariffs may appear intimidating to clinic owners and those newer to the field, there are proactive measures available to mitigate the associated risks for your clinic. Tan recommends that clinics should begin by assessing their supply chains. She says, “Consider exposure to not only US or Chinese suppliers, but also other regions impacted by trade tensions. As many tariff exemptions are temporary, the situation may change rapidly. Diversifying suppliers, exploring alternative product lines or renegotiating pricing terms can enhance flexibility. In a time of global uncertainty, being prepared isn’t just smart, it’s empowering.” Additionally, Tan emphasises that clinic owners need not navigate challenging economic conditions alone, and suggests that partnering with business support services – such as accountants and business consultants – can offer invaluable insights and strategic support.

Amidst this transformative period, in what position does this leave the UK medical aesthetics community?

Thomson also outlines various steps a clinic owner can take to future-proof clinic investments, suggesting, “To minimise the impact of future disruptions, clinics should consider building a buffer stock of high-turnover items likely to be affected by tariffs.” She also emphasises the importance of maintaining open dialogue with suppliers concerning risk management strategies, particularly in relation to components or packaging sourced from China. Without adequate contingency planning, she warns, clinics may be exposed to significant operational risks. Reflecting on potential strategies for clinic owners, Thomson states that in some cases, “Paying a small premium may be a worthwhile trade-off for greater supply security.”

Exploring the potential implications

Navigating what’s next

In practice, this means that US importers bringing goods into the country are required to pay higher taxes on those imports.7 This increases the overall cost of foreign goods, thereby incentivising consumers to purchase domestically produced alternatives and potentially reducing demand for imports.7

“UK clinics may face growing competition for essential products,” says Cindy Tan, accountant and founder of Core Connect Accountants. “The global supply chain is under sustained pressure with inflation projected to rise. As US buyers seek to avoid Chinese tariffs by turning to alternative Asian or European markets with lower import duties – many of which also supply the UK – demand on these sources is expected to increase. This may lead to higher prices, longer delivery times and potential shortages, particularly for high-demand medical and aesthetic supplies.” Sue Thomson, business specialist and CEO of SJ Partnership, similarly highlights the expected impact of rising costs and reduced exports from China, noting that such conditions may prompt suppliers to shift their focus toward alternative markets. “This reallocation could lead to supply chain disruptions within the UK, resulting in longer lead times, unexpected price fluctuations and reduced supply reliability – factors that can disrupt clinic operations and hinder consistent service delivery,” she explains. Thomson states that to reduce their own financial repercussions, distributors and brands are likely to pass on increased costs to

Maintaining optimism, Tan suggests that the tariffs could present an opportunity to the aesthetics specialty, stating, “In times of uncertainty, suppliers often prioritise reliability and stability. The UK, with its strong regulatory standards for products and trusted business environment, could position itself as a preferred partner, giving clinics here a potential edge if they’re ready to act.” The future of these tariffs remains uncertain, as President Trump has already revised, delayed or temporarily suspended some tariff measures, contributing to ongoing unpredictability.8 Starmer has reiterated his commitment to preserving a strong and productive relationship with the US, stating, “What I want to see is strong trading relations. In the discussions that I have had with President Trump, that is what we have centred on.”9 While UK tariffs are currently set at just 10%, they could still have a significant impact on the aesthetics sector. It is important for aesthetics professionals to remain vigilant of economic changes and seek expert guidance where necessary. VIEW THE REFERENCES AT AESTHETICSJOURNAL.COM

Aesthetics | May 2025

Event Preview CCR 2025

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25 & 26 September 2025

Shape Your Future in Medical Aesthetics Excel, London

CCR returns this year for learning, networking and connecting Following a successful Aesthetics Conference and Exhibition (ACE) in March, it’s time to look toward to your next aesthetics event – the Clinical Cosmetic Regenerative (CCR) Congress on September 25 & 26. Whether you want to learn the latest in regenerative medicine, view live demonstrations for the newest injectable techniques or gain invaluable business skills, CCR offers something for everyone in the aesthetics specialty.

What to expect this year… Aesthetics Journal Arena Brought to you by the Aesthetics Journal team, this arena brings the journal to life. It is the central hub for leading discussions, featuring keynote speakers, expert panels, live demonstrations and thought-provoking debates on the latest trends, clinical studies and advancements shaping the aesthetics sector. Galderma returns as CCR’s Headline Sponsor, once again setting the standard with cutting-edge clinical insights, scientific innovation and live injectable demonstrations from top aesthetics experts. Don’t miss Galderma’s daily one-hour symposiums, featuring a specialty-changing product launch. Session topics and speaker details coming soon! 18

NEW Aesthetics Mastery Theatre Immerse yourself in the art and science of medical aesthetics at the Aesthetics Mastery Theatre, with theatre sponsor DermaFocus showcasing the latest in regenerative medicine through one-hour lunchtime takeovers. Experience live demonstrations and in-depth discussions led by top experts, revealing the techniques and products that are shaping the field. From scientifically-backed approaches to the latest clinical advancements, this is your chance to gain valuable insights and see aesthetics mastery in action. This theatre is perfect for those who want to go beyond the surface and explore the precision, skill and expertise behind today’s leading treatments and brands. Don’t miss this opportunity to deepen your knowledge and be inspired by cutting-edge innovations! Brands confirmed to host talks on this stage include Dermapenworld, Fotona UK and Klira. NEW The Innovation Forum Step into the future of medical aesthetics at The Innovation Forum. Get ready for a series of electrifying 25-minute sessions, each bursting with the latest product launches, game-changing breakthroughs and revolutionary techniques. Specialty trailblazers will take the stage to unveil their boldest ideas and cutting-edge innovations, offering you an exclusive look into tomorrow’s top trends. This is your chance to stay ahead of the curve, be inspired and witness the next big thing in aesthetics before anyone else. Aesthetics | May 2025

Confirmed brands include: · Theatre Sponsor · Hydrafacial SkinCeuticals · InMode · Acclaro · Korea Meditech · BTL Aesthetics · Novus Medical · Cure Medical · Sciton · Cutera

· Fotona UK

· Sofwave

In Practice Theatre As well as clinical education, you will have the opportunity to set yourself apart from your competitors and expand your business knowledge at the In Practice Theatre. Situated inside the brand new In Practice Zone , sponsored by Dermis AI, this theatre provides invaluable insights into marketing strategies, clinic management, patient communication and legal considerations to help practitioners build thriving aesthetic businesses. You will also be able to get hold of a copy of our annual Trends Report, to help set you apart from your competitors and solidify the future of your clinic. Confirmed brands include Associate Sponsor Phorest. Medical Longevity Summit The Medical Longevity Summit (MLS) returns for the third year with a brand-new theme, focusing on women’s health. MLS is a dedicated space and theatre that looks into evidence-based practice in holistic care and wellness, including functional, integrative, regenerative and lifestyle treatment approaches. The content will be curated by Dr Mayoni Gooneratne, the founder of Human Health Professionals, alongside an exciting collaboration in association with the Women’s Integrative Health Collective.

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The Summit will also host key brands in the longevity and wellness space, allowing delegates to find out more about products and ask any questions. Confirmed companies within the summit include:

· · · · · · · · ·

Event Preview CCR 2025

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NAD at Home Nuchido Halo Health Hifas de Terra Human Health Professionals One Hyperbaric Nature’s Plus L-Nutra Roseway Labs

Totally Derma Dotolo Europe Toneko NL Vitacare & NAD Medica · Yotsuba Japan · Celluma Light Therapy · Meicet

· · · ·

More to be revealed soon!

Connect with top brands

(IBITA), returns to CCR once again to showcase the latest advancements from one of the world's most influential aesthetics markets. With Korean companies now expanding into new territories across the UK, the zone offers practitioners and distributors an exciting opportunity to discover the newest advancements in medical aesthetics and stay ahead of the competition. Discover cutting-edge technologies, revolutionary skincare and transformative techniques that are shaping the future of aesthetics.

VIP Experience The VIP Lounge is making a return for 2025. Designed for high-level networking and ultimate comfort, the VIP area provides a premium experience for guests, ensuring you can make the most of the event in a relaxed and luxurious setting. VIPs will be welcomed by invitation only, so stay tuned for more details.

As well as education, CCR will offer delegates easy access to the latest products, services and solutions so you can bring patients the very best in medical aesthetics. The exhibition offers one of the best places to network with 140 leading companies such as Alma, Crown Aesthetics, DermaFocus, Dermapenworld, Galderma, SkinCeuticals and many more!

Aesthetics Mentoring Education and mentorship are at the heart of CCR, and the Aesthetics Mentoring initiative will return to provide invaluable guidance from leaders in the specialty. Whether you’re a newcomer seeking career advice or an established practitioner looking for fresh perspectives, this mentorship programme is designed to empower your journey in aesthetics.

Injectable Avenue For professionals looking to refine their injectable expertise, the CCR Injectable Avenue offers a dedicated space to explore the latest products, techniques and training opportunities. You can engage with top-tier brands and thought leaders to elevate your skills and expand your practice.

Korea Pavillion The Korea Pavillion, in partnership with the International Beauty Industry Trade Association

Why should you attend? “Whether you're just starting out or have been in the specialty for 20 years, it's a place where you can learn from the best, while also discovering the latest innovations in injectables, devices and skin treatments. The talks were incredible, and the experts were top-notch. More intimate events, like 'Aesthetics Mentoring', offer 1-to-1 sessions with experienced practitioners, allowing you to engage directly and learn from their journeys. Staying connected to the specialty is vital, and I wish I had something like this when I was starting out, where you could speak to mentors and see that there's no single path to success, as everyone’s journey is different.” Dr Max Greenfield

Register Your Interest With so much to explore, CCR 2025 promises to be an essential event for every aesthetics professional. Stay ahead of the curve and immerse yourself in the future of medical aesthetics. Scan the QR code to register your interest for CCR 2025.

Aesthetics | May 2025

25 & 26 September 2025 Excel, London

Headline Sponsor

Innovative Treatment targeting the 3 processes of Cellulite Reducing Fat Reducing Fluid retention Breaking down fibrotic tissue

WHO ARE WE? Proteos Biotech, founded in 2010, is a leading company in the research and production of recombinant enzymes for biomedical and cosmetic use. pbserum, the first therapeutic system based on recombinant enzymes is present in over 50 countries, the company continues to expand globally with the U.K. now joining as the 51st country. SUBSTRATE

OUR ENZYMES Enzymes are essential proteins that accelerate

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key cellular reactions in the body. At pbserum, we harness their functions to develop products that improve health and quality of life. Our recombinant enzymes, produced through

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molecular biology, are highly specific, pure, and free of animal-derived components, meeting the highest clinical quality standards. INDUCED ADJUSTMENT MODEL

Sirona Aesthetics Ltd is the exclusive distributor of pbserum in the UK www.sironaaesthetics.co.uk jshand@sironaaesthetics.co.uk +447738351729

Proteos Biotech S.L. Avenida de la Osa Mayor, 4, 28023, Madrid, España info@pbserum.com | +34 915 417 001 | proteosbiotech.com Proprietary material of pbserum / Proteos Biotech for the exclusive use of qualiﬁed healthcare personnel only. Any part of this material may be copied, distributed, or edited by third parties without the prior explicit consent of Proteos Biotech, S.L. All photographs used have been provided by the treating physicians. Emial for reporting adverse reactions, allergies and all related information: technosurveillance@pbserum.com. Consultation of medical information: medinfo@proteosbiotech.com.

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Approaches to Treating Cellulite Four practitioners share their strategies for managing and improving the appearance of cellulite Cellulite is a common, benign condition that presents as uneven, dimpled skin, most frequently affecting the thighs, buttocks, hips and lower abdomen.1 Its appearance can vary in severity, ranging from subtle dimpling visible only when the skin is pinched, to more pronounced undulations at rest. Although not medically harmful, cellulite can have a considerable psychosocial impact, often contributing to reduced self-esteem and body confidence.1 Although cellulite is very common, affecting an estimated 80-90% of women, it can be associated with profound negative psychosocial and quality of life issues.2 The underlying pathophysiology of cellulite is complex and multifactorial, involving changes to the dermal and subcutaneous architecture, fibrous septae, local circulation, hormonal factors and skin laxity.2 Aesthetics speaks to four practitioners about their clinical experience in managing cellulite. They discuss assessment strategies, treatment selection and key considerations for optimising results in practice.

Understanding cellulite Consultant surgeon and trainer Mr Arturo Almeida notes that there are many misconceptions about cellulite. One of the most common is the belief that cellulite is primarily a fat problem. He explains that cellulite arises due to the interaction of subcutaneous fat deposits with fibrous connective tissue beneath the dermis.3 Despite being often associated with excess body fat, cellulite also affects slim individuals due to factors such as skin structure, circulation and connective tissue integrity.3 To gain further insight into device-led approaches for cellulite treatment, Aesthetics spoke with nurse prescribers Victoria Worthington and Khatra Paterson, key opinion leaders (KOLs) at Deleo. Worthington and Paterson both highlight that cellulite affects up to 90% of post-pubertal women, compared to a much lower incidence in men.4 This imbalance is due to differences in connective tissue structure; women’s fibrous septae are arranged vertically, allowing fat to protrude upwards into the dermis, while men’s are arranged in a crisscross pattern, providing more support.4 Aesthetics consulted Ms Yuliya Dyedyk-Gusarova, KOL for PB Serum – an injectable enzyme-based product used in the treatment of cellulite. According to the oral and maxillofacial surgeon, multiple factors contribute to the development of cellulite. “Hormonal influences – particularly oestrogen – play a significant role, alongside lifestyle factors, diet, genetic predisposition and skin quality,” she explains. “All of these elements interact to influence the severity and visibility of cellulite in affected individuals.”5 Additionally, habits such as smoking, excessive alcohol intake and prolonged periods of sitting may impair circulation and lymphatic drainage, exacerbating the condition.3 Paterson notes that vascular and lymphatic insufficiency play a significant role in the development and persistence of cellulite. According to her, poor microcirculation leads to fluid accumulation, tissue hypoxia and impaired collagen synthesis. She adds, “When there’s reduced blood flow and poor lymphatic drainage, tissue becomes congested and more prone to inflammation and fibrosis. That’s why one of our first priorities, especially with oedematous cellulite, is to restore circulation and support lymphatic movement.” Ms Dyedyk-Gusarova highlights the importance of addressing the vascular component of cellulite saying, “Increased vascular permeability, microcirculatory dysfunction and oedema contribute to tissue congestion and inflammation, which eventually promote fibrotic remodelling. This oedematous component is best addressed by enzymatic agents such as PB72K (Lyase), which help restore drainage and reduce interstitial fluid. Understanding and treating the vascular elements is essential to improving both the function and appearance of the affected tissue.” Aesthetics | May 2025

Special Feature Treating Cellulite Cellulite remains one of the most stubborn cosmetic complaints among women.2 Mr Almeida notes, “In a recent survey published by the American Society for Dermatologic Surgery in 2023, cellulite was listed – for the first time – among the top five most requested aesthetic treatments by patients in the US.4 This reflects a significant shift not only in consumer demand, but also in our understanding of what patients value in cosmetic care.”

Variants of cellulite The interviewees explain that classifying cellulite by its morphological presentation can aid practitioners in identifying the most suitable treatment approach for individual patients. “There are three main types of cellulite that we see in practice,” explains Worthington. “Adipose cellulite is soft and often associated with fat accumulation and reduced muscle tone. Fibrous cellulite is harder, more compact and can be painful, typically due to the presence of fibrotic septae. Oedematous cellulite, by contrast, is related to impaired lymphatic drainage and water retention, resulting in a swollen or spongy texture.”3

Effective patient consultation For many patients, the interviewees explain that the goal of cellulite treatment is modest but meaningful – often simply to feel more confident in wearing shorts or going to the beach. “It starts with listening to the patient,” explains Mr Almeida. “Understanding their expectations and concerns is essential.” A thorough consultation should follow, beginning with a detailed medical history and a proper clinical evaluation. “Assessment should always be conducted with the patient standing under good lighting to evaluate the severity of the cellulite,” he notes. “Using the Nürnberger-Müller Scale,6 practitioners can identify whether the cellulite is Grade 1, 2 or 3,” he adds. According to Worthington and Paterson, cellulite can be classified using a scale that evaluates its appearance, both at rest and during palpation. In Grade 1, dimpling is only visible when the skin is pinched. In Grade 2, dimpling is noticeable when the patient is standing but disappears when lying down. Grade 3 represents the most advanced stage, where dimpling is visible in both positions and is often accompanied by deeper depressions.6 Mr Almeida adds, “Similar to other visual scales that are valid for all skin tones, the Nürnberger-Müller Scale is still useful in Black skin. There are certain things, like the blanching that may occur related to the oedema that is found in cellulite, particularly in Grade 2 or Grade 3, that might not be 21

Special Feature Treating Cellulite as clearly visible in Black skin. However, in terms of using the scale it is still useful to assess cellulite even in Black skin.” “A cellulite consultation isn’t just about what we see, it’s about understanding what’s happening underneath the skin and what the patient wants to achieve,” says Worthington. The practitioners also conduct both visual and tactile analysis to assess skin tone, elasticity and underlying fat distribution, which are critical to determining the most appropriate treatment approach. While the scale is simple and practical for clinical use, Worthington and Paterson note that it is subjective and does not account for deeper anatomical contributors. They emphasise that an understanding of both the visible characteristics and the underlying structural issues is key to selecting appropriate treatment modalities – whether targeting adipose tissue, improving lymphatic drainage or addressing fibrotic bands. Photographic documentation is routinely used to track progress and provide patients with a clear view of their treatment outcomes over time. Additionally, lifestyle factors and any history of previous treatments are explored to gain a comprehensive understanding of the patient’s condition and expectations.7

Managing patient expectations Ms Dyedyk-Gusarova notes that setting realistic expectations is a key part of the consultation. “Patients need to understand the likely number of sessions required, and that complete resolution may not always be possible. Results vary between individuals, so we focus on achievable improvements rather than perfection. Before

After

Figure 1: 29-year-old female presenting with phototype II, oedematous cellulite on buttocks, Grade 2 on the Nürnberger-Müller Scale and after eight session of Cellution over four consecutive weeks.

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I always show before-and-after images to demonstrate potential outcomes. If the patient understands their role in the treatment journey and agrees with the plan, we proceed with confidence,” she says. This emphasis on expectation management is echoed by Paterson and Worthington. “We explain from the outset that cellulite is a chronic, structural issue – not just a cosmetic one,” says Paterson. “Improvement is absolutely possible, but it requires commitment.” They stress that improvement is gradual and cumulative, and that patient understanding of this is vital for satisfaction with outcomes.⁸

Clinical options for cellulite management There are a variety of treatment modalities available, each targeting different components of cellulite. As noted by Worthington, “The most successful approach is layered and individualised, addressing all the structural, vascular and dermal components of cellulite.” Mr Almeida notes that those with more advanced cellulite – typically Grade 3 – may require more intensive or device-led interventions, such as subcision techniques or other minimally invasive procedures. “However, most patients consulting for cellulite tend to fall within the Grade 1 or 2 categories,” Mr Almeida explains. “These individuals are often excellent candidates for injectable treatments currently available on the market, which can offer visible improvement with minimal downtime.” Topical products Topical products, such as those containing caffeine or retinol, offer mild and temporary improvement in skin appearance.9 For more targeted treatment, techniques like subcision and microneedling can be used for the mechanical release of tethered septae.9 Topical formulations can play a supportive role in the management of cellulite. Worthington notes, “Topical products are best suited for early-stage or mild cellulite and for patients committed to a daily regimen. We typically recommend them as a supportive home care step, especially between in-clinic treatments. It’s important to manage expectations though as they can improve skin texture, but they won’t address the deeper structural causes.” Ms Dyedyk-Gusarova agrees, emphasising their value as adjuncts to professional protocols. “Topical formulations can complement enzymatic therapy, particularly in patients with mild cellulite or as maintenance following a course of professional treatments. I typically recommend daily application for a minimum of eight to 12 weeks to observe meaningful Aesthetics | May 2025

Aesthetics

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improvement. It is important to select products with active ingredients that support microcirculation, tissue drainage or lipolysis. However, they should be regarded as adjuncts, not substitutes, to targeted in-clinic procedures,” she says. Manual therapies Manual therapies, including massage and lymphatic drainage, help support circulation and fluid reduction.9 “Lymphatic drainage or deep tissue massages can be beneficial for enhancing the outcomes of enzymatic therapy – particularly in patients with pronounced fluid retention,” says Ms Dyedyk-Gusarova. “I often incorporate them weekly (seven days apart from enzymatic treatment) during the active treatment phase, as they stimulate lymphatic flow, facilitate enzyme distribution and support tissue detoxification.” She adds, however, that “caution is advised in patients with vascular fragility or severe fibrosis, as aggressive manipulation may exacerbate inflammation.” Worthington explains that, “Manual techniques like lymphatic drainage or mechanical massage such as Endermologie work well for patients with fluid retention, post-surgical swelling or those in early stages of cellulite.” She notes that these methods are often used “as an entry point before moving into more advanced device-led protocols due to them being a more gentle, non-invasive option.” According to Worthington, the key to effectiveness is consistency and multiple sessions, with the best results seen when these techniques are integrated into a long-term plan alongside other modalities. They’re especially useful for oedematous cellulite or as post-treatment support. Injectables Injectables, such as collagenase or mesotherapy, are used to dissolve fibrous bands or promote lipolysis. Collagenase enzymes specifically target and break down collagen in fibrotic tissue, making them effective for treating cellulite and skin dimpling.10 Mesotherapy involves microinjections of vitamins, enzymes, hormones or medications to improve skin quality and stimulate localised fat breakdown.10 Mr Almeida notes that one of the injectable options available in the UK and internationally is Alidya, an anti-lipodystrophic agent developed by Marllor Biomedical, which is designed specifically to target the underlying causes of cellulite (Figure 2). “Unlike mesotherapy cocktails, Alidya is a standardised medical device with reproducible, consistent results. Sometimes, the ingredients we include in those mesotherapy cocktails aren’t

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Before

Aesthetics

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Ms Dyedyk-Gusarova says that successful outcomes depend not only on the treatment itself, but also on patient cooperation. “I have seen that approximately 60% of the result comes from clinical intervention, but the remaining 40% depends on the patient’s involvement,” she explains, adding, “Enzymes work synergistically with the body, so our patients must also commit to supporting that process.”

After

Figure 2: A 44-year-old woman with long-standing Grade 2 cellulite was treated with Alidya (an injectable treatment developed by Marllor Biomedical) on the posterior thighs over four sessions (one vial/10ml per session), with the after photo taken three weeks post treatment.

specifically targeting the underlying cause of cellulite. Instead, they’re formulated to act on fat cells – so it’s not exactly cellulite we’re treating,” says Mr Almeida. Mr Almeida continues, “Newer options using polydeoxyribonucleotides (PDRN) are emerging, but results are still mixed.” While early studies highlight PDRN’s regenerative effects – such as improved microcirculation, collagen stimulation and enhanced tissue repair – further clinical research is required to determine its efficacy in this context.11 Another injectable treatment option involves the use of a combination enzyme-based formulation containing lipase, collagenase and lyase, alongside high molecular weight hyaluronic acid. One example is PB Serum Medium manufactured by Proteos Biotech, part of a medical line developed to address multiple presentations of cellulite. As Ms Dyedyk-Gusarova explains, "This multi-enzyme approach allows us to target different pathophysiological factors involved in cellulite formation. Lyase is particularly effective in addressing oedematous cellulite, where fluid retention is a key concern. Lipase is included to target adipose hypertrophy, while collagenase GH PB220 helps to break down fibrotic septae associated with more advanced, fibrous forms of cellulite. By applying these enzymes synergistically and tailoring treatment to the patient’s clinical presentation, we can achieve more targeted and effective outcomes.”12 Devices Energy-based devices, like radiofrequency, ultrasound and infrared, stimulate collagen production and improve skin texture, while shockwave therapy works by breaking down fibrous septae and enhancing skin elasticity.9 Mr Almeida emphasises that no single treatment is a cure-all. “Devices like radiofrequency and carboxytherapy can complement injectable treatments,” he adds. In Paterson’s clinic, the Cellution device by Deleo is frequently used due to its comprehensive 4-in-1 technology. The

Special Feature Treating Cellulite

platform combines focused and radial shockwaves to remodel connective tissue and stimulate lymphatic and vascular flow, respectively. It also incorporates vacuum-assisted massage to enhance skin tone and support cellular exchange (Figure 1). Additionally, the device delivers active topical ingredients, including samphire and red algae, to complement the mechanical effects.13 “Cellution is highly adaptable,” explains Paterson. “The combination of radial and focused shockwaves with vacuum makes it a standout tool for tackling cellulite from all angles. It’s become one of our most reliable, results-driven technologies.”

Considerations and limitations According to Ms Dyedyk-Gusarova, patient selection plays a crucial role in the safety and efficacy of enzyme-based treatments for cellulite. “PB Serum enzymatic treatments yield optimal results in patients with a BMI under 30, where cellulite is more likely to be structurally driven rather than secondary to extensive adipose accumulation. In these individuals, the fibrotic and vascular factors are more isolated, making enzymatic remodelling more targeted and effective. Conversely, in patients with higher BMIs, a multimodal strategy combining weight management, body contouring and enzymatic therapy is often required,” she explains. She adds that they do not treat individuals who are pregnant or breastfeeding, as hormonal fluctuations during these periods contraindicate aesthetic interventions. According to Ms Dyedyk-Gusarova, patients with unregulated hormonal imbalances, such as oestrogen dominance, thyroid dysfunction or polycystic ovary syndrome, may exhibit persistent adipose and fibrotic remodelling, contributing to therapy resistance. She explains, “In such cases, we proceed cautiously and, where appropriate, collaborate with endocrinologists. Achieving hormonal balance enhances the long-term efficacy and predictability of aesthetic outcomes.” Aesthetics | May 2025

She outlines specific post-treatment recommendations, including adequate hydration, adherence to a high-protein diet and maintaining physical activity.3 “These lifestyle adjustments are vital for enhancing both the speed and longevity of results,” she adds. The practitioners share that a successful treatment approach must be personalised to match the morphological type of cellulite present, and tailored to each individual’s skin condition, fat distribution and lifestyle. It is equally important to assess patient suitability carefully, ruling out contraindications such as vascular compromise, active infection or pregnancy.14 Ms Dyedyk-Gusarova adds, “Patient safety is paramount when selecting candidates for enzymatic therapy. Active infections must be resolved beforehand, and caution is advised in individuals with inflammatory or autoimmune conditions, atopy or bronchial asthma, as they may have heightened immune sensitivity.” Worthington says that cellulite doesn’t exist in isolation, it’s part of the broader landscape of skin health and body confidence. She notes, “Our priority is to treat it holistically and ethically.”

Achieving patient-centric outcomes Cellulite remains a multifactorial condition requiring a nuanced, patient-centred approach. Multimodal protocols that address the structural, vascular and dermal components of cellulite – tailored to individual presentation and supported by lifestyle modification – offer the most consistent outcomes, as our interviewees explain. Ultimately, managing expectations and promoting long-term maintenance are as essential as the treatment itself. VIEW THE REFERENCES AT AESTHETICSJOURNAL.COM 23

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ANNIVERSARY

PRESCRIBING INFORMATION - UK BOCOUTURE® (botulinum toxin type A (150 kD), free from complexing proteins) 50/100 unit vials. Prescribing information: Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: 50/100 units of Clostridium Botulinum Neurotoxin type A, free from complexing proteins as a powder for solution for injection. Indications: Temporary improvement in the appearance of moderate to severe upper facial lines (glabellar frown lines, crow’s feet lines, horizontal forehead lines) in adults ≥18 and <65 years when the severity of these lines has an important psychological impact for the patient. Dosage and administration: For intramuscular use only. Unit doses recommended for BOCOUTURE are not interchangeable with those for other preparations of botulinum toxin. BOCOUTURE should only be administered by an appropriately qualified healthcare practitioner with expertise in the treatment of the relevant indication and the use of the required equipment, in accordance with national guidelines. The intervals between treatments should not be shorter than 3 months. Reconstitute with 0.9% sodium chloride. Glabellar Frown Lines: Total recommended standard dose is 20 units. 4 units into 5 injection sites (2 injections in each corrugator muscle and 1 injection in the procerus muscle). May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Total recommended standard dosing is 12 units per side (overall total dose: 24 units); 4 units injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Horizontal Forehead Lines: The recommended total dose range is 10 to 20 units; a total injection volume of 10 units to 20 units is injected into the frontalis muscle in five horizontally aligned injection sites at least 2 cm above the orbital rim. An injection volume of 2 units, 3 units or 4 units is applied per injection point, respectively. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Infection or inflammation at the proposed injection site. Special warnings and precautions: It should be taken into consideration that horizontal forehead lines may not only be dynamic, but may also result from the loss of dermal elasticity (e.g. associated with ageing or photo damage). In this case, patients may not respond to botulinum toxin products. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Caution in patients with botulinum toxin hypersensitivity, amyotrophic lateral sclerosis, peripheral neuromuscular dysfunction, or in targeted muscles

displaying pronounced weakness or atrophy. BOCOUTURE should be used with caution in patients receiving therapy that could have an anticoagulant effect, or if bleeding disorders of any type occur. Too frequent or too high dosing of botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Should not be used during breastfeeding. Interactions: Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects: Usually, undesirable effects are observed within the first week after treatment and are temporary in nature. Undesirable effects independent of indication include; application related undesirable effects (localised pain, inflammation, swelling), class related undesirable effects (localised muscle weakness, blepharoptosis), and toxin spread (very rare - exaggerated muscle weakness, dysphagia, aspiration pneumonia). Hypersensitivity reactions have been reported with botulinum toxin products. Glabellar Frown Lines: Common: headache, muscle disorders (elevation of eyebrow). Crow’s Feet Lines: Common: eyelid oedema, dry eye, injection site haematoma. Upper Facial Lines: Very common: headache. Common: hypoaesthesia, injection site haematoma, application site pain, application site erythema, discomfort (heavy feeling of frontal area), eyelid ptosis, dry eye, facial asymmetry, nausea. For a full list of adverse reactions, please consult the SmPC. Overdose: May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Legal Category: POM. List Price: 50 U/vial £90.00, 50 U twin pack £180.00, 100 U/vial £180.00, 100 U twin pack £360.00. Product Licence Number: PL 29978/0002, PL 29978/0005 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100,60318 Frankfurt/Main, Germany. Date of Preparation: April 2024. M-BOC-UK-0540. Further information available from: Merz Aesthetics UK Ltd., Ground Floor Suite B, Breakspear Park, Breakspear Way, Hemel Hempstead, Hertfordshire, HP2 4TZ Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at https://yellowcard.mhra.gov.uk/. Adverse events should also be reported to Merz Aesthetics UK Ltd at the address above or by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143.

1.BOCOUTURE Summary of Product Characteristics. Merz Pharmaceuticals GmbH: https://www.medicines.org.uk/emc/product/600/smpc (Last accessed December 2024).

REASONS TO CHOOSE BOCOUTURE • Results seen as early as 7 days, lasting up to 4 months in upper facial lines1 • A well characterised safety profile1 • Convenient – no refrigeration needed prior to reconstitution1

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Merz Aesthetics Exchange (MAX) is a promotional website developed and funded by Merz Aesthetics UK & Ireland.

PRESCRIBING INFORMATION - IRELAND BOCOUTURE® (botulinum toxin type A (150 kD), free from complexing proteins) 50/100 unit vials. Prescribing information: Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Additional information is available on request. Presentation: 50/100 units of Clostridium Botulinum Neurotoxin type A, free from complexing proteins as a powder for solution for injection. Indications: Temporary improvement in the appearance of moderate to severe upper facial lines (glabellar frown lines, crow’s feet lines, horizontal forehead lines) in adults ≥18 and <65 years when the severity of these lines has an important psychological impact for the patient. Dosage and administration: For inatramuscular use only. Unit doses recommended for BOCOUTURE are not interchangeable with those for other preparations of botulinum toxin. BOCOUTURE may only be administered by physicians with suitable qualifications and the requisite experience in the application of Botulinum toxin type A. The intervals between treatments should not be shorter than 3 months. Reconstitute with 0.9% sodium chloride. Glabellar Frown Lines: Total recommended standard dose is 20 units. 4 units into 5 injection sites (2 injections in each corrugator muscle and 1 injection in the procerus muscle). May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Total recommended standard dosing is 12 units per side (overall total dose: 24 units); 4 units injected bilaterally into each of the 3 injection sites. Injections too close to the zygomaticus major muscle should be avoided to prevent lip ptosis. Horizontal Forehead Lines: The recommended total dose range is 10 to 20 units; a total injection volume of 10 units to 20 units is injected into the frontalis muscle in five horizontally aligned injection sites at least 2 cm above the orbital rim. An injection volume of 2 units, 3 units or 4 units is applied per injection point, respectively. Contraindications: Hypersensitivity to the active substance or any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Infection or inflammation at the proposed injection site. Special warnings and precautions: It should be taken into consideration that horizontal forehead lines may not only be dynamic, but may also result from the loss of dermal elasticity (e.g. associated with ageing or photo damage). In this case, patients may not respond to botulinum toxin products. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Caution in patients with botulinum toxin hypersensitivity, amyotrophic lateral sclerosis, peripheral neuromuscular dysfunction, or in targeted muscles displaying pronounced weakness or atrophy. BOCOUTURE should be used with caution in patients receiving anticoagulant therapy or therapy that could have an anticoagulant effect, or if bleeding

M-BOC-UKI-0514 Date of Preparation December 2024

disorders of any type exist. Too frequent or too high dosing of botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy. Should not be used during breastfeeding. Interactions: Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects: Usually, undesirable effects are observed within the first week after treatment and are temporary in nature. Undesirable effects independent of indication include; application related undesirable effects (localised pain, inflammation, paraesthesia, hypoaesthesia, tenderness, swelling, oedema, erythema, itching, localised infection, haematoma, bleeding and/ or bruising), class related undesirable effects (localised muscle weakness, blepharoptosis), and toxin spread (very rare – excessive muscle weakness, dysphagia, aspiration pneumonia). Serious and/or immediate hypersensitivity reactions have been reported with botulinum toxin products (anaphylaxis, serum sickness, urticaria, soft tissue oedema, dyspnoea, swelling, erythema, pruritis, rash). If serious and/or immediate, appropriate medical therapy should be commenced. Glabellar Frown Lines: Common: headache, Mephisto sign. Crow’s Feet Lines: Common: eyelid oedema, dry eye, injection site haematoma. Upper Facial Lines: Very common: headache. Common: hypoaesthesia, injection site haematoma, injection site pain, injection site erythema, discomfort (heavy feeling of frontal area), eyelid ptosis, dry eye, brow ptosis, facial asymmetry, Mephisto sign, nausea. For a full list of adverse reactions, please consult the SmPC. Overdose: May result in pronounced neuromuscular paralysis distant from the injection site. Legal Category: POM. List Price: Ireland 50 U/vial €103.50, 50 U twin pack €207.00, 100 U/vial €207.00, 100 U twin pack €414.00 Market Authorisation Number: PA 1907/003/001, PA 1907/003/002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany. Date of Preparation: April 2024. M-BOC-IE-0042. Further information available from: Merz Aesthetics UK Ltd., Ground Floor Suite B, Breakspear Park, Breakspear Way, Hemel Hempstead, Hertfordshire, HP2 4TZ Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at https://www.hpra.ie/homepage/about-us/report-an-issue. Adverse events should also be reported to Merz Aesthetics UK Ltd at the address above or by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143.

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CPD Cryolipolysis

Analysing Cryolipolysis Dr Emmaline Ashley explores the current understanding of cryolipolysis as a method of non-surgical fat reduction The growing demand for methods to remove or reshape localised fat deposits has led to the increasing popularity of body contouring procedures.1 While liposuction remains the gold standard for fat reduction, it is associated with significant risks and recovery time.2 Potential complications include contour irregularities, infection, nerve injury, seroma, haematoma and risks associated with general anaesthesia or intravenous sedation.2 Consequently, there is a strong appeal for alternatives that are less invasive, safer and require minimal downtime, yet still deliver effective results. One such alternative is cryolipolysis. Cryolipolysis was first described as a body contouring technique in 2007.1,3 US Food and Drug Administration (FDA) approval was obtained in 2010 by CoolSculpting (Zeltiq), a non-surgical body contouring treatment that utilises cryolipolysis to target and eliminate localised fat in the flanks.4 Subsequently, FDA approval was gained for fat removal in the abdomen and thighs in 2012 and 2014 respectively.1 It has gained popularity in recent years as a safe and effective method of fat reduction.5 This review specifically focuses on the body of literature examining cryolipolysis as performed using the CoolSculpting system, as it currently represents the largest and most extensively studied dataset in this treatment category. While other cryolipolysis devices are available on the market and may be supported by emerging evidence, the clinical data, regulatory approvals and consensus guidelines most frequently reference CoolSculpting. As such, the treatment protocols, safety profiles and outcome data discussed here are primarily based on studies involving this platform.

Mechanism of action Fat cells’ sensitivity to cold injury was first described in 1902.6 Subsequently, several case reports emerged between 1940 and 1970, showing that there was gradual fat reduction in the lower cheeks of children who suck on popsicles, termed ‘popsicle panniculitis.’1 Cryolipolysis selectively targets fat cells through controlled cooling, inducing apoptosis-mediated cell death. When exposed to subnormal but non-freezing temperatures, adipocytes are preferentially affected because of their heightened sensitivity to cold temperatures, while surrounding tissues experience minimal collateral damage.7 The process triggers an inflammatory response that begins around day three and peaks by day 14, facilitating the removal of damaged fat cells.8 These cells are then naturally eliminated via the lymphatic system.4 The subsequent resolution of inflammation and lipid metabolism typically concludes within approximately three months post treatment.4 Histology has confirmed this selective reduction of fat in both humans and animals, with an observed gradual thinning of the fat layer over a period of two to four months.4

Standardised treatment techniques The literature has generally lacked consensus on standardised techniques and protocols for applicator placement, targeted tissue layers, patient selection criteria, optimal treatment cycles session duration, follow-up and adverse event management.9 In response to this, several consensus reports have been produced, including a set of expert recommendations, utilising the Delphi approach.9,10 The Delphi approach allows for expert consensus on a specific topic through multiple rounds of anonymous survey and questionnaires,

refining findings based on group feedback, in order to minimise bias and produce best practice guidelines.9 Patient selection Proper patient selection is a critical first step. Ideal candidates are those with well-defined, localised fat pockets that can be effectively targeted by the applicator.9,11 Cryolipolysis is reportedly preferred over liposuction for patients with a BMI below 30 kg/m2.10 Patients with generalised obesity or excessive skin laxity are not suitable for treatment.9,10 This is because the treatment is only designed to target localised fat deposits, not to achieve overall weight loss or treat widespread adiposity. Additionally, patients with excessive skin laxity may experience poor aesthetic outcomes, as the procedure does not tighten skin, potentially leading to sagging or uneven contours after fat reduction.9,10 A comprehensive assessment should include evaluating BMI, fat thickness and firmness to ensure proper applicator fit.9 Areas with scars, cellulite or stretch marks should be avoided as they can affect treatment outcomes.9 Contraindications include patients with conditions like cryoglobulinaemia or other cold-sensitive disorders.10,11 Generally, age is not a strict limitation, and even adolescents have shown positive outcomes with proper screening.11 One randomised control trial conducted in Egypt examined its use in adolescents with abdominal adiposity.12 General requirements are that candidates be in good health, with normal renal function.11 Cryolipolysis can be used post surgery to refine results, such as addressing residual lipodystrophy after abdominoplasty, after a waiting period of nine to 10 months.10 Treatment cycles and timing Effective treatment planning and execution are also key to optimal results. Visible improvements typically require two to four treatment cycles for smaller areas like the submental region and thighs, and three to five cycles for larger areas like the abdomen and back.9 The number of cycles should be customised based on body size and symmetry requirements.9,10 For regions requiring multiple treatments, sessions should be spaced four to eight weeks apart, and results should be assessed approximately eight weeks after the final session.9 Proper applicator selection and placement are critical, and the device must conform to the treatment area and be securely strapped.9 Traditional applicators require approximately 60 minutes per cycle, however, newer applicators have reduced this time to 35 minutes.10 Patient positioning and comfort Patient comfort and education play a significant role in successful outcomes. Common side effects such as erythema, oedema and discomfort in the treated area typically resolve quickly, often within a few hours or days.13 The importance of proactive pain management strategies is well-recognised, with pre-treatment analgesic administration shown to enhance patient satisfaction and mitigate adverse effects such as anxiety.14 Clinicians should ensure patients are properly positioned, apply gel pads correctly and provide detailed pre- and post-treatment instructions to manage expectations.9 The applicator must achieve a good seal to effectively target subcutaneous fat while minimising the risk of complications, which will be discussed in greater depth later in this article.10 Standardised before and after photographs are essential for

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CPD Cryolipolysis

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demonstrating visible improvements, as these can greatly influence patient satisfaction.9 Post-treatment massage is recommended to enhance fat reduction and alleviate discomfort, while patients should be advised on self-care practices such as staying hydrated and avoiding strenuous activity for 24 hours post treatment.9 Training Ensuring all practitioners are thoroughly trained in device handling, patient positioning and applicator placement is vital.9,15 Adherence to device-specific manuals and established guidelines reduces procedural risks and enhances treatment outcomes.9 Cryolipolysis is a procedure that can often be delegated to trained non-medical staff under supervision, allowing practices to expand their offerings without significantly increasing the physician’s workload. However, these staff members must also receive comprehensive training to ensure safety and efficacy, as well as ongoing clinical support and medical oversight.15

Literature review To better understand the current scope of research on cryolipolysis, an initial literature review of studies published between 2015-2024 was conducted. This identified 36 prospective and retrospective studies that were broadly focused on determining efficacy and safety for different applicators or treatment areas using the CoolSculpting system. While it is typical in broader reviews to include data from all available cryolipolysis devices, this review focuses exclusively on CoolSculpting because it currently represents the most extensively studied and widely reported platform in the literature. These were primarily prospective interventional cohort studies with small sample sizes, variable outcome measures and treatment protocols which would make it difficult to aggregate their data quantitatively in a meaningful way, however a qualitative synthesis was conducted. Results In general, the results were overwhelmingly positive. Studies showed that cryolipolysis is safe and effective at reducing fat in various body areas including the abdomen, flanks, thighs, arms, submental area and in male pseudogynecomastia.16,21 For example, one recent study assessed patient-reported outcomes (PROs) for CoolSculpting treatment of the abdomen and flanks in a multinational, prospective, single-cohort study.22 A total of 112 participants underwent up to 24 treatment cycles across two sessions, with a final follow-up at 12 weeks post-treatment.22 Results showed that 89.6% of participants were satisfied or very satisfied with their results, and 90.6% reported noticeable or very noticeable fat reduction.22 Fat volume reduction, measured by 3D photography, averaged 264.8ml.22 The study also evaluated the psychosocial impact, showing improved body confidence, reduced self-consciousness and increased satisfaction with clothing fit.22 Generally, an average gradual fat reduction of 15-27% across various body areas has been reported.10 High levels of patient satisfaction reported via questionnaires reveal the majority of patients notice visible fat reduction and would recommend treatment to others.23 In the example study detailed above, 93.4% of participants stated they would recommend the procedure to a friend.22 Another retrospective study evaluated patient satisfaction, recommendation rates and comfort levels following cryolipolysis treatment using the CoolSculpting Elite system in a single clinic.23 Among 91 patients, 84% reported satisfaction (rating 1 or 2 on a 5-point scale), 88% would undergo further treatment and 92% would recommend the procedure to others.23 28

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In addition to this, multiple sessions of cryolipolysis completed in one sitting were found to be safe and may increase efficacy.24 For example, a prospective, single-centre study was conducted on 28 patients undergoing cryolipolysis treatment, with follow-ups at 12 weeks.24 Participants received up to four treatment cycles per session, with the option for an additional session after four weeks.24 Results demonstrated a mean reduction in skinfold thickness of 40%, significantly higher than previously reported studies, and an 88% patient satisfaction rate.24 Adverse events Most studies showed no incidents of serious adverse events. Common side effects include transient erythema, numbness and oedema, which typically resolve without intervention.25 One retrospective study detailed that pain levels were generally low, with 78% rating discomfort as mild.23 Temporary side effects such as redness and swelling were observed but resolved without intervention, and no serious complications occurred.23 However, several high publicity cases have increased awareness of the risk of paradoxical adipose hyperplasia (PAH). Clinicians should be aware that patients may ask them about the incidence of these events, and it is important to reassure patients that while the risk of PAH exists, it remains rare, with reported incidence rates between 0.05% and 0.67%.25 Practitioners should acknowledge the concerns raised by high-profile cases but provide evidence-based context, explaining that PAH is an uncommon complication and that advances in technique and proper patient selection have likely reduced its occurrence. Open discussions about individual risk factors, alternative treatment options and expected results will help patients make an informed decision while maintaining confidence in the procedure. PAH is characterised by an increase in fatty tissue volume in treated areas, often requiring surgical correction. Several retrospective chart reviews looked at the incidence of PAH and determined that risk factors for this complication included older cryolipolysis models and applicators, and the male gender.26,27 Other documented complications include frostbite, burns and cold panniculitis, highlighting the importance of careful device use and monitoring during treatment.25 However, these remain exceptionally rare, with only a handful of case reports available in the literature. Due to the limited data, it is difficult to establish an exact incidence rate. For example, one incidence of severe frostbite occurring in a non-medical clinic, highlighting the importance of proper training and medical oversight for successful outcomes.28 The submental region poses unique risks, such as marginal mandibular nerve injury, underscoring the need for anatomical knowledge and precise applicator placement.25

Limitations A key limitation of this article is its reliance on data derived predominantly from studies involving the CoolSculpting system, which currently represents the most extensively researched cryolipolysis platform. While this allows for a detailed and evidence-based discussion, it may limit the generalisability of findings to other cryolipolysis devices. Different manufacturers may employ variable cooling mechanisms, applicator designs, treatment durations and safety protocols, all of which can influence clinical outcomes, patient comfort and complication rates. As such, the treatment protocols and safety considerations described here may not directly apply to all devices on the market. Clinicians using alternative systems should refer to manufacturer-specific guidance and adapt treatment plans accordingly. Further comparative research is needed to broaden the evidence base and inform best practice across the full spectrum of cryolipolysis technologies.

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CPD Cryolipolysis

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Gaps in the literature There were, however, some clear gaps in the literature. Generally, there has been criticism of the lack of rigorous methodology in much of the existing body of evidence.29 Concerns have also been expressed about potential conflicts of interest and commercial bias in those conducting studies.29 There has been little data looking at outcomes across sex and ethnicity, and demographic information was often excluded from study reports. Only one study compared Chinese participants to the treatment group as a whole, and showed no statistically significant differences.22 Additionally, only one study looked for statistically significant differences in outcomes between males and females, finding none.30 In evaluating treatment outcomes, most studies use 2D photographic documentation as their primary end point, raising questions about the validity of more subjective outcome measures.29 It is difficult to standardise lighting, camera settings and positioning of the patient using 2D imaging. In addition, it is impossible to ignore that fact that photograph interpretation is subjective, with research supporting that there is not enough homogeneity in photographic outcome measures. This level of subjectivity also extends to tape measure and calliper measure – two traditional methods of quantifying fat loss outcomes. While callipers are valid for assessing adiposity-related variables, consistent use of the same calliper model is recommended for longitudinal studies or comparisons across datasets to ensure accuracy.31 There is inherent variability in measurement techniques and equipment. Inexperienced or unskilled investigators may make errors in identifying anatomical landmarks or in pressure application when using callipers or tape measures. One study of 138 participants showed that using four different skinfold callipers caused variations in estimates of fat thickness.31 Additionally, research has shown that callipers were less accurate in estimating body fat percentage than imaging methods like ultrasound.15 Finally, it is worth noting patient-reported outcomes are vitally important in assessing the success of aesthetic treatments, as patients form the driving force in deciding to pursue elective cosmetic procedures. Understanding patient drivers and satisfaction is of key importance for clinicians providing aesthetic treatments. Clinicians should recognise that PROs provide valuable insight beyond objective clinical measures, as they capture the real-world impact of aesthetic treatments on a patient’s self-perception, confidence and satisfaction. While a procedure may demonstrate a statistically significant reduction in fat, this may not always translate to a meaningful improvement from the patient’s perspective. The subjective nature of aesthetic treatments means that even minor contour changes can have profound psychological benefits for some, whereas others may perceive a similar reduction as insufficient or disappointing. Understanding these nuances ensures a more holistic approach to treatment success in medical aesthetics.

Using technology safely Cryolipolysis has emerged as a transformative non-surgical fat reduction technique, driven by its safety, efficacy and minimal downtime. Cryolipolysis offers patients an innovative solution for addressing stubborn, localised fat deposits, making it a compelling alternative to liposuction for select candidates. Although the literature supports its effectiveness with fat reduction across various treatment areas and high levels of patient satisfaction, the procedure’s success hinges on critical factors such as proper patient selection, standardised treatment protocols and practitioner expertise.

While transient side effects are common and typically resolve without intervention, rare complications like PAH highlight the necessity for rigorous training and adherence to device protocols. Moreover, gaps in the literature, particularly regarding demographic variability, methodological rigour and objective outcome measures, underline the need for future research to refine its application and enhance treatment precision. As the field of non-surgical body contouring evolves, cryolipolysis continues to be a valuable tool in medical aesthetics. However, ongoing efforts to improve evidence quality and treatment guidelines are essential to ensure that practitioners can deliver consistently optimal outcomes, and meet the growing demand for safe, effective and patient-centred aesthetic solutions. Dr Emmaline Ashley is the academic head of education at Acquisition Aesthetics. She holds a degree in biology and postgraduate qualifications in surgery, dermatology and aesthetics. She has worked as a clinician in London and Edinburgh, and currently splits her time between the UK and the Cayman Islands. Qual: BA, MCh (Surgery), MBBChBAO, PGCert Dermatology, PgDip Aesthetics

Test your knowledge! Complete the questions and email memberships@aestheticsjournal.com to receive your CPD certificate! Questions

Possible answers a. Fat cell rupture through high-frequency sound waves

1. What is the primary mechanism by which cryolipolysis achieves fat reduction?

b. Apoptosis-mediated fat cell death due to controlled cooling c. Mechanical disruption of fat cells via suction d. Immediate necrosis of fat cells through freezing temperatures a. A 45-year-old with a BMI of 35 kg/m² and generalised obesity

2. Which of the following patients would be an ideal candidate for cryolipolysis?

b. A 28-year-old with well-defined, localised fat deposits and a BMI of 25 kg/m² c. A 50-year-old with severe skin laxity and a history of cryoglobulinaemia d. A 35-year-old with diffuse cellulite and extensive stretch marks

3. What is the recommended interval between treatment sessions for areas requiring multiple cycles? 4. Which of the following is a rare but significant complication associated with cryolipolysis?

a. 1-2 weeks b. 3-4 weeks c. 4-8 weeks d. 10-12 weeks a. Severe burns b. Paradoxical adipose hyperplasia (PAH) c. Marginal mandibular nerve palsy d. Frostbite in every treatment area a. Using outdated applicator models

5. What is a critical component of ensuring patient satisfaction with cryolipolysis?

b. Limiting patient education about expected outcomes c. Setting realistic expectations during patient consultation d. Avoiding post-treatment follow-up Answers: B,B,C,B,C

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Treatment Focus Xanthelasma

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Treating Periocular Xanthelasma Three practitioners explore the various treatment options for periocular xanthelasma Periocular xanthelasma, often referred to as xanthelasma palpebrarum, is a benign condition characterised by the formation of yellow, fatty deposits on the eyelids, typically near the inner canthus.1 It is commonly associated with elevated cholesterol levels and is often seen in individuals with hyperlipidaemia.2 While xanthelasma itself not a serious health concern, it can be considered aesthetically unappealing and can negatively impact self-esteem.1 This article provides a comprehensive overview of the available treatment options for periocular xanthelasma, including chemical peels, laser ablation and surgical excision.

Presentation of xanthelasma Xanthelasma is a benign condition characterised by the accumulation of lipid-laden macrophages in the dermis.1-3 The exact mechanism of its formation remains incompletely understood, but it is generally believed to be associated with hyperlipidaemia, a condition where there is an abnormally high level of lipids (cholesterol and triglycerides) in the blood.3 The pathogenesis of xanthelasma involves three key steps: 1. Hyperlipidaemia: Elevated levels of low-density lipoprotein (LDL) cholesterol is thought to contribute to the development of xanthelasma. LDL cholesterol can become oxidised, leading to inflammation and the formation of atherosclerotic plaques.3 2. Macrophage accumulation: Oxidised LDL is taken up by macrophages, which become engorged with lipids and transform into foam cells. These foam cells accumulate in the dermis, forming the characteristic yellow deposits seen in xanthelasma.3 3. Inflammation: The accumulation of foam cells triggers an inflammatory response, further contributing to the development of xanthelasma.1,3 The condition has variable presentations ranging from raised, waxy-appearing, yellowish-coloured plaques to red-brown macules, papules or nodules of variable consistency. They are often distributed symmetrically and can either be multiple or coalescing.1

Xanthelasma classification Xanthelasma can be classified based either on its distribution, its appearance (e.g. solitary, multiple, confluent) or its depth within the skin.6-8 All will have implications on management.6,8 The xanthelasma grading system is based on the location and extent on the eyelids as follows: grade I is limited to the upper eyelid; grade II involves the medial canthus; grade III affects both eyelids on the medial side; and grade IV involves both the medial and lateral sides of the upper and lower eyelids.7 Higher grade lesions involving larger areas will require careful consideration, as excising large areas of eyelid skin will likely require significant reconstruction with skin grafts if surgical modalities alone are employed.6,8-11 The depth of xanthelasma also significantly influences the choice of treatment.6,8 Superficial xanthelasma primarily affects the epidermis (the outermost layer of the skin), and often appears as flat, yellow patches.8 Typically, superficial xanthelasma responds well to less invasive treatments like chemical peels or superficial laser ablation, which can effectively target the superficial layers of the skin where superficial xanthelasma is located.12-14 Deep xanthelasma involves the dermis, and is generally more raised or nodular, sometimes having a more orange or brown hue.8 Treatment often requires more aggressive treatments, such as surgical excision, erbium laser ablation, CO2 laser or Q-switched Nd:YAG laser therapy, to penetrate deeper into the skin to target the layers where deep-seated xanthelasma is located.9,10,15-17 Subcutaneous xanthelasma extends into the subcutaneous tissue beneath the dermis. The appearance of this can be quite large and prominent, often appearing as yellow or orange nodules.8 This usually requires surgical excision due to the size and depth.8-11 32

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These categories can overlap, and the depth of xanthelasma can vary within the same lesion or between adjacent lesions. A thorough examination is fundamental to ascertaining the most appropriate treatment plan, which can include a combination approach.14

Medical associations and investigations Xanthelasma is associated with hyperlipidaemia in 30-50% of cases.1-3 Individuals with xanthelasma should be evaluated for other signs and symptoms of hyperlipidaemia, such as coronary artery disease, stroke and peripheral artery disease. In addition to hyperlipidaemia, xanthelasma has also been linked to diabetes, hypothyroidism and primary biliary cholangitis.5 Primary biliary cholangitis is a rare autoimmune disease that can cause elevated cholesterol levels and increase the risk of xanthelasma.4,5 Given these associations, it is recommended to undertake the following medical tests for all patients presenting with xanthelasma.1-3

· Lipid profile: To measure total cholesterol,

LDL cholesterol, high-density lipoprotein (HDL) cholesterol and triglycerides. · Liver function tests: These tests can help to assess the health of the liver, which plays a role in cholesterol metabolism. · Thyroid function tests: Hypothyroidism can sometimes contribute to hyperlipidaemia, so thyroid function tests may be indicated. · HBA1c: To screen for diabetes. It is important to note that while xanthelasma is often associated with these medical conditions, it is not always a direct cause or consequence. In some cases, xanthelasma may occur in individuals with normal lipid levels or without any underlying medical conditions.1-3

Treatment options There are several treatment options for xanthelasma, including chemical peels, laser removal or surgical excision. Chemical peels Chemical peels are a popular non-invasive treatment option, of which trichloroacetic acid (TCA) peels are the most extensively studied.12-14 Evaluation of three different strengths of TCA indicated that best results are achieved with 50-100% TCA depending on the type of lesion (flat or nodular).13 The advantages are that they are generally less invasive than other treatment options, are easily available and can be performed in a clinic setting. They are also relatively affordable and can be repeated as needed. The disadvantages of chemical peels are the reported rates of dyspigmentation of

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the skin, and a recurrence risk of 30%.12-14 Additionally, the depth of treatment is less controlled and precise than with more sophisticated laser ablation, which increases the risk of ocular damage and further complications.18 Laser removal Laser therapy is another effective option for treating periocular xanthelasma. It involves the use of focused light energy to ablate the fatty deposits. Various lasers have been employed as options to treat xanthelasma, including argon, pulsed dye (PDL), carbon dioxide (CO2) and erbium yttrium aluminium garnet (Er:YAG).15,19,20-27 The CO2 laser has been reported as the most common modality, followed by Er:YAG laser.14 The laser ablates the lesion through vaporisation, and the treated area subsequently heals through re-epithelisation. Overall, this laser can be adapted for deeper lesions, and is considered less invasive than surgery.16 Ablation depth can be titrated according to the lesion size and depth. It is associated with hypopigmentation, however, particularly with the CO2 laser.16,23,25 The use of Er:YAG allows for more precise tissue ablation (and can be used with or without additional coagulation), resulting in less collateral damage compared to traditional laser therapies.15,26,27 Flexibility with settings and omitting coagulation for this specific indication provides more efficient tissue ablation with little thermal damage. This reduces the risk of adverse effects of hypopigmentation and scarring seen more commonly with use of CO2.25,26 Downtime due to post-procedure erythema and swelling is typically seven to 14 days, mirroring that of surgical recovery time.26,27 Surgical excision Surgery involves excision of the fatty deposits followed by closure with skin sutures, and is generally performed under local anaesthesia.9 For larger areas requiring excision, reconstruction with a skin graft or flap may be required.10,11 Surgical removal is the most definite treatment option with the lowest rate of recurrence, and is the most suitable option for deep-seated or subcutaneous xanthelasma.9,14 It is considered a more invasive option, carrying the risks of bleeding, infection and scarring, with a typical downtime of seven to 14 days.6 Electrocautery While electrocautery has historically been employed as another treatment option for xanthelasma, its use around the delicate periorbital area warrants significant caution.28,29 Electrocautery, a form of electrosurgery, uses an electrode tip which becomes hot, converting electrical energy

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Treatment Focus Xanthelasma

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into molecular energy. This leads to denaturation of intracellular and extracellular proteins, resulting in coagulation or desiccation effects.28,29 It can cause tissue burns and carries notable risks, including the potential for persistent hypopigmentation and scarring.29 More concerningly, electrocautery can cause damage to deeper anatomical structures, such as the orbital septum. Focal injury to this fibrous barrier can result in localised fat prolapse, leading to cosmetic disfigurement.30 Therefore, alternative and less invasive treatment modalities are generally preferred in this sensitive region.

Case study A 52-year-old male presented with bilateral upper and lower lid xanthelasma. Baseline investigations identified no underlying cause. The extensive distribution with minimal skin laxity (particularly on the lower eyelids) rendered full surgical excision and direct closure impossible. Treatment was performed with a combination of surgical excision and erbium ablative lasering of the xanthelasma lesions. Skin incisions were closed with 6-0 prolene sutures. For the remaining, flatter lesions, successive Er:YAG was meticulously applied to achieve layer by layer ablation of 20-35 microns depth until the xanthelasma removed (Figure 1). This case demonstrates that combination treatment with surgical excision and Er:YAG laser represents a promising treatment option for extensive or unresectable periocular xanthelasma.

Before

After - seven days post-treatment

After - 14 days post-treatment

Figure 1: 52-year-old man treated for xanthelasma using surgical excision and Er:YAG laser

Individualised treatment plans Periocular xanthelasma is a common skin condition that can be treated effectively with a variety of methods. Chemical peels, laser ablation and surgical excision are all viable options, each with their own advantages, disadvantages and indications. The best treatment for each individual will depend on the location, depth and extent of the xanthelasma, and the patient's preferences. Ms Aoife Naughton specialises in aesthetic and reconstructive eyelid surgery. She combines her substantive NHS role at Portsmouth University Hospitals NHS Trust with private practice at Harley Street Specialist Hospital, London and Perfect Skin Solutions, Portsmouth. Her expertise has been recognised through numerous accolades, including Finalist for ‘Best Surgical Result’ (Aesthetics Awards 2025). Qual: MB BCh BAO, MRCSI (Ophth), FRCOphth, FEBO Mr Richard Scawn is a consultant ophthalmologist and oculoplastic surgeon based at The Clinic at Holland Park, Harley Street and Chelsea & Westminster NHS Trust. He specialises in blepharoplasty, ptosis, eyelid reconstructions for cancer, burns and trauma. He is the founder and surgical lead for The Clinic Holland Park. Qual: MBBS, BSc, FRCOphth Miss Jennifer Doyle is a consultant oculoplastic surgeon based at The Clinic at Holland Park and at Milton Keynes University Hospital. She has a Bachelor’s in Medicine and a Bachelor of Surgery with distinction, as well as a Master’s in Medical Sciences from the University of Oxford. She is head of aesthetics and chief operating officer at the Clinic at Holland Park. She is a key opinion leader for companies including Sciton, Sofwave & Ameela. Qual: BMBCh, MA(OXON), L7Cert, FRCOphth

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Introducing the New Generation Tranexamic Acid Peel Pigmentation disorders are a significant concern for patients, with research indicating that 23.6% of men and 29.9% of women seek dermatological care primarily to combat discolouration.1 To support professionals in effectively addressing melasma, post-inflammatory hyperpigmentation or age-related discolouration, medical-grade skincare brand AlumierMD continues to innovate its professional range. Harnessing the power of nature with its new peel, designed to both prevent and correct discolouration. Radiant TXA Peel is a breakthrough professional treatment combining the triple-action brightening power of 1.95% tranexamic acid (TXA) with the gentle exfoliating action of 30% lactic acid, and the brightening properties of white shiitake mushroom extract. Skin and medical aesthetic expert Dr Nina Bal, founder of Facial Sculpting by Dr Nina Bal “Tranexamic acid is a game-changer for modern skincare,” says leading aesthetic practitioner Dr Nina Bal, founder of Facial Sculpting by Dr Nina Bal. She shares, “It is not just brilliant for its brightening effects, but for its ability to act as a barrier against inflammation – a key factor when it comes to pigmentation. By targeting the inflammatory responses within the skin that stimulate melanin production, tranexamic acid prevents dark spots, melasma and an uneven skin tone from the outset. It helps calm the skin, reducing redness and irritation, and ultimately inhibits the overproduction of pigment. This dual action (both corrective and preventative) makes tranexamic acid an integral ingredient in modern skincare, resulting in a smoother and more even complexion over time.”

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She continues, “Tranexamic acid is a key player when it comes to professional in-clinic treatments like chemical peels. When incorporated into peels, it accelerates the removal of pigmented skin cells while preventing deeper inflammatory responses that can occur as a result of exfoliation. It’s ideal for those seeking to treat hyperpigmentation without the risk of exacerbating it. Whether used in at-home skincare routines or clinical treatments, tranexamic acid delivers results. In short, offering a brighter, more uniform complexion with minimal irritation.”

The power of Radiant TXA Peel The in-clinic treatment aims to:

· Enhance brightness: Enhances luminosity

Advertorial AlumierMD patient satisfaction and more follow-up treatments. The peel has integrated seamlessly into my wider clinical practice, as it can be used alone or adjunctively with at-home medical-grade skincare and other in-clinic treatment modalities like laser and microneedling, depending on my patients’ needs.”

Providing maximum patient results TXA has a sophisticated delivery system, layering ingredients which are carefully formulated to ensure compatibility with all skin types and varying levels of skin sensitivity. Tranexamic acid’s low acidic base allows actives to penetrate deeply for maximum efficacy, hitting five mechanisms of action of melanogenesis with a carefully considered ingredient combination.2 Tranexamic acid targets the skin’s information pathways, addressing pigment-producing enzyme tyrosinase. Lipophilic molecule resorcinol drives the peel’s ingredients deeper into the skin, helping to activate more quickly. Lactic acid, the largest AHA molecule, plumps and saturates the skin with moisture; this ensures the peel will support dehydration and ageing lines in addition to hyperpigmentation and melasma.

and promotes a more radiant and even-toned complexion. · Targeted brightening for uneven skin tone: Effectively prevents the appearance of melasma, hyperpigmentation and uneven skin tone.1 · Boosts hydration and barrier support: Fortifies the skin’s moisture barrier, delivering deep and long-lasting hydration. Its low, pure acidic base enhances cutaneous absorption, delivering highly effective results while maintaining versatility for all skin types and tolerance Before After levels. The peel helps skincare professionals support patients’ comprehensive skin health, enabling a 360-degree approach by combining brightening, exfoliation and barrier-supporting properties. The ingredients work synergistically to promote a brighter and more uniform Figure 1: 35-year-old patient before and after receiving six Radiant skin tone, while stimulating TxA peels every two weeks for twelve weeks (in combination epidermal renewal and with polynucleotides) improved texture. AlumierMD’s award-winning, professional Offering both preventative and corrective treatments and prescribed homecare solutions — proactively preventing the risk products embrace both the diverse needs of discolouration ahead of the summer of patients and clinicians’ practices, and months, while also effectively targeting and Radiant TXA Peel is no different. The brand’s correcting existing pigmentation concerns comprehensive, expert-led system is built on – this new peel providing valuable on-going performance-based, innovative ingredients commercial opportunities for your practice. and technologies. Most significantly, AlumierMD’s new Radiant TXA Peel enhances radiance instantly, while being tolerable to sensitive skin.

“As a melasma sufferer myself, I understand the challenges of treating this stubborn skin condition,” says Dr Bal. “A harsh peel can cause patients to have an inflammatory response, which can actually damage the skin. Instead, we need to look for an effective formula which enables us as clinicians to go ‘low and slow’ to get better long-term results. Patients will see an instant brightening result, which gives rise to greater Aesthetics | May 2025

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Case Study Upper Arm Laxity

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Case Study: Treating Upper Arm Skin Laxity Aesthetic nurse prescriber Yuliya Culley discusses how she treated upper arm skin laxity with poly-L-lactic acid in a 65-year-old patient Women, particularly those aged 55 or more, can experience skin laxity on their upper arms for a variety of reasons. Weight loss or large weight fluctuations, fat distribution and loss of muscle tone all have a role to play in increased skin laxity.1 Menopause can also have an effect because a dip in oestrogen can inhibit collagen production, resulting in looser skin.1 Extrinsic factors such as diet, recurrent sun exposure and lifestyle behaviours can further cause skin laxity.2 Laxity in the arms is a problem which is often overlooked by both patients and practitioners, yet various literature sources suggest that the number of the patients seeking non-surgical, short-downtime body rejuvenation treatment options is growing rapidly.3-5 This article explores a case study where a patient’s arm laxity was treated using poly-L-lactic acid (PLLA).

Case study This patient was a 65-year-old woman with skin laxity on her inner, upper arms. She originally reached out to me believing that thread lifts would address the crepey, loose skin on her upper arms. The skin made her feel self-conscious, and consequently she only chose to wear tops with long sleeves. She told me that treatments performed at other clinics, including hyaluronic acid (HA) skin boosters and radiofrequency skin tightening, had made no discernible difference. The patient wished to look at conservative, non-surgical treatment options with sufficient longevity. Treatment planning At this patient’s initial consultation, a complete overview of her medical history was taken, including her emotional health. She was fit and healthy, with no known medical issues. We discussed her concerns in detail and the treatment options that were open to her. It was advised that thread lifts were not a suitable treatment for this particular concern due to the extent of her skin laxity, the technical difficulty in the threads’ fixing point, the variability of results and the longevity and quality of products from different manufacturers.6 Instead, I suggested that an alternative treatment option would be PLLA – in this case, Lanluma, a collagen stimulating treatment for skin laxity on various parts of the body.4,7,8 PLLA replaces lost skin volume, induces collagen production to restore inner structure and shape and causes fibroblast proliferation by stimulating the body’s subclinical inflammatory response, leading to gradual results.9 The outcomes are long-lasting, with a gradual collagen type I increase over eight to 24 months post treatment.7,9-11 Unlike other collagen stimulators, such as Radiesse and Ellansé, which are both currently off-label for this type of treatment, PLLA is specifically approved for the body, including the arms, and has a body of research to prove its efficacy and safety.4,7,10,12 The treatment was fully explained, alongside any possible side effects, such as tenderness, bruising, swelling, infection, treatment outcome dissatisfaction, allergic reaction, nodule formation and granulomatous reaction.5,7,13 It was emphasised that a number of sessions would be required (the manufacturer’s recommended number of treatments is three), a financial commitment would be involved and the results would be gradual rather than immediate.5 At that point, the patient was still keen to have thread lifts because she was not aware of PLLA or how it worked, so decided to research threads further. However, after seeking a consultation at another clinic, she returned for PLLA treatment. 36

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Once the patient had decided to go ahead, she was provided with written information about PLLA, details of her personalised treatment plan and more materials based on the discussions around aftercare and possible side effects. Key considerations and contraindications PLLA can be a costly treatment, requiring multiple sessions depending on the degree of skin flaccidity.4,5 It was also important for the patient to understand that PLLA treatment does not offer immediate results. Neocollagenesis takes place gradually, with initial changes to skin elasticity taking between six and 12 weeks, while progressive improvements happen over nine months and results last up to 24 months. To maintain long-lasting outcomes, retreatment is suggested after approximately 12 months.5,8 It was impressed on the patient that other factors, such as sun exposure, smoking and changing skin elasticity, due to menopause, might all affect the overall efficacy of the treatment.8 However, although the skin laxity on the patient’s arms was quite advanced, her muscles underneath were unaffected. This was an important consideration because muscle atrophy would be a contraindication, making the treatment ineffective.14 Other contraindications for PLLA treatment include an infection of the treatment site or an untreated autoimmune condition. The patient was warned that there is likely to be some short-term discomfort, redness, swelling and a risk of bruising.4,5,13 She was made aware of some reports of post-treatment nodules that could appear from several days up to two years post treatment, with spontaneous resolution in most cases.5,7,13,15 In order to minimise the possibility of adverse side effects, a prolonged healing process or nodule formation, commitment to regular massage, which will be explained later in this article, was emphasised.2,4,5,7,13 Finally, as part of her pre-treatment consultation, it was stressed that collagen stimulation is triggered by the PLLA injections via a complex, sub-inflammatory reaction which is not yet fully understood.10 There is also not a mechanism through which the treatment can be reversed.4 As someone who had undergone aesthetic treatments in the past, the patient was happy to comply to achieve her desired results. Treatment This patient received six treatments over a 12 month period, with seven to eight weeks between each treatment.

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Pre-treatment photographs were taken, targeted areas were examined for absence of inflammation and infection and the skin was prepared with hypochlorous acid (Clinisept+).5 The product was reconstituted as per manufacturer instructions – one vial of PLLA biostimulator agent containing 210mg powder combined with 15ml of water for injections.12 Each vial was shaken for 10 minutes and left for one hour prior to treatment to ensure complete hydration.12 Lidocaine hydrochloride 2%-1ml was also added to each vial.16 Immediately prior to treatment, each vial was vigorously agitated for one minute.12 Double dilution of the product was employed – 5ml of reconstituted PLLA dermal filler combined with 5ml of water for injections using a 10ml syringe, constituting 1:1 volume.16 Overall, 15ml of the ready solution was used bilaterally.16 Entry points were made with a 19G needle-introducer, with use of 21Gx50mm cannula for injections of the ready solution as per manufacturer recommendation.12 Multiple entry points were made on each side at the level of her brachialis triceps, applying a criss-cross technique of injections from the medial line on the level of biceps.12 A slow, low-pressure retrograde vector technique was then utilised at a subcutaneous level with the cannula, which prevented product being introduced away from the entry points, avoiding possible nodule formation.5,12,16 Cannula entry points were sealed using spot plasters. The area was massaged vigorously, during which the best technique and where to massage at home was demonstrated to the patient as part of her aftercare of the area.2 Cold packs were applied to treated areas for several minutes to reduce discomfort and minimise the possibility of bruising.5 Aftercare The patient was told to expect redness, swelling and tenderness in the first 24 to 48 hours post treatment which would be resolved within two to four days, and potential bruising from a few days up to two weeks, depending on severity.17 I advised her to apply a wrapped ice pack to the treated area two to three times for 25 to 45 minutes within the first 24 hours in the case of any discomfort or bruising. Before

Case Study Upper Arm Laxity

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After

She was also told to massage the treated areas for 10 minutes twice daily, or for five minutes five times a day, for at least two weeks.17 She was told to avoid applying makeup or other skin products to the injection sites for one week post treatment, plus avoid sun exposure, swimming or using a sauna, or partaking in vigorous exercise.17 I also advised avoiding exposure to UV light until after the initial swelling and redness had resolved.4,17 With PLLA procedures, it is recommended to follow up with patients between one and three months post treatment to assess results and patient satisfaction levels due to the gradual treatment progress, as well as monitor any signs of adverse reactions such as nodules.3,4,7,12,17 Four-week and two-month follow-ups have been completed, and a 12-month review will take place. The patient will also visit the clinic for other procedures prior to her follow-up, so there will be multiple opportunities to review her post-treatment progress. Results The patient understood not to expect results after the first treatment because it takes a number of months for the collagen to develop.10 However, she has now seen noticeable improvements, particularly when we have compared her before and after photographs (Figures 1&2). The patient said the treatment and its results had boosted her self-esteem and confidence. She also noted that she felt more comfortable wearing short-sleeved clothing during the summer months.

Long-lasting treatment PLLA is an effective treatment for skin laxity of the inner and upper arms, and offers a long-lasting effect if patients are willing to wait for results to become evident. If appropriate, it can be combined with LED phototherapy, microneedling and radiofrequency skin tightening for enhanced outcomes. Knowledge and understanding of possible benefits of PLLA treatment for skin laxity of the arms is rising among patients, and my practice has noticed a particular increase in enquiries prior to holiday seasons. Yulia Culley has been a registered general nurse since 1998, with experience in emergency, cardiology and dermatology nursing. She started practising aesthetics in 2009 and has performed a considerable number of nonsurgical procedures. She was a Finalist in the Aesthetic Nurse Practitioner of the Year Award at The Aesthetics Awards 2022 and 2025. Qual: RGN, INP, BSc, MSc

VIEW THE REFERENCES AT Figures 1&2: 65-year-old patient before and 11 months after PLLA treatment in the upper arms

Aesthetics | May 2025

AESTHETICSJOURNAL.COM 37

Advertorial Pure Tone Aesthetics

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Pure Tone Aesthetics: High-End and Multi-Functional Aesthetic Devices Built on Decades of Expertise Pure Tone Aesthetics brings high-end electronics and affordable, high-performance aesthetic machines – empowering clinics worldwide Pure Tone Aesthetics may be a recent entrant into the aesthetics world, but our heritage spans more than 30 years in high-end electronics and innovation. With headquarters in Manchester and Seoul, we bring together global expertise, technical precision and a clear mission – to offer affordable, high-performance aesthetic machines that empower clinics to deliver exceptional results across a broad range of treatments. Our machines are designed for versatility and clinical performance, enabling clinics to expand their services without compromising on quality or cost-efficiency. From cutting-edge laser systems and skin tightening technologies, to advanced AI analysis and pelvic floor rehabilitation, Pure Tone Aesthetics is redefining what’s possible with just one device. As a CPD-certified supplier, we offer accredited training and a commitment to long-term support, helping clinic owners get the most from their investment, whether they’re new to aesthetics or looking to upgrade existing systems.

Gemma Cartwright, nurse practitioner and owner of Aesthetic Creations in Doncaster, has seen this first-hand, saying, “I have completed treatments on 20 patients over the last four weeks and the results are outstanding. Every patient has booked in for a second treatment – the results speak for themselves.” Another standout in our portfolio is the Neon 7D Pro HIFU machine, which uses next-generation 7D HIFI technology to deliver more precise and uniform ultrasound energy. This allows for highly targeted lifting and contouring, especially in the lower face and neck. The device features a full range of cartridges for both face and body, making it an excellent choice for clinics looking to expand their non-surgical facelift offerings.

Skincare platforms that maximise value and treatment potential At the core of Pure Tone Aesthetics is the belief that one machine should do more. Multi-functionality is built into every platform we design, giving clinics the ability to offer a wider range of treatments from fewer devices – saving both space and money, while increasing return on investment. One of our most powerful examples of this is the Ultra Silk Plus, a 3-in-1 platform that combines IPL-SHR, Nd:YAG Laser and Diode Laser technologies. This single machine enables practitioners to perform hair removal, tattoo removal and skin rejuvenation treatments for various skin types and conditions. Each handpiece is interchangeable, making it easy to switch between treatment modes, while integrated cooling systems enhance comfort throughout the treatment.

Figure 2: Neon 7D Pro HIFU machine

For skin resurfacing, our CO2 Fractional Laser provides powerful yet customisable results for a wide range of skin concerns including scars, fine lines, texture irregularities and sun damage. With adjustable pulse duration and treatment density, practitioners can tailor each session to individual skin types with precision and confidence. To further support personalised treatment planning, our AI-powered photo analysis systems provide a detailed diagnostic view of the skin using high-resolution imaging and artificial intelligence. These platforms assess key factors like pigmentation, pore size, texture, moisture levels and UV damage, giving practitioners the tools to track progress and offer targeted solutions that resonate with patients.

Supramax Pelvic Floor Chair: Powerful technology, transformative results Figure 1: Ultra Silk Plus IPL super hair removal and tattoo removal

For clinics focused on skin rejuvenation and tightening, our RF Microneedling and Thermage RF combination device offers two highly sought-after treatments in one unit. With adjustable needle depth and multi-polar radiofrequency energy, the machine delivers exceptional results in improving texture, reducing fine lines and lifting the skin – particularly around the jawline and cheeks. 38

Among our most talked-about innovations is the Supramax Pelvic Floor Chair, which has quickly become a standout in the market due to its performance and patient outcomes. This non-invasive device uses high-intensity focused electromagnetic energy to trigger thousands of supramaximal pelvic muscle contractions per session, effectively restoring muscle strength and function.

Aesthetics | May 2025

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Designed for individuals experiencing urinary incontinence, postpartum weakness or general pelvic floor decline, practitioners have found the Supramax has proven to be both effective and easy to integrate into any clinic environment. And with some of the most advanced specifications available – a 30cm magnetic coil, maximum 7 Tesla magnetic field strength and a 3,000W power supply – it is one of the most powerful chairs in its class. Each 30-minute session delivers up to 10,000 supramaximal contractions, while the ergonomic design and high load-bearing capacity (up to 200kg) ensure a comfortable treatment for a wide range of patients. The user interface features a 7" removable touchscreen for simple, intuitive control.

Advertorial Pure Tone Aesthetics

Dr Apostolos Vlachogiorgos, plastic surgeon and an international authority in aesthetic and reconstructive surgery, had this to say about his experience with us, “Pure Tone Aesthetics stands out for their exceptional product quality and innovation. Their devices deliver outstanding results, their technical support is unparalleled – always responsive, knowledgeable and ready to assist with any queries.” That trust is something we work hard to maintain. All Pure Tone Aesthetics machines are backed by comprehensive warranties, UK-based servicing and a dedicated support team that understands the clinical and commercial pressures of running a busy practice.

CPD-certified training and aftercare that sets you up for success Our commitment doesn’t end once the machine is delivered. Every purchase includes CPD-certified training delivered by qualified nurses and experienced aesthetic practitioners. We offer both remote and on-site training, tailored to suit your team’s needs and treatment goals.

Figure 3: Supramax Pelvic Floor Chair

Clinic owners across the UK have reported exceptional results. Katie Govind, nurse prescriber and owner of KG Aesthetics in Harrogate, commented, “I recently purchased the Supramax chair for my clinic and have been extremely impressed. The level of support and customer service throughout the purchasing process and after delivery has been fantastic. She continued, “The chair itself is providing great results. One patient who had been struggling with urinary incontinence for nearly a decade described the impact of her condition as life-limiting. She was changing pads as often as once an hour and had tried multiple interventions over the years, including GP referrals and physiotherapy, with little to no improvement. After undergoing an intensive eight-week course using the Supramax Pelvic Floor Chair, she experienced a dramatic transformation. By the end of the treatment programme, she could go up to six hours without needing to change a pad – something she hadn’t thought possible.” She concluded, “I would highly recommend Pure Tone Aesthetics and their Supramax chair to any clinic or practice.” With increasing awareness around non-surgical pelvic floor health, the Supramax offers clinics a new way to attract and support patients – particularly women experiencing postpartum or menopause-related changes – while opening up a fresh, recurring revenue stream.

A trusted partner for aesthetic professionals We are proud to work with a wide network of aesthetic professionals, from clinic owners to world-renowned plastic surgeons, who trust Pure Tone Aesthetics to deliver technology that performs – and support that lasts.

This approach ensures that clinic staff feel confident and capable, while patients receive safe, effective and consistent results. We also provide marketing materials, treatment protocols and expert-led guidance on integrating each machine into your existing services. For us, every clinic relationship is a partnership. Whether you’re investing in one device or building a multi-room treatment centre, we’re here to provide the tools, knowledge and support you need to succeed.

The Pure Tone promise At Pure Tone Aesthetics, we understand that clinic owners – especially aesthetic nurses running their own practices – want devices that deliver great results, without the high price tag. Our portfolio has been built with that in mind: compact, powerful and multi-functional machines that offer maximum return and minimal complexity. Whether it’s the Ultra Silk Plus offering three technologies in one, the Neon 7D Pro HIFU for advanced lifting and tightening, the Inthera RF Microneedling system praised by professionals like Gemma Cartwright or the Supramax chair delivering life-changing pelvic floor rehabilitation, every Pure Tone device is designed to meet real clinical needs.

Ready to upgrade your clinic? Discover why more and more aesthetic professionals are choosing Pure Tone Aesthetics for technology they can trust, without compromising on results or support. This advertorial is written and supplied by

Visit puretoneaesthetics.com to explore our full product range, read more testimonials or speak to a member of our team about how we can help grow your clinic. Call 0330 102 5578 or email info@puretoneaesthetics.com Pure Tone Aesthetics – Affordable Aesthetic Solutions | Proven Results

Aesthetics | May 2025

Light Treatment LED Therapy

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Utilising LED Photobiomodulation Mr George Christopoulos explores the science behind LED photobiomodulation For millennia, light has been recognised for its regenerative effects, and recommended for healing and skin revitalisation.1 In the past 20 years, the use of light therapy, in the form of light-emitting diode (LED) phototherapy or photobiomodulation, has expanded significantly in medical aesthetics and dermatology due to its non-invasive nature and clinically proven efficacy across various skin conditions.2-13

Biological effects of LED therapy LED phototherapy is a non-invasive treatment that harnesses specific wavelengths of light energy to elicit targeted biological responses at the cellular level.3,4,14 Unlike laser or intense pulsed light (IPL) treatments, which rely on thermal effects and specific chromophore targeting, LED therapy stimulates existing natural processes at the cellular level without generating thermal damage.15,16 This mechanism of action makes LED phototherapy a safe and effective option for a wide range of dermatological and aesthetic applications, which will be explored further within this article.13 The therapeutic effects of LED phototherapy are driven by photobiomodulation, a process where light energy is absorbed by cellular photoreceptors, leading to an increase in adenosine triphosphate (ATP) production, reactive oxygen species (ROS) modulation and enhanced intercellular signalling.2-4,17,18 These molecular effects contribute to improved cellular metabolism, accelerated tissue repair, reduced inflammation and enhanced skin rejuvenation.19,20 This has been proven in experiments conducted by the National Aeronautics and Space Administration (NASA). This research initially focused on using light to create optimal conditions for sustaining life in challenging environments.2,16-18 However, the studies led to key insights into skin regeneration, ultimately deepening our understanding of the regenerative and rejuvenating effects of LED phototherapy.2,18-16 Research has demonstrated that specific wavelengths of light can modulate cellular function, enhancing wound healing, reducing inflammation and stimulating collagen production.12,17-21 Red (633 nm) and near-infrared (NIR) (830 nm) wavelengths have been widely recognised for their ability to enhance mitochondrial function and stimulate fibroblast proliferation, leading to improved skin elasticity and faster recovery post procedure.4,9,22 Meanwhile, blue 40

light (415 nm) phototherapy has emerged as a potent disinfectant tool, finding applications in various dermatological pathologies like acne, leveraging its ability to destroy bacterial overload while reducing inflammation.10 All tissue targets have an optimum wavelength at which they absorb light.2 One of the primary advantages of LED therapy is its ability to penetrate the skin at varying depths, depending on the wavelength used.3,4,6,9-23 Different wavelengths correspond to specific therapeutic benefits, making LED phototherapy a versatile treatment option for conditions ranging from acne and rosacea, to wound healing and skin ageing.2,6,9,13

The role of wavelengths in treatment The contraindications for LED phototherapy align with standard precautions for skin treatments, including active skin malignancies. Not enough research has been conducted to confirm that LED light is safe for pregnant women, therefore, it is not advisable to treat pregnant patients with this therapy.24 Additional contraindications specific to light-based therapies encompass photosensitive epilepsy and the use of photosensitising medications, such as isotretinoin and tetracycline.25,26 It is advisable to initiate treatment at a lower energy setting, with gradual titration to medium or high intensities, based on the specific therapeutic indication and individual skin characteristics. Blue light (415 nm) Blue light therapy (415 nm) has been extensively researched for its antimicrobial and anti-inflammatory properties.9,11,27-29 One of its primary clinical applications is the treatment of superficial infectious conditions, such as acne vulgaris.11 It is also increasingly recognised for its ability to reduce bacterial load on the skin in preoperative settings.30,31 The epidermal layer of the skin serves as a primary barrier against microbial invasion.32 Pre-treatment with blue light phototherapy has been shown to effectively reduce microbial presence, thereby lowering the risk of post-surgical infections and complications.12,24,33 In the context of chronic inflammatory skin conditions, such as acne, perioral dermatitis and seborrheic dermatitis, blue light serves as a powerful disinfectant for the skin’s surface.11,31,32 By reducing Aesthetics | May 2025

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bacterial overgrowth and controlling microbial activity, it helps alleviate chronic inflammation, redness and flare-ups.9,11,30-35 When combined with other topical or systemic treatments, such as long-term oral medications including benzoyl peroxide or salicylic acid, blue light therapy enhances overall treatment efficacy, often leading to more rapid symptom relief and long-term management of persistent dermatological conditions.36 The antibacterial effects of blue light extend beyond dermatological applications. It has been studied for its potential to sterilise surfaces and prevent microbial contamination in clinical and surgical environments, hence it is an ideal treatment for pre-operative skin priming.3,30,37 Red light (633 nm) Red light is well-documented for its ability to penetrate into the dermis, where it stimulates cellular activity and promotes tissue regeneration without causing disruption or damage to the skin's surface.2,4-6,10,11,13 This property makes red light therapy an effective, non-invasive treatment for skin rejuvenation, wound healing and post-procedural recovery.10,11,38 At the cellular level, red light stimulates fibroblasts, enhancing collagen and elastin synthesis, which improves skin elasticity, firmness and texture.6,39 By increasing cellular metabolism and ATP production, red light activates repair processes, helping the skin restore itself after damage, or counteract intrinsic and environmental ageing factors.4,40 Red light promotes angiogenesis – the formation of new blood vessels – which enhances microcirculation and tissue oxygenation.39 These mechanisms contribute to faster wound healing, reduced inflammation and improved overall skin function.10,39 This makes red light therapy particularly beneficial post-surgically or after minimally invasive procedures, where accelerated healing and scar optimisation are critical for a smooth recovery.9,40 Near-infrared light (830 nm) NIR light (830 nm) possesses the deepest penetration capacity of all therapeutic wavelengths, reaching the subcutaneous layer where it influences vascular and lymphatic function.3,4,6,9,42 Unlike blue and red light, which primarily targets the epidermal and dermal layers, NIR light is capable of stimulating deeper tissue structures, optimising blood circulation, reducing oedema and modulating chronic inflammatory responses.2,4-6,9-11,13,30-32

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This wavelength has also been shown to enhance tissue oxygenation and promote angiogenesis, both of which are critical for post-surgical recovery, chronic wound healing and musculoskeletal regeneration.4 By stimulating the vascular and lymphatic plexuses, NIR light reduces fluid retention, supports a faster resolution of swelling and accelerates the transition into the proliferative and remodelling phases of wound healing.10 A key application of NIR therapy is in post-operative care, especially after the first week, when the focus shifts to controlling inflammation and optimising tissue repair. This stage is critical, as the early phases of scar formation are most responsive to NIR light during recovery.3 There is clinical evidence to suggest that applying NIR light after the haemostatic and inflammatory wound healing phase can significantly reduce post-surgical oedema, avoiding prolonged inflammation and allowing the body to progress efficiently through the next stages of tissue regeneration.3,42 Beyond surgical recovery, NIR light therapy has demonstrated significant benefits in managing chronic inflammatory skin conditions such as rosacea, psoriasis and deep-seated inflammatory disorders.9,39,43 Its ability to modulate inflammatory cytokine responses makes it particularly effective in conditions where persistent inflammation extends beyond the skin’s surface.12

Combining wavelengths for enhanced outcomes The ability to combine multiple wavelengths in a single treatment enhances the efficacy of LED phototherapy by addressing multiple skin concerns simultaneously.12,40,41,44 In a combination approach, light intensity and energy dosage can be modulated: increased for therapeutic purposes such as post-operative recovery and chronic wound management, or decreased for maintenance therapy and application on delicate or sensitive skin.45 Additionally, different wavelengths can be delivered at varying intensities within the same session, enabling a customised approach that optimises treatment efficacy and ensures patient comfort, especially by tailoring wavelengths to suit sensitive skin.12 When blue and red light are combined, clinical studies have demonstrated a synergistic effect, improving overall acne clearance rates while mitigating scarring and reducing sebum production.9,46,50 Further research is required to validate the safety and effectiveness of combining wavelengths.

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Clinical applications for LED LED phototherapy plays a crucial role in optimising skin health, whether for accelerating wound healing or managing chronic dermatological conditions.41 Its inclusion in a treatment protocol can significantly enhance cellular regeneration, reduce inflammation and improve overall skin function.9 It is recommended that patients apply appropriate sun protection following treatment. Skin rejuvenation and antiageing The application of red and NIR LED phototherapy has been widely studied for its ability to stimulate collagen production, enhance skin elasticity and reduce fine lines and wrinkles.13,39 These wavelengths penetrate deep into the dermal layers, where they are absorbed by mitochondrial cytochrome c oxidase (CCO), leading to an increase in ATP and fibroblast activity.13 Through the increased fibroblast activity, this process triggers collagen and elastin synthesis, which improves skin firmness, hydration and overall texture.6 In hyperpigmentation treatment, NIR LED phototherapy has shown promise by downregulating tyrosinase activity, effectively reducing melanin synthesis in both monolayer and 3D skin cultures.9 Acne and inflammatory skin conditions As discussed, blue light phototherapy has been extensively researched for its efficacy in treating acne and inflammatory skin conditions.9,11,30-32,39,40,43,46 By inducing photo-oxidation of bacterial porphyrins, blue light generates ROS, leading to bacterial destruction without promoting antibiotic resistance – a growing concern in dermatology.11 Studies have demonstrated that regular exposure to blue light significantly reduces inflammatory acne lesions, often leading to faster and more sustained skin clearance when used as part of a comprehensive acne management plan.9,11,40,45,46 In addition, as inflammation plays a significant role in acne pathogenesis, red light therapy has been shown to reduce erythema, calm post-inflammatory hyperpigmentation and accelerate skin healing.39 Wound healing and post-surgical recovery LED phototherapy plays a crucial role in accelerating wound healing and enhancing post-surgical recovery.2,4,6,9,18,21 LED light can fit into a preparatory treatment before any operation and following any surgical or minimally invasive intervention to aid recovery.9,40 Aesthetics | May 2025

Light Treatment LED Therapy Studies have shown that NIR light penetrates into the subcutaneous tissue, where it stimulates angiogenesis, enhances blood circulation and promotes cellular regeneration.2-6,10,11,13,39 This wavelength has been shown to effectively reduce post-surgical inflammation, minimise scar formation and accelerate the healing process, making it an essential tool in plastic and reconstructive surgery.10,40 Based on the existing scientific research and my clinical experience, I incorporate pre-operative sessions, recommending one or two treatments with blue and red LED one to two weeks before surgery to prepare the skin and optimise tissue response. Post-operatively, patients receive LED phototherapy at key intervals, starting with blue and red light a few days after surgery. At week one, a combination of red and NIR LED is introduced in weekly sessions for the next four to six weeks, targeting treated areas to promote optimal healing.

Frequency and duration The efficacy of LED phototherapy is not solely dependent on prolonged exposure, but rather on delivering the optimal energy dose within a controlled timeframe.47 The general rule of basic physiology suggests therapeutic effects reach a plateau beyond a certain threshold, meaning that longer treatment durations do not necessarily yield greater benefits.47 Clinical studies indicate that sessions lasting between 10-20 minutes provide sufficient photobiomodulation to stimulate tissue repair, collagen production and inflammatory modulation without the need for extended exposure, and treatments should be scheduled as often as once every one to two weeks.47-50

The growing possibilities of LED phototherapy With advancements in device technology and a growing body of clinical evidence, LED therapy is becoming an integral component of modern dermatology and regenerative medicine. As more research continues to unfold, the future of photobiomodulation will undoubtedly bring new innovations and expanded clinical applications. Mr George Christopoulos is a plastic surgeon and aesthetic practitioner, who specialises in body-contouring operations and regenerative medicine. Mr Christopoulos has a clinical background in reconstructive plastic surgery, and holds a PhD title on skin cancer management. Qual: MD, PhD, MSc

VIEW THE REFERENCES AT AESTHETICSJOURNAL.COM 41

Case Study Vaginal Rejuvenation

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Examining Vaginal Rejuvenation for Cancer Patients Dr Ioannis Liakas explores how vaginal rejuvenation can enhance intimate health for post-cancer patients Cancer treatments, particularly chemotherapy and radiotherapy, can have profound effects on a woman's body, often leading to side effects that extend well beyond the immediate physical challenges.1-3 These effects can include lymphedema, neuropathy and changes in vaginal health, impacting women’s quality of life.1,2,4 In their systematic review of 34 studies, Carter et al. highlight that gynaecological cancer survivors often face a wide range of sexual concerns. These include physical issues such as dyspareunia, vaginal changes and reduced sexual activity; psychological challenges like low libido, negative body image and performance anxiety; and social difficulties involving disrupted sexual roles, emotional distancing from partners and perceived declines in partner interest. While psychoeducational interventions may partially improve physical function or increase knowledge, they rarely resolve these concerns entirely.5 Changes in vaginal health can be seen as a possible result of inflammation of all mucous membranes caused by chemotherapeutic agents, including the vagina, that can result in irritation, pain and a burning sensation in the intimate area. The same agents can damage the ovaries, leading to early menopause, thus resulting in conditions such as vaginal atrophy, dryness and discomfort. These issues can severely affect a patient's sexual health, emotional wellbeing and overall quality of life.6 For many cancer survivors, hormone replacement therapy (HRT) may not be an option due to the contraindications associated with their treatment and the primary oncological diagnosis, such as hormone-sensitive cancers. Often during

intense oncological interventions, systemic impact of the treatment can potentially be overlooked. Consequently, addressing vaginal health becomes imperative, and innovative treatments like vaginal rejuvenation offer new avenues for restoring comfort and intimacy.7 This article will explore the importance of maintaining vaginal health after cancer treatment, emphasising the need for personalised care and highlighting how understanding these concerns helps practitioners deliver safe treatment.

Impact of early menopause on aesthetic and surgical outcomes The link between cancer treatments and early menopause is well established. Chemotherapy and radiotherapy can induce menopause at a younger age, resulting in symptoms such as hot flushes, mood swings and, importantly, vaginal atrophy.8 This condition is characterised by a decrease in elasticity and moisture, leading to increased fragility of the vaginal tissues.1 A recent study showed that of the 85 participants, up to 60% of breast cancer survivors experience vaginal dryness and atrophy post treatment, significantly affecting their sexual function and quality of life.9 This situation is compounded by the fact that many cancer patients are often advised against the use of systemic hormone therapies which are generally considered the gold standard for managing menopausal symptoms.7 This is due to the potential risks associated with their specific oncological diagnosis.10 For instance, hormone-sensitive cancers such as breast cancer may be exacerbated by the introduction of exogenous hormones. Alternative

The implications of vaginal atrophy extend beyond physical discomfort; they can significantly impact self-esteem and intimate relationships 42

Aesthetics | May 2025

treatments for managing vaginal atrophy in cancer survivors include the use of vaginal lubricants, moisturisers and non-hormonal options such as vaginal dilators.11 The implications of vaginal atrophy extend beyond physical discomfort; they can significantly impact self-esteem and intimate relationships. Many women report feeling less desirable, anxious about intimacy and disconnected from their partners. These psychological challenges can exacerbate the physical symptoms of vaginal atrophy, creating a vicious cycle that hinders recovery.12 Research indicates that untreated vaginal atrophy can lead to increased anxiety and depression, further complicating the recovery process. In a survey of 83 breast cancer survivors, 64% reported that treatment negatively impacted their sexual function.13 Meanwhile, during a prospective study by Kingsberg et al., with 150 pre-menopausal breast cancer survivors, 82.6% reported sexual dysfunction at three months post treatment, with vaginal dryness and decreased libido being common issues.14 These insights highlight the need for effective interventions.15

Safety and considerations for cancer patients When evaluating the suitability of vaginal rejuvenation for cancer patients, several safety considerations must be taken into account. Alternative treatment options for vaginal concerns For patients where hormonal therapies are contraindicated, alternative treatments such as radiofrequency (RF) therapy and hyaluronic acid (HA) injections, and also a combination of both, have been reported to improve vaginal tissue hydration and elasticity. These can help address both functional and aesthetic concerns, and alleviating symptoms of vaginal dryness, dyspareunia and enhancing sexual function.16-18 Other treatment options for managing vaginal changes caused by chemotherapy-induced menopause or prolonged oestrogen suppression include vaginal dilators. These gently stretch the vaginal tissue, helping to prevent or

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reduce vaginal stenosis and maintain elasticity, comfort and sexual function.19,20 Vaginal moisturisers and lubricators can be beneficial for restoring and maintaining vaginal moisture and pH balance, particularly in women experiencing oestrogen deficiency. When used consistently, they can relieve dryness and irritation, improving comfort during everyday activities and intimacy.19 A non-invasive option for managing pelvic floor dysfunction related to vaginal tightness is pelvic floor physiotherapy to improve muscle tone, reduce discomfort during intercourse or pelvic examinations and support long-term vaginal health in cancer survivors.21 Importance of the consultation When considering any aesthetic or wellness treatment, it’s essential to take a patient’s full medical history into account; this is especially true for those who have undergone cancer treatment. Cancer and its therapies, such as chemotherapy and radiotherapy, can have lasting effects on the body, impacting skin sensitivity, tissue healing and overall resilience. Hence, before undergoing any treatment, it is essential for cancer patients to consult their healthcare providers.22 Practitioners must consider the patient's specific type of cancer, the treatment options and modalities available and their individual health status, and tailor treatment accordingly. Practitioners can carry out various methods to assess a patient's history, such as detailed questionnaires, physical examinations and discussions with oncologists or other healthcare providers involved in the patient's care.23 It is vital to take a personalised, medical-led approach to ensure that every treatment is both safe and suitable for the individual.24 Risks and contraindications It is important to discuss potential risks and contraindications before proceeding with any treatment. For instance, patients who have undergone radiotherapy may experience increased sensitivity due to the potential damage to the vaginal mucosa and surrounding tissues, necessitating a tailored approach to treatment.25 Healthcare providers must ensure that any interventions align with the patient's overall treatment plan and recovery goals. This personalised care model is vital for achieving optimal outcomes and ensuring patient safety. Contraindications for vaginal rejuvenation treatments may include active vaginal infections, recent surgical interventions in the pelvic area and certain autoimmune conditions that affect tissue healing.26 Additionally, complications may arise, such as discomfort during the procedure,

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Case Study Vaginal Rejuvenation

temporary increased sensitivity or other adverse effects that could impact the patient's overall recovery.27

Psychological and emotional benefits The psychological implications of restoring vaginal health in cancer survivors are profound. Research indicates that improvements in vaginal health can lead to enhanced self-esteem and intimacy, which are critical components of emotional recovery and emotional stability.28 Restoring sexual function and comfort can significantly impact a patient's mental health, fostering a sense of normality and connection. In my clinical experience, patients report feeling more like themselves after treatment, highlighting the importance of addressing sexual health as a vital aspect of holistic medical post-cancer care.

Case study A 52-year-old patient, who had to discontinue her HRT due to breast cancer treatment, visited our clinic with symptoms of vaginal atrophy, namely pain, dryness and significant dyspareunia. The patient stated, “After being diagnosed with breast cancer in 2022, and coming off my HRT, being intimate with my husband had become so painful I couldn't do it.” The chosen treatment was Caress Flow Vaginal Tightening for this patient. This was considered over other treatments, as the patient wanted to go for a non-invasive procedure with the least discomfort. The technology combines oxygen therapy and hyaluronic acid (HA) to stimulate blood flow and promote collagen production within the vaginal tissues. This innovative approach seeks to address the root causes of vaginal atrophy by enhancing tissue hydration and elasticity.29 The procedure involves administering 95% pure oxygen through a vaginal cannula, delivered at a controlled rate. Highly concentrated oxygen is able to diffuse easily through the vaginal mucosa, counteracting the hypoxia generated by the reduction of microcirculation and reactivating the metabolic function of cells. In the final five minutes of the treatment, a low molecular weight sodium hyaluronate solution is introduced. No injections or needles are involved in the process.30 This combination not only improves the local microenvironment, but also triggers a healing response by fostering the production of collagen, hence leading to the regeneration of healthy vaginal tissue.31 The session lasts 20 minutes and, according to the patient, was completely pain free. The treatment protocol involved six sessions, with each session spaced two weeks apart.8,9 After the third session, the patient reported significant improvement in the area with respect to hydration, elasticity and comfort. After the completion of her course of Caress Flow Vaginal Tightening, she reported, “Intimacy has become 1,000 times better, almost completely pain free. My chronic thrush, urinary tract infections, friction and burning have gone completely. I couldn't be more excited to see where this will take me as it would be amazing to think I could have a normal sex life again!” The patient’s positive feedback, especially the improved intimacy with her partner, underscored the importance of this treatment in alleviating physical symptoms and enhancing emotional wellbeing.

Elevating quality of life Addressing vaginal health in cancer survivors is a vital part of post-treatment care, as many experience symptoms like dryness, discomfort and atrophy. Research and patient reports show that non-hormonal treatments can improve hydration, elasticity and comfort, enhancing quality of life. A personalised approach, guided by open communication and clinical assessment, is key. Vaginal rejuvenation treatments, when appropriate, should only be performed by qualified medical professionals with specific training in women’s or gynaecological health. Practitioners must work within their professional scope and refer when necessary, ensuring patient safety, maintaining standards and helping survivors restore both physical wellbeing and emotional confidence. Dr Ioannis Liakas is the lead clinician and medical director at Vie Aesthetics. He studied Medicine at Aristotle University, Greece and a Masters in the Physiology of Ageing at UCL, London. Dr Liakas is a Fellow of the Royal College of Physicians, member of BCAM and honorary lecturer at Queen Mary Medical School. He has a special interest in antiageing and longevity and has been practising regenerative medicine since 2005. Qual: MBBS Aristotle University, Greece; MSc, FRCP, BCAM

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Assessing Candidacy for Jaw-Slimming Injections Dr Mariam Al-Ani outlines how to deliver safe and tailored masseter toxin injections for optimal results The masseter muscle, a key muscle in mastication, plays a significant role in jaw movement and facial contour.1 Masseter treatments with botulinum toxin type A (BoNT-A), also known as jaw-slimming injections, have gained popularity not only for providing functional relief from muscle tension, but also for their role in medical aesthetics and their ability to effectively contour the lower face.2 In the right candidate, this non-invasive treatment can significantly and safely enhance facial harmony by creating a more balanced and refined lower face.3 This article will explore the factors that make certain individuals unsuitable for masseter toxin, emphasising the importance of understanding facial anatomy in aesthetics, alongside careful patient selection and assessment.

Effectiveness of BoNT-A BoNT-A has been extensively studied and utilised for treating masseter muscle hypertrophy, particularly in cases of bruxism (teeth grinding) and for cosmetic facial slimming. Bruxism involves involuntary clenching or grinding of the teeth, often leading to discomfort, headaches and dental issues. BoNT-A injections into the masseter muscles have shown significant efficacy in reducing the frequency and intensity of bruxism episodes.3 By partially paralysing the masseter muscle, it reduces in strength and size, thereby alleviating associated pain and preventing further dental damage.3 Individuals wanting to address a pronounced posterior jawline, often due to masseter muscle hypertrophy, may exhibit a wider or more square-shaped lower face. BoNT-A injections induce a gradual reduction in muscle size through atrophy, leading to a softer and more contoured jawline.1

Clinical presentation Patients seeking treatment for masseter muscle hypertrophy, often due to bruxism, or for facial slimming, typically present with a combination of discomfort and/or aesthetic concerns. Patients often report persistent jaw discomfort, which may be accompanied by

tension-type headaches, especially in the temporal regions. Clinically, the masseter muscles may appear visibly enlarged and feel firm or tender upon palpation. In advanced cases, dental examination may reveal signs of tooth wear, such as flattening of the posterior cusps, indicative of chronic bruxism.3 Patients may also present with noticeable asymmetry in the lower face, often stemming from habitual chewing on one side, leading to overdevelopment of the masseter muscle. Additionally, premature tooth contact or missing teeth on one side can influence chewing patterns, further exacerbating asymmetry and facial imbalance.3

Assessing male and female faces It is crucial to assess male and female faces differently for aesthetic treatments because their anatomical structures, ideal proportions and aesthetic goals vary requiring a tailored approach to enhance natural features while maintaining gender harmony and balance. The female face There has been a noticeable shift in female aesthetics over recent years, moving away from overfilled faces and heavily augmented features with dermal filler (such as overfilled lips, cheeks and jawlines), to a more natural, subtle approach, with more patients requesting to have their fillers dissolved.2 In female patients, the aesthetic goal typically is to achieve a softer, more delicate appearance.4 A wider jawline can sometimes detract from the desired proportions of the face, making jaw-slimming injections a suitable option. The cheekbones should ideally be wider than the jawline in a female face.4 It is therefore advisable to address the masseters before considering cheek augmentation. For optimal results, it is best to wait six to eight weeks post initial treatment to allow for visible slimming effects due to muscle atrophy (Figure 1).5 This approach reduces the width of the lower face, ensuring that any subsequent additions to facial structure complement a smaller and more refined baseline without the risk of making the face look disproportionately and unnecessarily larger. Aesthetics | May 2025

Clinical Approach Masseter Toxin Before

After

Figure 1: Frontal view of a 33-year-old female with bilateral masseter hypertrophy, eight weeks after BoNT-A treatment using onabotulinumtoxinA (40 units per side: 30 initially, 10 as a top-up), targeting both superficial and deep fibres.

The male face In male patients, the aesthetic focus often draws upon features that convey strength and masculinity. A broad, angular jawline has long been a hallmark of an attractive male face in Western society.4 Therefore, reducing the masseter muscle in male patients requires careful consideration. In a male face, the width of the cheeks should ideally match that of the jaw to maintain balanced and masculine proportions.4 Treatments may still be warranted in cases of significant masseter hypertrophy causing discomfort or asymmetry, but aesthetic goals must be communicated and aligned. If treatment were to be considered, a balanced reduction approach should be taken, and the toxin administered gradually, starting with lower doses and assessing the response to ensure controlled atrophy.5

Assessing patient suitability When planning masseter treatment, not all patients are ideal candidates. Class 3 malocclusion patients Class 3 malocclusion, also known as an underbite, is a dental condition where the lower jaw and teeth protrude forward. This means the lower molars are positioned too far forward compared to the upper molars.6 For individuals with a prominent chin, reducing the width of the jawline can disrupt the harmony between the height and width of the face.7 This imbalance may exaggerate the appearance of prognathism, making the face appear disproportionately long or the chin overly dominant. Facial assessments should carefully evaluate the relationship between the chin, jawline and overall facial dimensions before proceeding. The cheeks and upper lip should be assessed in these cases, as they are often deficient in class 3 patients.7 45

Clinical Approach Masseter Toxin

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Patients without masseter hypertrophy Some patients have a broad jaw due to bone structure rather than muscle hypertrophy.8 In such cases, masseter reduction will not achieve a slimming effect, as it does not address the underlying skeletal framework. Accurate diagnosis through palpation and imaging is essential for differentiating between muscle hypertrophy and bony prominence. In these cases, the chin should be assessed, as a recessed chin can make the posterior jaw appear wider.8 Therefore, augmenting the chin to bring it into the correct position can restore balance and facial harmony. Patients with jowling and/or skin laxity The masseter muscle contributes to the structural support of the overlying facial tissues and provides support to the lower face.1 Reducing its size in individuals with skin laxity or jowls can lead to decreased support, potentially resulting in increased skin sagging, jowls or marionette lines.9 Therefore, assessing skin quality and support is essential before treatment to ensure a good aesthetic outcome. Thinning skin and reduced skin laxity can occur due to natural ageing, which involves diminished collagen and elastin production, fat loss and lower cell turnover.9 Additionally, lifestyle factors such as smoking and UV exposure accelerate collagen breakdown, contributing to premature ageing.9 Medications such as prolonged corticosteroid use can cause skin thinning.9 Therefore, patients seeking symptomatic relief should be informed of potential aesthetic drawbacks, and other options should be discussed. Alternative options include skin tightening procedures such as CO2 lasers or radiofrequency. Coupled with microneedling, they encourage collagen and elastin production and remodelling of the skin. Another suitable treatment would be dermal fillers strategically placed along the pre-jowl sulcus or jawline to camouflage sagging and create a smoother jawline.10 Finally, surgical options such as lower face or neck lifts should be discussed if there is significant skin laxity.10 Patients with prominent buccal fat pads Patients with prominent buccal fat pads should avoid masseter slimming injections as they can alter facial proportions.5 These fat pads contribute to the natural fullness of the lower face. If the masseter muscles are slimmed, it could create an imbalance by accentuating the fullness of the cheeks, making the face appear disproportionately round or ‘puffy’ in the mid-face area, rather than achieving a balanced, sculpted look.11 46

Figure 2: Recommended safety zone markings for BoNT-A injection into the masseter muscle, including (A) the anterior border of the masseter, (B) the superior border marked from the ear lobe to the corner of the mouth and (C) the posterior border of the masseter.

For optimal results, a careful assessment is essential to determine whether surgical buccal fat pad removal or other contouring procedures, such as fat-dissolving injections or radiofrequency, may be more appropriate in combination with masseter slimming, depending on the individual’s anatomy and aesthetic goals.10-12

Risks and considerations Practitioners should be aware of potential risks, and tailor dosing carefully to minimise complications: 13-16

· Bruising and swelling: These are the

most common side effects and typically resolve within a few days. · Facial asymmetry: Uneven dosing or incorrect injection technique can result in asymmetry, which may affect both aesthetics and function. · Chewing weakness: Over-reduction of the masseter muscle can impair chewing and jaw function, particularly in patients with smaller masseters. · Paradoxical bulging: A rare phenomenon that results in a localised protrusion or bulge in the masseter region after treatment, caused by overcompensation of the superficial masseter muscle fibres. It usually resolves spontaneously, but if it persists beyond two weeks, a small amount of additional toxin, usually five to 10 units, can be delivered in the untreated superficial layer.

· Xerostomia: Patients may report dry

mouth or reduction in salivary flow if BoNT-A diffuses or is mistakenly injected into the parotid gland. This can be avoided by keeping injections away from the posterior and superior aspects of the masseter muscle where the parotid is located. Symptoms usually resolve as the symptoms of the toxin wear off (three to six months). · Asymmetric or weak smile: Injections placed too high in the zygomaticus major muscle or too anterior in the risorius muscle can impair the patient's ability to smile. To minimise unwanted diffusion into these muscles, it is important to treat within the safety zone (Figure 2).

Anatomy and injection technique Anatomically, the masseter is divided into two distinct layers: deep and superficial fibres. These layers are integral to the muscle's structure and function, and their precise treatment is crucial when performing masseter toxin injections.13 The superficial masseter muscle fibres are primarily responsible for the visible bulk of the muscle and should be targeted for aesthetic slimming. The deep fibres play a critical role in bite force and should be targeted for bruxism and functional relief.14 Understanding the difference between the deep and superficial fibres allows for a more controlled and customised treatment

For individuals with a prominent chin, reducing the width of the jawline can disrupt the harmony between the height and width of the face Aesthetics | May 2025

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approach. Proper anatomical knowledge and careful marking are crucial to avoid danger zones and minimise risks during treatment. Landmarks for injection Practitioners should accurately identify the boundaries of the masseter muscle to avoid injecting into adjacent structures (Figure 2). The risorius muscle is most likely to be at risk during treatment.13 It is a muscle responsible for pulling the corners of the mouth outward and upward. It is located just superficial and slightly anterior to the masseter.13 Therefore, ensuring injections are placed in the posterior half and within the lower and middle masseter area will avoid unwanted diffusion, resulting in drooping on one corner of the mouth and an asymmetric smile.13 This zone helps avoid critical structures such as the parotid gland, facial artery and vein, and branches of the facial nerve, including the marginal mandibular and buccal branches.13

Injection techniques Injection sites (X shown in Figure 2) should be placed within a defined zone, maintaining a 1cm margin inside all borders to minimise the risk of toxin diffusion into adjacent muscles or structures. A three-point injection technique is recommended for safe and effective distribution of the toxin within the muscle.17 In my clinical experience, I find that a 30 G ½ inch needle is optimal for patient comfort and effective delivery. The full length of the needle should be inserted perpendicularly into the muscle. If the bone is contacted prematurely, then withdrawing slightly before administering the toxin will ensure intramuscular placement.17 The average BoNT-A dose to treat masseter muscle hypertrophy is 20-30 units on each side (onabotulinumtoxinA).18 This can vary based on individual muscle size and desired effect. A two-week follow-up review allows for assessment of dosing and ensures optimal results.

Clinical Approach Masseter Toxin

If necessary, additional toxin can be safely administered without the risk of excessive diffusion by avoiding overdosing in a single area. The most noticeable slimming effects, resulting from muscle atrophy due to reduced activity, often become evident around six to eight weeks after treatment.19 The effects of masseter toxin injections typically last between three to six months, depending on individual factors such as muscle strength, metabolism and dosage administered.20 For sustained results, it is generally recommended to repeat treatment every four to six months to help maintain muscle relaxation and prevent the masseter muscle from regaining its original bulk and strength. Over time, consistent treatments may lead to prolonged effects due to muscle atrophy, potentially extending the interval between repeated treatments.20

Personalised assessment To ensure optimal patient outcomes, practitioners should conduct a comprehensive evaluation of facial anatomy, engage in detailed discussions about aesthetic objectives and identify potential risks. This thorough approach allows for the recognition of patients who are suitable candidates for treatment, thereby facilitating the delivery of exceptional and personalised care. Dr Mariam Al-Ani is the co-founder of a dental and facial aesthetic clinic in Birmingham. She is a general dental surgeon and gained her qualification to the Membership of the Faculty of Dental Surgery (MFDS). She went on to complete a postgraduate certificate in aesthetic and restorative dentistry and has specialised in carrying out advanced aesthetic treatments since 2016. Qual: BDS, MFDS RCSEd, PGCert

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Exploring Innovative

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Skincare Solutions Mr Dalvi Humzah discusses innovative and novel products that will enhance clinic returns, outcomes and patient experience Following an in-depth discussion with leading researchers on product development and patient requirements, the MDH Range was developed with the MDH Skin, Nano Skin and MediChlor S solutions. The concepts behind these products were to produce ‘no fluff’ skincare for both patients and the clinics involved. The team was asked to look at what actives are needed in a skincare product and what are not. Based on this, many of the ingredients found in other products were removed, and we concentrated on those that are needed with minimal padding. This enables us to provide specific skincare at a lower cost to both you and your patients, making the range commercially attractive to the clinic, and economically acceptable for your patients. The team has also developed a unique nanoparticle Lipodisq™, which has the specific ability to bind active substances and penetrate through the epidermis to the reticular dermis, and deliver actives without loss of bioavailability.1 This allows a sustained release of actives, and prevents ‘dose dumping’ which may cause unwanted effects. This is the main carrier that is now included in MDH products for delivering vitamin C (MDH SKIN C serum), retinol (MDH SKIN Ret Night balm) and oxyresveratrol for pigment control (Nano Skin LYSA).

MDH Skincare The Skincare Range is based on the principle of Cleanse-Invigorate (Vit C)-Hydrate (Dew) and Rejuvenate (Ret). This means you need only have a smaller stock of products through which you can tailor simple skincare programmes for your patients to follow.

NANO Skin by DH – LYSA™: A skin pigment control serum containing oxyresveratrol (2,3,4,5-tetrahydroxystilbene), a natural compound which has a potent tyrosinase inhibitor activity. It is 32 times more effective at inhibiting tyrosinase than kojic acid. Oxyresveratrol also has antioxidant and anti-inflammatory properties, further promoting skin health and reducing the inflammatory process in hyperpigmentation. It is combined with the patented nano carrier molecule Lipodisq™ to enhance dermal penetration of the active compound with no oily residue.

MediChlor S hypochlorous solution Finally, we have developed a useful addition for clinics and patients – the MediChlor S hypochlorous solution. This is produced through electrolysis of aqueous sodium chloride (salt water) and is stable on the shelf for 18 months. It offers unparalleled antimicrobial properties, effectively eliminating a wide range of bacteria, viruses and fungi, including resilient strains resistant to traditional disinfectants.2 Its broad-spectrum efficacy makes it an ideal solution for various applications in your clinic and for patients to use.2 Hypochlorous acid, the active ingredient in MediChlor S, is a naturally occurring compound produced by the human body's immune system to fight infections. By harnessing this remarkable compound, we have created a powerful disinfectant that is both highly effective and remarkably gentle. But that's not all – MediChlor S is also very eco-friendly. Unlike many conventional disinfectants that rely on harsh chemicals, our hypochlorous solution is biodegradable, non-toxic and environmentally responsible. It leaves no harmful residues or unpleasant odours, making it safe for use in even the most sensitive environments.

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We are committed to driving innovation that improves lives while respecting our planet. MediChlor S is a testament to our dedication to delivering solutions that seamlessly merge cutting-edge technology with environmental stewardship. These novel products lead the way in providing you and your patients with innovative and efficient care throughout their medical aesthetic journey. These products will not be available on any open sites and can be obtained through the Medical Aesthetic Group. Mr Dalvi Humzah is a consultant plastic surgeon with extensive qualifications including an Anatomy degree and MBA. A member of multiple prestigious organisations, he has received numerous awards including the Aesthetics Journal Award for Outstanding Achievement in Medical Aesthetics. He delivers internationally recognised training courses and serves as an examiner, educator and opinion leader in the aesthetics sector. This advertorial is written and supplied by MDH Skin and Medical Aesthetic Group To find out more, visit magroup.co.uk or call 02380 676733

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Clinical Papers Abstracts

A Summary of the Latest Clinical Studies The latest research highlight from Professor Sebastian Cotofana and The Harley Academy Research Group World-renowned anatomist Professor Sebastian Cotofana shares a key study influencing the world of medical aesthetics. Title: Understanding the Impact of Eyebrow and Lateral Canthal Height on the Perception of Character Traits: A Rating-Based Analysis of 2081 Participants Authors: Kempa J, et al. Published: Journal of Plastic, Reconstructive & Aesthetic Surgery, March 2025 Keywords: Devices, Muscle Stimulation, Radiofrequency Aesthetic treatments are still high in demand globally, with special focus on lips and periorbital treatments. While lip treatments predominantly address lip volume, periorbital treatments focus on eyebrow shape and/or on the position of the lateral canthus. For surgical and non-surgical changes of the lateral canthal region, the terms ‘foxy eyes’ or the ‘Bella look’, named after model Bella Hadid, were coined; even though foxes do not have eyebrows. The underlying idea is to increase the height of the tail of the eyebrows and/or in combination to increase the palpebral angle, which positions the lateral canthus more cranial than the medial Title: Artificial Intelligence-Generated Educational Curriculum on Facial Neurotoxin Injections: Assessment of Educational Content, Curriculum Structure, and Course Logistics Authors: Abi-Rafeh J, et al. Published: Journal of Drugs in Dermatology, April 2025 Keywords: Artificial Intelligence, Education, Neurotoxin This study aims to assess AI’s ability in developing an educational curriculum on facial botulinum toxin injections. 10 suggested steps for curriculum design and implementation were proposed by AI. A list of 12 course learning objectives and a suggested curriculum overview were provided. A two-day schedule with appropriate session allocations was created, along with a 49-page curriculum compendium generated entirely by AI. A nine-step approach towards implementation of hands-on practice sessions was provided, complete with quantities of equipment needed. Rubrics evaluating trainees’ practical performance and a form soliciting feedback were created. Budget estimates for anticipated costs and finances were also provided, along with 12 target cities with potential dates and venues, 12 suggested instructors, guidelines for obtaining sponsorships, draft sponsorship packages and a list of potential sponsors. Validation of AI performance in the development of an educational course for facial toxin injections demonstrated promising utility for course design and implementation logistics. While AI performance remains imperfect and can never replace human educators, AI can provide a practical framework for physicians in the development and implementation of large-scale educational endeavours in medical aesthetics and beyond.

canthus. These changes are currently considered to increase attractiveness and to create a more feline facial appearance. To investigate the clinical merit of such aesthetic treatments, a research group from Poland conducted a large-scale survey-based study in which the opinion of 2,081 volunteers was assessed. In detail, the volunteers were presented with a total of nine artificially modified periorbital full-facial images in which the eyebrow was elevated (level 1 and level 2), the lateral canthus was elevated (level 1 and level 2) or a combination of both. The results were surprising to the authors because all conducted modification resulted in a statistically significant decrease of attractiveness which was applicable for both male and female observers. Additionally, the attributed character trait of trustworthiness was likewise reduced, whereas the traits of dominance, threat and disgust were increased. When only females were asked for their opinion, they stated that femininity decreased and instead masculinity increased – both statistically significant. The results of this study show in a very convincing way that not all aesthetic treatments result in an increase of attractiveness, and that especially females do not rate periorbital changes positively. The aesthetics community might want to consider the results of such studies when addressing the periorbital region of especially female aesthetic patients. Increasing the position of the tail of the eyebrow via the injection of toxins, soft tissue fillers or facial suspension threads might be nice to look at in the mirror, but the effect on others might be a surprising one. Future studies will need to further explore the true effects of aesthetic treatments to better guide the aesthetics community. Title: Is Acupuncture Effective in Diminishing Frown Lines? Evidence From a Randomized Controlled Trial Authors: Hossein H, et al. Published: Journal of Cosmetic Dermatology, April 2025 Keywords: Acupuncture, Alternative Therapies, Frown Lines This study aimed to evaluate the effects of body and facial acupuncture on reducing frown lines in women aged 30-59. In this double-arm randomised wait-list controlled trial, 72 participants were randomly assigned to either an intervention group, receiving facial and body acupuncture twice weekly for six weeks or a control group with no treatment. The primary outcome was assessed using the Global Aesthetic Improvement Scale (GAIS) based on standardised photographs. Secondary outcomes included the Subject Satisfaction Scale (SSS) and Quality of Life (QOL) scores. Measurements were taken at three time points: week zero (pre-treatment), week seven (post-treatment) and week 12 (follow-up). At week seven, 63% of the intervention group showed reduced frown lines at rest, and 72% during maximum frowning. The improvements observed in the intervention group persisted at week 12, with 68.6% at rest and 57.2% at maximum frown. The SSS indicated that 72.2% and 62.9% of the intervention group were satisfied with their frown lines at weeks seven and 12, respectively. Notable improvements in social functioning were seen in the intervention group over the control group at weeks seven and 12. No serious adverse effects were reported; minor bleeding occurred in 4.86% of treatment sessions.

Aesthetics | May 2025

Devices Counterfeit Threats

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Protecting Your Clinic from the Surge of Counterfeit Threats Aesthetic technology and device specialist Sian Keane examines the rise of counterfeit machines in the aesthetics specialty The aesthetics field is built on one foundational principle – trust. Every treatment you provide, every result you achieve and every connection you make with your patients fortifies the reputation you’ve spent years building. But what happens when that trust is broken, not because of your skills, but because of the very devices you depend on? This article will address how to identify counterfeit devices, the hidden dangers they pose and the steps you can take to protect your practice and your patients.

The counterfeit crisis The counterfeit device market is a multi-billion-pound crisis, with estimates suggesting its global value exceeds £60 billion.1 In 2022, the UK’s Medicines and Healthcare products Regulatory Agency (MHRA) seized over 60,000 unlicensed medical devices, including unauthorised lasers and energy-based machines.2 However, for every device confiscated, countless more enter clinics undetected, as counterfeiters exploit loopholes in import regulations and online marketplaces. A 2023 survey reported that 40% of aesthetic practitioners could not verify the origin of their equipment, meaning thousands of treatments may be performed with unregulated and potentially unsafe devices.3 A separate survey conducted by the American Society for Dermatologic Surgery (ASDS) found that 37.4% of dermatologists had encountered counterfeit medical devices in their practices, and 20.1% had treated complications related to these devices.4 This issue has raised serious concerns within the field. The British Association of Aesthetic Plastic Surgeons (BAAPS) has warned about the growing prevalence of counterfeit devices, urging practitioners to be vigilant and only purchase from verified, regulated suppliers.5 The risks extend far beyond burns, scarring and ineffective treatments. Counterfeit devices can irreparably damage a clinic’s reputation, leading to legal liability, regulatory action and loss of patient trust. With regulators struggling to keep pace, BAAPS and the UK’s health authorities continue to push for stricter enforcement and improved practitioner awareness and education.5 50

Until stronger regulations are in place, practitioners must take responsibility, verifying device authenticity, purchasing from authorised distributors and reporting suspicious products before they reach the treatment room.

Research and development Investing in quality technology isn’t just about getting the best deal – it’s about securing your clinic’s future. High-quality devices undergo rigorous research and development (R&D) and advanced engineering, ensuring they meet strict safety standards and provide consistent, effective results.6,7 Manufacturers who prioritise R&D do not cut corners. Their focus is on innovation, safety and long-term reliability, ensuring that the equipment they provide is clinically validated and compliant with medical regulations. Counterfeit devices, on the other hand, are built with substandard components, lack proper engineering validation and often bypass regulatory requirements, including UK Conformity Assessed (UKCA), the Conformité Européene (CE) marking, manufacturer obligations under ISO 13485, and post-market surveillance responsibilities required by the UK medical device regulation (MDR).6-8 Why is CE marking crucial? The CE marking is a legal certification indicating that a medical device meets European safety, health and environmental protection standards. For aesthetic and medical equipment, this ensures the device has been tested for clinical safety, performance and reliability. Counterfeit devices lack this validation, meaning they pose unknown risks to both practitioners and patients. Without proper testing, clinical studies and regulatory validation, counterfeit devices present unproven and unacceptable risk which no clinic can afford to take.6,7

Understanding regulatory requirements In addition to UKCA and CE marking, medical aesthetic devices must meet several other key regulatory requirements to ensure patient safety and legal compliance. Aesthetics | May 2025

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These include:

· ISO 13485 certification: A global quality

management standard for medical devices that ensures design, production and servicing processes are robust and consistent.9 · Post-market surveillance: Manufacturers must monitor the performance of their devices once in use and report any adverse events. · Technical documentation: Manufacturers must maintain thorough records demonstrating how the device complies with regulations. · Risk management files: Clinical and technical evaluations are required to show the device is safe under intended use.

Why counterfeits are a dangerous gamble Would you allow an unlicensed surgeon to perform a procedure? Counterfeit aesthetic devices operate on the same principle: no safety checks, no accountability and no guarantees. While these machines may appear to offer cost savings, the financial and reputational risks far outweigh any perceived benefits. Regulatory breaches and legal liability Counterfeit devices bypass essential safety standards, exposing clinics to fines, legal disputes and potential insurance refusals. Many of these machines feature fake CE marks or misleading compliance claims, making it easy for clinics to unknowingly violate UKCA and MHRA regulations.8 If a counterfeit device causes injury or harm, the clinic is liable, not the manufacturer. Without the legal protections offered by certified equipment that ensures proper testing, clinical studies and regulatory validation, counterfeit devices present unproven and unacceptable risks and that’s a risk no clinic can afford to take. The business impact of patient complaints Patient complaints, especially those related to negative outcomes or counterfeit products, can have far-reaching consequences for a business. One bad patient outcome can trigger a cascade of complaints, negative online reviews and reputational damage. In the aesthetics specialty, word-of-mouth and patient trust drive success, meaning a single counterfeit-related incident could permanently impact future bookings and referrals.

How certified technology protects profitability Refunds and treatment corrections Clinics using unregulated devices frequently bear the costs of retreatments, refunds and

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corrective procedures required to satisfy unhappy patients. This not only impacts profitability but diverts resources away from meaningful business growth. Additionally, staff members often feel compromised and demoralised when working with substandard equipment, negatively affecting operational efficiency and overall workplace morale.

my experience in the sector, to safeguarding your investment.

Long-term financial security

· What has your hands-on experience with

Investing in approved, clinically tested technology ensures consistency, reliability and predictable treatment outcomes. Unlike counterfeits, which frequently malfunction and require costly repairs or replacements, certified devices come with warranties, servicing and manufacturer support, protecting your investment.

Protecting your clinic from counterfeits In today’s fast-paced world, protecting your clinic from counterfeit chaos starts with due diligence. Here’s a foolproof guide, based on

Case study example One case involved a nurse who, with budget constraints in starting her own clinic, spent thousands of pounds on what she believed to be a high-quality laser hair removal device. The machine looked legitimate and was marketed as a great starter deal, promising high performance at a fraction of the usual cost. However, soon after introducing the device into her clinic, patients began complaining that treatments were ineffective, even after multiple sessions. Realising something was wrong, she attempted to contact the distributor. She found their profile on Instagram, but by that point, the distributor had either shut down or could no longer be reached. With no manufacturer support, she hired an independent engineer to inspect the device. The findings were alarming: the laser was non-functional, unregulated and hazardous, operating without any of the safety mechanisms found in certified machines. Ultimately, the device had to be scrapped, leaving the nurse with a significant financial loss. The fallout extended beyond lost money; patients lost confidence in the clinic, leading to a drop in bookings and a decline in revenue. She also faced the difficult task of rebuilding trust, compensating unhappy patients and investing in new equipment to restore her clinic’s reputation.

Using locator tools Before making any investment in aesthetic technology, it’s essential to do your homework. A valuable step is picking up the phone and speaking directly with other clinics, asking questions like: the device been like?

· Did the device deliver the results promised?

· How intuitive or user-friendly did you find it in day-to-day practice?

· Was the manufacturer's support reliable and timely?

· How thorough and useful was the training provided?

· How did the manufacturer handle issues

or unexpected situations? Many reputable brands offer clinic locator tools, which can show you where their devices are already in use. Use this as a starting point to independently identify clinics to speak with. Most practitioners are happy to share their real-world insights, especially if it helps protect others from making costly mistakes, so don’t be afraid to call and ask questions! Verify certifications It is crucial to always confirm that energy-based devices (EBDs) are fully compliant with safety regulations such as CE marking in the UK and EU. CE marking signifies that a device has undergone rigorous testing for safety, performance and regulatory compliance.6,7

If in doubt, cross-check a device against trusted databases such as the MHRA Device Register (UK)5 and The European Commission NANDO Database (EU).7 Devices without these certifications pose significant legal and clinical risks. Ensuring that devices are properly certified and traceable is not just a regulatory requirement – it protects both practitioners and patients while safeguarding the clinic’s reputation and business longevity. Demand documentation Genuine devices come with clinical studies, safety certifications and a manual. If these are not readily available, you should question the legitimacy of the device. Look for quality clinical trials Clinical trials are essential in proving a device’s effectiveness and safety. Double-blind randomised controlled trials (RCTs) offer the most reliable validation. Without quality studies, device claims may be unproven marketing. To verify whether a device is backed by credible research, Aesthetics | May 2025

Devices Counterfeit Threats business owners should: Check manufacturer websites: Reputable brands publish clinical studies and white papers. Search scientific databases: Platforms like PubMed, Google Scholar and ClinicalTrials. gov list peer-reviewed research.10,11 Consult regulatory bodies: The MHRA Device Register (UK) and European NANDO Database (EU) confirm regulatory compliance.6,7 Request data directly: The absence of clinical studies or safety documentation from a supplier should be considered a significant concern. Engage with specialty associations: Groups like BAAPS and British College of Aesthetic Medicine (BCAM) offer insights on evidence-based devices.5,12 Social media vigilance Social media has provided counterfeit devices with a direct route into clinics, using flashy ads and influencer endorsements. However, leading brands actively monitor these platforms and can take legal action if they discover you are using a duplicate device. Clinics using counterfeit devices risk:8,9 Intellectual property violations: Under the UK Trademarks Act 1994, brands can take action against unauthorised use of their technology. Regulatory breaches: The UK Medical Devices Regulations 2002 require devices to be CE-marked or UKCA-certified, with clinics facing liability for non-compliance. Account bans and legal risk: Meta, TikTok and Google Ads prohibit counterfeit medical devices, meaning clinics can face account suspensions and content removal.

A call for accountability By investing in certified, evidence-based technology, you’re not just protecting your business, you're securing its future. In aesthetics, your reputation is your most valuable asset. Protect it. Sian Keane is an experienced consultant and educator in medical aesthetics, specialising in advanced treatments and medical devices. With higher education in laser science and clinical education experience, she has trained professionals at all levels and demonstrated training for a range of advanced medical devices and treatments.

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Clinic Operations Profitable Pricing

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Evaluating Profitable Clinic Pricing Business analyst Liz McKeon discusses clinic pricing strategies and offers insights on boosting profitability Pricing is the process of determining what a company will receive in exchange for its product or services. In the case of aesthetic clinics, this means how much you charge for your treatments and services. The factors that influence this include manufacturing cost, marketplace, competition, marketplace condition, brand and quality of product.

value quality, trust your expertise and are most aligned with your clinic’s philosophy and approach. Strategic pricing can help position your clinic as accessible, aspirational or exclusive, depending on your ideal demographic.

This article will explore the key factors and discussions surrounding clinic pricing, offering advice on how to develop a profitable pricing strategy.

A pricing strategy is a method used by businesses to set the price of their products and services.1 This involves analysing market dynamics, consumer preferences, competitor pricing and internal cost structures to strike the perfect balance between profitability and market competitiveness. To stay on top of this, regularly communicate with your suppliers to stay informed about market changes, then seek financial guidance from both your accountant and suppliers to ensure your pricing remains sustainable. Without ongoing financial reviews, you risk falling behind because if suppliers increase prices and you fail to adjust, for example, your clinic’s profitability could be impacted.

Considerations when implementing clinic prices When evaluating pricing within a clinic, a well-chosen price list should aim to achieve the financial goals of the clinic business while fitting the realities of your market. Pricing your services correctly involves asking many questions, such as:

· How much should you charge for a service? · How do patients value the overall experience, including the service, atmosphere and design?

· · · · · ·

What are the pricing objectives?

There are several different pricing strategies clinics can adopt. Cost-plus pricing

What prices are competitors charging? What image do you want the price to convey? Do universal price points already exist for your services? How flexible can you be on pricing? What are the chances of getting involved in a price war – when competitors continuously undercut each other’s prices, driving them lower and lower until profits are wiped out?

The correlation between price and quality Setting the right price is one of the most difficult decisions to make when starting an aesthetic business or introducing a new service. It requires a basic understanding of both your financial and business goals, and it can feel intimidating. Retaining patients while maintaining profitability is essential, as pricing decisions can be challenging. Setting prices too low may result in financial losses, while overpricing can drive potential patients away. Many clinic owners make the mistake of setting up a flawed pricing structure, resulting in them working too hard for too little. The relationship between price and quality refers to the perception by most consumers that a relatively high price is a sign of good quality. This is especially true when it comes to clinic services. A low treatment price isn’t necessarily a cause for concern, such as the use of counterfeit products – rather, it simply reflects a different level of service quality. When analysing this correlation, the premium pricing strategy plays a role. This strategy involves consistently setting prices at or near the high end of the possible range to attract status-conscious patients. Premium pricing reinforces a luxury image, making high-end services and products more desirable, as patients believe high price is an indication of good quality. However, pricing should reflect the value of your services while aligning with the patients you genuinely want to attract. It’s not necessarily about attracting the wealthiest patients, but those who 52

Defining a pricing strategy

This is a traditional approach which involves setting a price based on the cost of production, including materials, labour and overheads, and then adding a mark-up for profit. This approach is commonly used where the costs of production are relatively stable and well understood. The drawback with this strategy is it may neglect market demand and overlook more competitive pricing strategies.2 Competitive pricing This involves pricing based solely on what competitors are charging for their services, without considering the cost of their overheads or consumer demand. This strategy aims to capture market share by offering comparable value at a competitive price point. However, it requires regular monitoring and adjustments to stay competitive.2 Value-based pricing This entails focusing on pricing services according to the perceived value they offer to patients, rather than based on cost or competition. By understanding the benefits and value proposition of your services, you can then set prices that reflect the value they provide to patients. This requires a confident understanding of patient needs to justify premium pricing.2 Penetration pricing This refers to setting a low initial price to attract patients and gain market share quickly and easily. This is particularly effective for new market entrants looking to establish a service or compete in a saturated marketplace. Offering lower-priced services aims to boost demand and attract price-sensitive patients. While this may reduce revenue initially, it can drive rapid service adoption, increase brand awareness and foster long-term loyalty. Additionally, it creates a barrier for competitors relying solely on price competition.2

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Clinic Operations Profitable Pricing

Skimming pricing

Monitor and adjust

This is a strategic approach where a clinic initially sets a high price for its service before gradually reducing over time, commonly used for new services with unique features. High pricing maximises profits from early, premium-paying patients. As demand slows, prices drop to attract price-sensitive patients. This strategy helps recoup costs quickly while maintaining an exclusive, high-quality image, but risks alienating those who cannot afford the initial price.2

Pricing is an ongoing process – it will always require continuous monitoring and adjustment. Monitor market conditions, patient behaviours and competition closely. Building strong relationships with suppliers can be valuable, as they can offer useful insights. Since market trends can impact your pricing strategy, remaining proactive will help you stay ahead of the game. It is advisable to meet with your accountant twice a year to evaluate market trends and review your clinic’s costs. Alternatively, there are various networking groups online for clinic owners to keep ahead of aesthetics trends in correlation with pricing in your clinic.

How to build a profitable pricing strategy Building a profitable pricing strategy for your aesthetic clinic requires careful consideration. This includes analysing the competition in the current market, identifying your target audience – ranging from price-sensitive patients to those willing to pay premium prices – and regularly monitoring and adjusting your prices throughout the year to account for market fluctuations. Understand your costs Before you can set your prices, you need to understand your costs. Understanding your expenses will help you determine the minimum price you need to charge to break even. Your break even point is when your total revenue equals your total costs – meaning you're not making a profit, but you're not operating at a loss either. Start by considering your fixed costs, such as rent, utilities, salaries and insurance. Then, account for your variable costs, including the materials and professional stock needed to carry out your services, such as consumables used for treatments. If you're uncertain about your costs, start by consulting your suppliers – they can provide valuable insights into the expenses associated with your services. Additionally, work closely with your accountant to break down all financial specifics, ensuring you account for every operational expense, from rent and equipment maintenance, to staff wages and your own salary. Determine your target market Your target market will have a significant impact on the prices you charge. If they primarily comprise price-sensitive patients, you may need to price your services lower than you would otherwise. Conversely, if your target market values quality, you may justify charging a premium price. Ask yourself: Who is your target market, and where are you positioning yourself? Pricing tends to be lower outside city centres, so location plays a huge role. You can’t be everything to everyone, so focus on the demographic you want to serve. Consider who you are targeting, and just as importantly, who you are not. Are you unintentionally leaving anyone out? Analyse your competition Analysing your competition provides valuable insight into what patients are willing to pay. Research your competitors' pricing strategies by searching for similar clinics in the area and consulting suppliers about what other companies charge. Use this information to refine and adjust your own pricing. However, avoid lowering prices solely to match others if it doesn’t align with your clinic’s needs. Test your prices After you have decided on a price point, always test your prices before making them final. Conduct market research and get patient feedback. Are your prices too high, too low or just right? Testing your prices will help you make informed decisions and adjust your pricing strategies accordingly. Talking with customers you have a good relationship with is a great way to gauge pricing. A casual conversation can offer valuable consumer feedback without needing to be too formal. There are also various surveys available that can help gauge prices within the community; this can be particularly useful for new practitioners who may not yet have an established patient base.

Another key factor to consider is the impact of the cost of living crisis on the medical aesthetics field. With ongoing price fluctuations in the UK and some patients feeling uncertain about price increases, this becomes a critical consideration when determining your clinic's pricing.3 Check your prices against inflation. Inflation increases the cost of doing business, and if you maintain your prices despite raising inflation, you will erode your profit margin. Allow your business to increase your prices at least once a year, but give your patients sufficient notice about the price increase.

Common pricing mistakes Here are some common pricing mistakes that I have encountered, and ways to avoid them:

· Weak controls on discounting and special offers: Avoid

reactive discounting when bookings are low – plan ahead for strategic pricing. Offering discounts in a clinic setting requires caution, as prescription-only medicines (POMs) cannot legally be discounted, and doing so may breach regulatory and ethical guidelines4

· Not tracking competitor selling prices: Monitor competitors' prices regularly – set aside five minutes each month to review them

· Disorganised price increases: Train your team who are at the interface with patients to comfortably explain potential price increases, avoiding embarrassment and confusion

· Not factoring in all running expenses: Understand the clinic's operating costs and treatment expenses

· Selling services under cost price: Losing money by offering products or services at prices too low to sustain profitability

Evaluating your clinic’s pricing strategy Pricing is crucial for several reasons, primarily because it directly impacts your clinic's profit margins, and ultimately, your own salary. A strong pricing strategy requires regular review. Sitting down with your accountant twice a year to analyse market trends, inflation and clinic performance ensures your prices remain sustainable and competitive. Don’t underestimate the value of patient feedback – open conversations can offer insight into perceived value and guide thoughtful adjustments. Liz McKeon is an international business specialist, entrepreneur and business coach. She studied Business at the College of Business Studies in Belfast, and has since authored '30 Days to Beauty Business Success.' McKeon qualified as an executive and business coach at The Institute of Coaching in 2006, and further attained the Teacher Training Certificate at Maynooth University in 2007.

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Mental Health Patient Psychology

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The importance of comprehensive patient consultation The consultation stage is crucial for understanding a patient’s motivations, expectations and emotional state. It’s not just about examining the physical issue; it is about asking the right questions to assess psychological factors that may influence treatment outcomes. Open-ended questions such as “What made you seek this treatment now?” or “How do you feel about your appearance, and how do you expect this procedure to change that?” allow us to gauge whether the patient’s expectations are realistic. It also helps identify any red flags, such as signs of Body Dysmorphic Disorder (BDD), anxiety or depression, which may require further assessment or referral.8

Assessing Patient Psychological Needs

Types of psychiatric presentations in aesthetics

Nurse prescriber Julie Scott shares why it is crucial to assess the psychological needs of patients In the world of medical aesthetics, the distinction between the medical model and the purely aesthetic model is vital. At its core is a fundamental question: Are we addressing our patients’ psychological needs in tandem with their physical concerns? Understanding and assessing our patients' psychological wellbeing isn’t just a nice-to-have – it’s essential. This holistic approach is what makes medical practice more than just a surface treatment.1 The mind and body are deeply interconnected, and patient psychology plays a massive role in the success and satisfaction of aesthetic treatments.2 This article will explore how we, as practitioners, can adopt a truly holistic approach to our practice.

A historical perspective on medical aesthetics Historically, medical aesthetics was often dismissed as superficial, with practitioners derided as “beauty doctors.” It was not until the psychological benefits of these treatments gained recognition that the field became more respected within the medical community. Research has since shown that aesthetic treatments can provide psychological relief, particularly for individuals with self-image concerns.3 For instance, studies and meta-analyses have revealed that botulinum toxin treatments in the glabellar region can be associated with significant improvements in depressive symptoms.4,5 While findings like these should be interpreted with caution, they highlight how interconnected aesthetic treatments and mental health can be. Nevertheless, the relationship between aesthetic procedures and psychological outcomes is far from straightforward, and it is essential to consider each patient’s unique psychological needs.

Why psychology matters in medical aesthetics The welfare of the patient must always come first, as medical ethics demands. This means considering not only physical health but also mental wellbeing when developing treatment plans. While aesthetic procedures aim to enhance physical appearance, they can have profound psychological effects, both positive and negative.3,4 For example, a patient may hope that an aesthetic procedure will ‘solve’ deeper psychological issues like low self-worth, only to find that the treatment does not provide the emotional relief they expected. This can lead to disappointment, or even exacerbate existing psychological conditions. On the flip side, a well-considered aesthetic treatment can significantly boost confidence and emotional wellbeing for many patients.6,7 54

Aesthetic patients often present with various psychological needs, which can be categorised into three main groups. Primary psychiatric presentations These cases involve psychological concerns that exist independent of any physical issue. The most significant and often most challenging condition in this category is BDD. BDD involves obsessive concern over perceived flaws in appearance, and these patients frequently seek aesthetic treatments to ‘fix’ what they see as imperfections.9,10 Unfortunately, because the root issue is psychological, aesthetic treatments often fail to alleviate distress and can even worsen it.10 When BDD is suspected during consultation, practitioners should refrain from offering treatment, provide empathetic reassurance and refer the patient to an appropriate mental health professional for further assessment and support. Secondary psychiatric presentations These cases arise when emotional or psychological distress stems from dermatological or aesthetic issues. Patients may experience depression, anxiety or social withdrawal due to their appearance. For example, a patient with acne scarring might suffer from social anxiety or low self-esteem.11,12 In such cases, our role extends beyond treating the physical issue; we must address the emotional distress that accompanies it. Practitioners should use clear, empathetic language to explain that while aesthetic treatments may improve certain physical features, they are unlikely to resolve deeper emotional or psychological concerns. Our treatments may offer significant relief, but it is essential to manage patient expectations and clarify the limitations of what aesthetic procedures can achieve.12 Psychophysiological presentations Psychological stress itself can trigger or worsen skin conditions like eczema, psoriasis and alopecia.12 Many of us can relate to experiencing flare-ups during stressful periods. When treating such cases, we must remember that addressing the root psychological stressor is as important as the physical treatment. Emergence of psychological concerns might involve referring the patient to a psychologist or counsellor, or offering support that goes beyond the aesthetic treatment.12 This could include signposting patients to reputable self-help resources, recommending support groups or offering wellness strategies such as stress-reduction techniques, mindfulness or lifestyle advice tailored to their specific concerns.

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Managing patient expectations and the role of informed consent A key element in providing safe and ethical aesthetic treatments is managing patient expectations. It is not uncommon for patients to come in with an idealised version of what they expect a procedure to achieve. As practitioners, it is our duty to ensure they understand both the possibilities and limitations of the treatment. This is where the concept of informed consent becomes critical.13 Informed consent isn’t just about explaining the physical risks of a procedure; it is about ensuring that patients have a clear understanding of the emotional and psychological outcomes as well. For patients without overt psychiatric presentations, this may involve gently exploring their motivations, gauging emotional expectations and using open-ended questions to identify whether they are hoping for deeper emotional change from a procedure. While written or online resources can support understanding, meaningful consent ultimately comes from knowing your patient and tailoring the conversation to their emotional needs. Some points to emphasise during the consent process include:

· The potential psychological effects, both positive and negative, of the procedure

· The realistic outcomes they can expect from the treatment · The possibility that the procedure may not resolve deeper

emotional or psychological concerns Setting appropriate expectations helps to avoid disappointment and promotes a healthier, more trusting relationship between the patient and clinician.14

Learning from others to enhance care While aesthetic procedures require technical expertise, addressing the psychological aspects of patient care demands a different set of skills. Practitioners need ongoing training in mental health awareness, screening for conditions like BDD and communication strategies that build empathy and trust.15 This should be done through structured training in psychological assessment, and by embedding validated tools such as the PHQ-9 for depression and the Veale Body Image Questionnaire into routine consultations.11,16 While not every patient will present with overt symptoms, universal screening promotes consistency, reduces bias and ensures that underlying concerns are not overlooked. Practitioners can deepen their communication strategies by engaging in training focused on active listening and empathy-driven dialogue; good communication involves asking open-ended questions and creating a non-judgmental space where patients feel genuinely heard and understood. Continuing education courses, workshops on mental health and collaboration with mental health professionals can enhance our ability to provide holistic care.17 Collaborating with other professionals such as dermatologists, psychologists and even nutritionists allows us to address the patient’s needs holistically.18 For example, a patient with skin-related anxiety might benefit from seeing both a dermatologist for the physical issue and a psychologist to address the emotional component. Building a network of trusted professionals allows us to refer patients when necessary, ensuring they receive the most suitable and complete care.19

The ethics of declining treatment Sometimes, the most ethical choice may be to decline a procedure. Performing an aesthetic treatment may not always be in the patient’s best interest, especially if unrealistic expectations or unresolved psychological issues are involved. Patients seeking repeated treatments or those driven by psychological distress

Mental Health Patient Psychology

may benefit more from psychological support than from further aesthetic procedures.20 Additionally, if a patient provides concerning responses on a mental health questionnaire, such as indications of suicidal thoughts or obsessive focus on flaws, you have a duty of care to pause the treatment journey, explain your concerns compassionately and signpost or refer the patient to an appropriate mental health service.13 Saying no can be difficult, but it is an essential part of maintaining the integrity of our practice and ensuring the wellbeing of our patients. When patients respond negatively to being declined treatment, practitioners should remain calm, provide a clear and empathetic explanation for their decision, document the reasoning carefully and offer alternative support or referral pathways. This reinforces that the decision was made in the patient’s best interest and in accordance with ethical guidelines.21

Psychological aftercare Our responsibility to the patient doesn’t end once the procedure is complete – psychological aftercare is a crucial but often overlooked aspect of patient management. Following up with patients to assess both physical outcomes and emotional responses allows us to identify and address any concerns early on.18 Patients may feel a range of emotions post procedure, from elation to anxiety, or even regret. Regular check-ins – whether in person or through follow-up calls – offer reassurance and allow us to provide further support or referrals if necessary. This is especially important for patients with pre-existing psychological conditions, as it ensures their wellbeing is fully supported. Follow-up should typically occur the following day, and then subsequently within two weeks of treatment to assess initial physical and emotional responses, with an additional check-in at around six weeks to evaluate patient satisfaction and the need for ongoing support. While in-person follow-ups are ideal, especially when assessing treatment results, remote follow-ups via phone or video can still be effective.22

Elevating aesthetics through holistic care The complex relationship between psychology and aesthetics highlights the need for a patient-centred, holistic approach. As practitioners, it is our responsibility to not only focus on physical outcomes, but also understand the emotional landscape that accompanies each treatment.17 Ultimately, by addressing the psychological needs of our patients and treating aesthetic concerns within a medical framework, we can elevate the field beyond physical enhancements. This thoughtful, ethical approach nurtures the whole person – mind and body alike – creating lasting, positive impacts that go far beyond the surface. Julie Scott is an independent nurse prescriber, Level 7 qualified aesthetic injector and trainer with more than 30 years of experience in the field of plastics and skin rejuvenation. She is an aesthetic mentor and international speaker, who has won The Aesthetics Awards ‘Aesthetic Nurse Practitioner of the Year’ in both 2022 & 2024, and ‘Best Clinic South of England’ 2023 awards. She also sits on the Aesthetics Reviewing Panel for the Aesthetics Journal, is a Board member for DANAI and is an ambassador and KOL for the JCCP and several leading aesthetic brands. Qual: RGN, NIP, PGDip(Aes)

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“Restoring someone’s confidence can be life-changing!” Sara Cheeney reflects on the defining moments and toughest challenges of her aesthetics journey Sara Cheeney, awarded The Evolus Award for Nurse Practitioner of the Year at The Aesthetics Awards 2025, is a North Wales-based laser skin treatment specialist and nurse prescriber, passionate about transformative results. Cheeney was born and raised in Glyn-Dyfrdwy, North Wales. Throughout secondary school, she struggled with psoriasis and was prescribed steroid creams by her GP, which thinned her skin and led to the development of stretch marks on her legs through puberty. Eventually, Cheeney’s GP referred her to a clinic on Rodney Street, Liverpool, for some light therapy treatment to help. She says, “This was a time when leaflets were still a thing, and the waiting room wall was filled with leaflets about all the different laser treatments you could have done. I instantly thought – what an incredible career, being able to restore confidence in people!” Enrolling at Bangor University in 2000, Cheeney kickstarted her nursing career by completing her Bachelor of Nursing degree, undertaking student placements at local hospitals and officially qualifying in 2003. She reflected, “I remember wondering at the beginning of my placements if I would ever reach the level of those inspiring women who mentored me.” After years as a theatre nurse in hospital surgical wings, she dedicated herself to further training, completing a nurse prescribing course and earning a Level 7 certification. Cheeney opened her first clinic in 2008, describing it as “a huge leap of faith,” as she started independently. She bought an old nail bar, located in Rossett on the North Wales border, and converted it into a medical spa, balancing both the world of beauty and medical aesthetics. When she opened the practice, Cheeney started her journey with botulinum toxin, before advancing with peels and expanding into laser treatments for vascular pigmentation and skin tightening. She shared, “Restoring someone’s confidence, whether that’s treating teenage acne, a non-surgical rhinoplasty or treating a lip deformity, is life-changing!” As the years went on, Cheeney explained that the clinic became her passion, and she wanted to dedicate her time solely to the aesthetics side, playfully expanding on her theory, “As a fan of Ramsay’s Kitchen Nightmares, I remember him saying, ‘If the menu is too big, it’s never going to work'.” After she reopened her clinic following the COVID-19 pandemic, she chose to focus on medical aesthetics solely. Reflecting on the specialty, she stated her favourite approach to medical aesthetics is advancing a healthy skin journey before embarking on other treatments, such as botulinum toxin or dermal fillers. Cheeney commented, “It’s not just about facial enhancement – it’s about what you put into your body, along with maintaining a healthy diet, lifestyle and the right supplements.” Cheeney currently teaches on dermal fillers for global medical aesthetics company Neauvia, contributes to the advanced toxin training course for pharmaceutical company Evolus and serves as a faculty member and UK trainer for ZO Skin Health. These roles entail teaching through live demos, webinars, clinic shadowing and conference presentations. Reflecting on the challenges she has faced in her life and career, Cheeney opened up about her battle with breast cancer. She discussed the glamour of the aesthetics specialty in contrast to the personal struggles she endured following her diagnosis, including hair loss, a mastectomy and the loss of her menstrual cycle. Cheeney candidly shared, “At first, I feared that patients would expect their injector to embody the aesthetic they desired – and I didn’t believe I fit that image.” Cheeney paid thought to the time she was invited to speak at an event on behalf of ZO Skin Health, saying, “I thought I couldn't! I had no hair and no chest, so who would listen?” Aesthetics | May 2025

In Profile Sara Cheeney However, once she shifted her mindset, the diagnosis became easier to face. She specifically mentioned David Hicks, chairman of Wigmore Medical, recalling a pep talk he gave her at a time she was struggling with her diagnosis. Cheeney shared, “He told me to stay focused on my end goal and lean on my aesthetics support network. His support really helped me through a dark time in recovery.” Over time, Cheeney cultivated a supportive community of women within her clinic, offering guidance and reassurance. She shared, “Many have dropped by my clinic not just for treatments, but for a cup of tea and a heartfelt conversation – seeking advice, sharing diagnosis and finding comfort in a space where they feel understood.” Outside of the medical aesthetics sector, Cheeney has developed a new charitable organisation following her battle with cancer, recognised as ‘Star Box’. With continued support from NHS charity Awyr Las, and additional endorsment from Wigmore Medical this year, the care package is for cancer patients using the Shooting Star Unit at Wrexham Maelor Hospital, where Cheeney herself was treated after her breast cancer diagnosis. Cheeney reflected on her journey in aesthetics thus far, admitting she never imagined reaching this stage in her career. She described the specialty as “one big work family,” adding, “What other field can you work in, where you travel miles away and still recognise everyone in the room?" Reflecting on her recent win at The Aesthetics Awards 2025, Cheeney expressed this as a milestone within her career. She shared, “I used to look up to the people winning these awards, wondering if I’d ever be as good as them one day. That’s why being recognised at The Aesthetics Awards – such a credible and well-judged platform – feels absolutely huge.”

If you could choose a career outside the medical field, what would it be? I’ve always loved high-pressure, fast-paced roles, so being a Helimed would be a dream. That, or winning X Factor... but I can’t sing!

What is your dream holiday destination? A trip around the world on the Orient Express.

Who is your role model, in the field or outside of it? My mum, for her caring and strong personality.

The Last Word Fitzpatrick Scale

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Aesthetics

Evaluating the Usefulness of the Fitzpatrick Scale Dr Derrick Phillips argues for the use of an alternative to the Fitzpatrick scale The Fitzpatrick skin type (FST) scale is a widely used classification system that was originally developed by American dermatologist Thomas Fitzpatrick in 1975 as a tool for assessing the propensity of the skin to burn during phototherapy for psoriasis.1-4 The scale was designed for white populations, and in its original incarnation comprised four phototypes (I, II, III and IV) based on skin colour, tanning ability and reactivity to sun exposure.3,4 Black and brown skin were added as phototypes V and VI respectively to complete the scale.3 Over the decades, the Fitzpatrick scale has evolved into a tool used for describing constitutive skin colour, predicting skin cancer risk and projecting outcomes in skin surgery and laser treatment, all of which are beyond the scope of Fitzpatrick’s original vision.2,4,5 The simplicity of the scale and the lack of a suitable alternative has led to its widespread adoption in clinical practice. I argue that it is time to replace this outdated tool with a more objective and equitable scale without the bias or limitations inherent in the FST scale.

Fitzpatrick limitations There are a number of limitations that should be considered when using the FST scale. Bias The most obvious limitation when using the FST scale is the inherent bias for fair skin.1 There are four phototypes describing lighter skin tones, whilst the breadth of skin colours observed in black and brown skin are condensed into phototypes V and VI.3 This gives an erroneous perception of a lack of diversity in moderately and darkly pigmented skin, and results in individuals of different ethnicities being incorrectly grouped together (e.g. North African and South Asian populations as Fitzpatrick type V), despite clear differences in skin tone, hair texture and response to UV exposure.3 Moreover, studies have shown that there are large variations in skin colour amongst sub-Saharan Africans with dark skin.6,9 In my view, condensing all of these tones into one phototype (VI) fails to capture the true diversity of black skin. Constitutive skin colour The FST scale does not correlate with biological measures of skin colour.7 Constitutive skin colour refers to the genetically predetermined amount of melanin in the skin, which is not influenced by endogenous or exogenous factors.2 It can be objectively measured using reflectance spectrophotometry of non-sun exposed sites, and studies have shown that it does not correlate with FST.7,10 I see the lack of correlation as a concerning flaw, as the FST scale is widely used to describe populations of colour. Subjectivity The FST scale is a highly subjective tool, and relies on the participant’s understanding of descriptive language and the assessor’s level of training.2 In non-white populations, use of phrases such as ‘tanned’ instead of ‘skin getting darker’ can lead to misunderstanding and incorrect self-reporting, particularly in cultures where tanning is not a norm.2 The perception of fair skin is highly subjective; for example, Japanese women often self-identify as FST II, although Asian skin is generally considered non-white.4 Minimal erythema dose discrepancy Although the Fitzpatrick scale was designed to predict the propensity of skin to burn during phototherapy, it does not correlate with minimal erythema dose (MED) – the objective measure of redness used to plan modern phototherapy treatments.2

A potential alternative As dermatology and medical aesthetics strives towards equity and inclusivity, I argue that the retirement of outdated Eurocentric frameworks like the Fitzpatrick scale is becoming increasingly important. There are a number of alternative frameworks such as the Individual Typology Angle, Taylor Hyperpigmentation Scale, Goldman World Classification of Skin 58

Aesthetics | May 2025

Aesthetics

aestheticsjournal.com

Types and the Eumelanin Human Skin Colour Scale (EHSCS), of which, in my view, the EHSCS has shown the most promise. The EHSCS is a novel five-point descriptive scale for describing constitutive skin colour in humans.3 The use of ‘Eumelanin’ in the title is to highlight its role as the predominant pigment in human skin, and the main determinant of skin colour.3 The scale uses objective Melanin Index (MI) measurements from reflective spectrophotometry of well-referenced indigenous populations to create five categories that can be utilised to describe the full breadth of constitutive human skin colour.3 The five categories and associated MI cut-off points are:8 1. Eumelanin low: <25 2. Eumelanin intermediate low: 25-<50 3. Eumelanin intermediate: 50-<75 4. Eumelanin intermediate high: 75-<100 5. Eumelanin high: >100 I argue that the EHSCS allows constitutive skin colour to be described in a simple, objective, reproducible and equitable manner. It does not predict how individuals will respond to UV radiation or other stimuli, but it can be used as a framework on which other scales can be developed.3 A potential barrier to its widespread adoption is the requirement for a skin reflectance instrument to measure the melanin index in clinic.2

Reconsidering skin classification The Fitzpatrick scale’s contributions to dermatology are undeniable, but in my view, its limitations highlight an outdated approach to skin classification. I argue that a more inclusive approach is required which accurately describes the full spectrum of skin colours observed in a manner that is objective and reproducible. Of the alternative classification systems that have been proposed, I believe that the EHSCS has shown the most promise. Dr Derrick Phillips is a consultant dermatologist at OneWelbeck and Skin55 Dermatology. He has an interest in general dermatology, inflammatory skin conditions, skin lesion assessment and skin rejuvenation. He is actively involved in clinical research and has published widely in scientific literature. He is an official spokesperson for the British Skin Foundation and a member of the Aesthetics Journal Reviewing Panel. Qual: MBBS, BSc, FRCP (Dermatology)

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