Aesthetic Practitioners Research Articles

Anatomy, Etiology, Management, and Medico-Legal Implications of Botulinum-induced Blepharoptosis

Abstract: Botulinum toxin injections, a popular aesthetic treatment, have over 7.4 million beneficiaries in the U.S. Despite their safety record, these injections pose potential complications. It is essential for aesthetic practitioners to manage these complications with the least impact on the patient. Upper eyelid ptosis, though rare, is a significant side effect of botulinum toxin injections. Through our study, we have identified the etiology, anatomy, and therapeutic management of botulinum- induced blepharoptosis. Hence, the goal of this study was to identify the basic aetiology of blepharoptosis and manage this complication, as well as discuss the basis of medico-legal implications involving this popular drug. The complex medico-legal implications of botulinum toxin-induced blepharoptosis call for continuous discourse, education, and clarity on drug-use legal standards. With evolving global and Italian legislation, practitioners must ensure they meet care standards, weighing treatment benefits against potential legal and ethical outcomes. Blepharoptosis is a rare but significant complication of botulinum-type injections. Etiology and thorough anatomy are crucial for avoiding this complication and handling it with the least impact on the patient. Medico-legal implications are currently not fully established, but the basis of aesthetic treatment standards, as well as continuing medical education, will ensure correct medico-legal coverage of such complications.

Body contouring: a sculptural art

Lucy Glancey discusses the ways in which our aesthetic preferences for the shape of the human body can change over time, and the methods aesthetic practitioners are using to keep up with these ever-evolving preferences

ABCD Classification of Skin Types.

The classification of an individual's skin type is important because it helps dermatologists and aesthetic clinicians select the most effective methods for treating the skin. To select suitable cosmetic products and procedures that help ensure healthy and beautiful skin, clinicians must consider the patient's skin type. An individualized classification of skin types allows the clinician to develop personalized skin care recommendations that consider an individual's genetic and physiological characteristics. In the fields of dermatology and aesthetics, the classification of skin types is the basis for scientific research. Skin type classification systems are additionally important for both dermatologists and aesthetic practitioners because they influence the selection of cosmetic products, procedures, and treatments. The purpose of this paper was to provide a detailed review and evaluation of the relevance, suitability, and benefits of the new ABCD Classification of Skin Types, to compare it with other systems for classifying skin types, and to identify parameters for its improvement.

Real-world Implications of Botulinum Neurotoxin A Immunoresistance for Consumers and Aesthetic Practitioners: Insights from ASCEND Multidisciplinary Panel.

As long-term, regular aesthetic botulinum neurotoxin A (BoNT-A) use becomes more commonplace, it is vital to understand real-world risk factors and impact of BoNT-A immunoresistance. The first Aesthetic Council on Ethical Use of Neurotoxin Delivery panel discussed issues relating to BoNT-A immunoresistance from the health care professionals' (HCPs') perspective. Understanding the implications of BoNT-A immunoresistance from the aesthetic patient's viewpoint allows HCPs to better support patients throughout their aesthetic treatment journey. A real-world consumer study surveyed 363 experienced aesthetic BoNT-A recipients across six Asia-Pacific territories. The survey mapped participants' BoNT-A aesthetic treatment journey and characterized awareness and attitudes relating to BoNT-A immunoresistance and treatment implications. At the second Aesthetic Council on Ethical use of Neurotoxin Delivery meeting, panelists discussed survey findings and developed consensus statements relating to the impact of BoNT-A immunoresistance on the aesthetic treatment journey. Aesthetic BoNT-A patients' depth of knowledge about BoNT-A immunoresistance remains low, and risk/benefit communications need to be more lay-friendly. The initial consultation is the most important touchpoint for HCPs to raise awareness of BoNT-A immunoresistance as a potential side effect considering increased risk with repeated high-dose treatments. HCPs should be cognizant of differences across BoNT-A formulations due to the presence of certain excipients and pharmacologically unnecessary components that can increase immunogenicity. Standardized screening for clinical signs of secondary nonresponse and a framework for diagnosing and managing immunoresistance-related secondary nonresponse were proposed. These insights can help patients and HCPs make informed treatment decisions to achieve desired aesthetic outcomes while preserving future treatment options with BoNT-A.

Identifying Levels of Competency in Aesthetic Medicine: A Questionnaire-based Study.

In 2022, the US experienced a significant increase in demand for minimally invasive aesthetic procedures, underscoring its rising acceptance amid an unregulated educational environment for practitioners. The absence of standardized educational pathways and quality control in aesthetic medicine, primarily provided by nonacademic institutions, highlights a critical need for establishing educational standards to ensure practitioner competence and patient safety. The aim of this study was to identify levels of competency for the aesthetic practitioner and necessary achievement milestones during the educational path from novice to expert injector. A total of n = 386 international study participants responded to an online questionnaire regarding their experience in aesthetic medicine practice. The questionnaire comprised 58 questions focusing on professional data, the perceived difficulty of injection, and risk for the occurrence of adverse events for specific facial regions in soft tissue filler and toxin injections. Regardless of medical specialty and experience level, averages of 3.85 (1.8) years, 786.4 (2628) filler injections and 549.9 (1543) toxin injections were estimated to progress from novice to advanced injector, while averages of 6.10 (3.7) years, 1842.2 (4793) filler injections, and 1308.5 (3363) toxin injections were estimated to advance from advanced to expert injector. The nose and the perioral region have been ranked as the facial regions where it is most difficult to achieve a perfect aesthetic outcome and with the greatest risk for the occurrence of adverse events for filler and toxin injections, respectively. In this study we establish an educational framework in aesthetic medicine by defining the progression from novice to competent and expert injector levels, suggesting 4 years of practice and over 790 filler and 550 neuromodulator injections for competence, and at least 6 years with 1840 filler and 1310 neuromodulator injections for expertise. We also identify critical facial regions for targeted treatments by different expertise levels.

The transformative power of gender-affirming healthcare: recommendations for effective treatment

The demographics of aesthetic clinic attendees are changing, and the aesthetic practitioner should be cognisant of the needs and patient-related factors of the growing variety of individuals encountered in their practice. This includes transgender individuals who wish to seek gender-affirming surgical or non-surgical procedures as part of their transition. Francesca Ramadan explores the transformative power of gender-affirming healthcare and the treatment considerations and recommendations for this demographic, so that aesthetic practitioners are well-equipped to help their patients reach their full potential.

Caring for Patients With Body Dysmorphic Disorder Seeking to Undergo Plastic Surgery and/or Aesthetic Interventions.

In the field of medical aesthetics and plastic surgery, it is not uncommon to interact with clients who never seem to be satisfied, regardless of the success of an intervention. Medical professionals may attribute this to the patient having an overly critical nature; however, this continual dissatisfaction could also be the result of a mental health disorder known as body dysmorphic disorder (BDD) that is significantly underdiagnosed and prevalent within the plastic surgery and aesthetic patient population. According to the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5; American Psychiatric Association, 2013), BDD is defined as, "a preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others" (Substance Abuse and Mental Health Services Administration, 2016, Table 23). Having the ability to identify the signs of BDD, utilize appropriate communication skills with individuals who may have BDD, and understand the implications of providing additional aesthetic treatments for patients who present with BDD allows aesthetic practitioners to prioritize and promote patient safety, well-being, and satisfaction.

Tips for the Perfect Lips.

Lip augmentation can correct lip asymmetries, reduce fine lines, define lip shape and Cupid's bow, and add natural fullness to the lips. Achieving a perfect result when injecting lip filler is an art that combines the desire of the patient with the skill of the practitioner and the practitioner's understanding of the surrounding anatomy. It is essential for aesthetic practitioners to prioritize open communication, provide custom-tailored treatments, and have a strong commitment to achieving natural and harmonious results. By following these principles, patients can enjoy the benefits of enhanced lips that boost their self-confidence while maintaining their unique beauty.

LED light therapy: the evidence behind the efficacy

The plethora of modalities available to improve skin health and appearance is greater than ever, with one of these options being LED light therapy. Various LED-based devices for dermatological and cosmetic usage have become widely available, but the average consumer or aesthetic practitioner may not be confident in their efficacy or safety. Francesca Ramadan summarises the latest evidence-based applications of LED phototherapy and the research supporting its benefit to the aesthetic practitioner's toolkit.

Hyaluronidase for Dermal Filler Complications: Review of Applications and Dosage Recommendations.

Hyaluronidase (Hyal) can reverse complications of hyaluronic acid (HA) fillers, which has contributed substantially to the popularity of such procedures. Still, there are differing opinions regarding Hyal treatment, including dosage recommendations in filler complication management. We aimed to address unanswered questions regarding Hyal treatment for HA filler complications, including timing and dosage, skin pretesting, properties of various Hyals and interactions with HA gels, and pitfalls of the treatment. PubMed and Google Scholar databases were searched from inception for articles on Hyal therapy for filler complications. Articles were evaluated regarding their contribution to the field. The extensive literature review includes international leaders' suggestions and expert panels' recommendations. There are limited controlled data but increasing clinical experience with Hyal treatment. The currently used Hyals provide good results and have an acceptable safety profile. Nonemergent complications such as the Tyndall effect, noninflamed nodules, and allergic or hypersensitivity reactions should be treated with low or moderate Hyal doses. Hyal should be considered with prior or simultaneous oral antibiotic treatment in managing inflammatory nodules. Hyal may be tried for granulomas that have not responded to intralesional steroids. Emergent complications such as vascular occlusion and blindness require immediate, high-dose Hyal treatment. Regarding blindness, the injection technique, retrobulbar versus supraorbital, remains controversial. Ultrasound guidance can increase the efficacy of the above interventions. Hyal is essential in aesthetic practice because it can safely treat most HA filler complications. Immediate Hyal treatment is required for emergent complications. Aesthetic practitioners should be versed in using Hyal and effective dosage protocols.

Design and Validation of an integrated Objective Structured Clinical Examination (i-OSCE) for a non-surgical aesthetics postgraduate program.

Introduction: The Objective Structured Clinical Examination (OSCE) is a popular and practical method for evaluating future clinicians’ competence and suitability for independent clinical practice. The present study aimed to develop and validate an integrated objective structured clinical examination to assess aesthetic physicians’ critical thinking and clinical competency. Methods: Initially, an expert panel consisting of five Aesthetic Practitioners with over 15 years of experience and a senior clinical academic were invited to develop a blueprint for the integrated objective structured clinical examination. Through this blueprint, the essential qualities and skills were identified for assessment. In addition, training workshops for examiners and simulated patients were organized to ensure process standardization. The final integrated objective structured clinical examination consisted of 12 stations (four clinical, four critical thinking, and four rest stations lasting 180 min). Results: The Interclass correlation coefficient between the station checklist items was 0.946 (average upper bound 0.916, lower bound 0.968; p<0.00), which was considered significant. The Inter-Item Correlation Matrix among the clinical station and critical thinking checklist items also showed statistical significance. The Pearson correlation coefficient (PCC) was used to ascertain the correlation between the checklist and global ratings, yielding a high correlation (0.80 0.934). Conclusion: The integrated objective structured clinical examination is a valuable and reliable tool for assessing trainees’ aesthetic physicians’ clinical competence and critical thinking.

Energy-based treatments: a promising alternative to surgical intervention

Introduction An increasing number of patients are seeking out non-invasive modalities to address their concerns around fat reduction and body contouring. However, with so many options available, it can be difficult for a practitioner to choose the most appropriate modality for their patient. Here, Francesca Ramadan reviews the mechanisms, benefits and limitations of the most common energy-based treatments, empowering aesthetic practitioners to provide more effective and personalised solutions for their patients.

Addressing the Real-World Challenges of Immunoresistance to Botulinum Neurotoxin A in Aesthetic Practice: Insights and Recommendations from a Panel Discussion in Hong Kong

With increasing off-label aesthetic indications using higher botulinum neurotoxin A (BoNT-A) doses and individuals starting treatment at a younger age, particularly in Asia, there is a greater risk of developing immunoresistance to BoNT-A. This warrants more in-depth discussions by aesthetic practitioners to inform patients and guide shared decision-making. A panel comprising international experts and experienced aesthetic practitioners in Hong Kong discussed the implications and impact of immunoresistance to BoNT-A in contemporary aesthetic practice, along with practical strategies for risk management. Following discussions on a clinical case example and the results of an Asia-Pacific consumer study, the panel concurred that it is a priority to raise awareness of the possibility and long-term implications of secondary non-response due to immunoresistance to BoNT-A. Where efficacy and safety are comparable, a formulation with the lowest immunogenicity is preferred. The panel also strongly favored a thorough initial consultation to establish the patient’s treatment history, explain treatment side effects, including the causes and consequences of immunoresistance, and discuss treatment goals. Patients look to aesthetic practitioners for guidance, placing an important responsibility on practitioners to adopt risk-mitigating strategies and adequately communicate important risks to patients to support informed and prudent BoNT-A treatment decisions.

Profiling UK injectable aesthetic practitioners: A national cohort analysis

The United Kingdom (UK) injectables market has been growing rapidly with a lack of robust regulation and to date, no information regarding the profile of practitioners has been published. We aim to provide a descriptive and qualitative analysis of the advertised practitioners in the United Kingdom. We performed a systematic search using the internet search engine Google to perform a qualitative descriptive analysis of aesthetic practitioners in the UK. For each contiguous country in the UK: England, Scotland, and Wales, five searches were performed. The list of practitioners was then cross-referenced with professional regulatory bodies, with extraction of registration number, date of registration and presence or absence from the Specialist Register or General Practitioner Register. 3000 websites were visited and evaluated. 1224 independent clinics with 4405 practitioners were identified. 738 were identified as those in business support functions and the remaining 3667 practitioners were undertaking injectable practice. The profile of professions were doctors 32%, nurses 13%, dentists 24% and dental nurses 8%. Of the 1163 doctors identified 481 were on the specialist register (41%) and 219 were on the GP register (19%). 27 specialties were represented in this cohort analysis. Plastic Surgery formed the majority of those who were on the specialist register at 37%, followed by Dermatology at 18%. This paper is the first to describe the range of practitioners, their professional backgrounds and experience who perform non-surgical aesthetic interventions. The range of backgrounds may have an impact on the potential risks to patients and will be an important consideration in proposed legislation to introduce licensing to the industry.

O161 Profiling UK injectable aesthetic practitioners: a national cohort analysis

Abstract Introduction The United Kingdom injectables market has been growing rapidly. The lack of formal, robust regulation has led to the UK Government seeking to evaluate methods of regulating the industry, as very little information or evidence is available regarding practitioners. We aim to provide a descriptive and qualitative analysis of the advertised practitioners in the United Kingdom. Methods Between June-December 2022, we performed a systematic search using the internet search engine Google to perform a qualitative descriptive analysis of aesthetic practitioners in the UK. For each contiguous country in the UK: England, Scotland, and Wales, five searches were performed. The list of practitioners was then cross-referenced with professional regulatory bodies. Results 3,667 practitioners were identified as those undertaking injectable practice. Doctors formed the majority of practitioners at 32%. Dentists and dental nurses formed 24% and 8% respectively of practitioners, and trainee dental nurses–2%. Of the 1,163 doctors identified, a total of 481 were on the specialist register (41%) and 219 were on the GP register (19%). A total of 27 specialties were represented in this cohort analysis. Plastic Surgery formed the majority of those who were on the specialist register at 37%, followed by Dermatology at 18%. Conclusion This paper is the first to describe the range of practitioners, their professional backgrounds and experience who perform non-surgical aesthetic interventions. The range of backgrounds may have an impact on the potential risks to patients and will be an important consideration in proposed legislation to introduce licensing to the industry.

Redefining Beauty: A Qualitative Study Exploring Adult Women's Motivations for Lip Filler Resulting in Anatomical Distortion.

Lip filler enhancement has fast become one of the most popular minimally invasive cosmetic procedures. Motivations for "overtreatment" with lip fillers are poorly understood. The aim of this study was to explore female motivations for and experiences of procedures that achieve an aesthetic of distorted lip anatomy. Twenty-four females who had undergone lip filler procedures resulting in strikingly distorted lip anatomy, determined by the Harris classification of filler spread, took part in semistructured interviews about their motivations, experiences, and perceptions related to lip fillers. A qualitative thematic analysis was carried out. Four major themes are discussed: (1) the normalization of lip fillers, (2) perceptual drift which is mediated by exposure to repetitive images of larger lips on social media, (3) perceived financial and social benefits of larger lips, and (4) the relation between mental health and seeking repeated lip filler procedures. Motivations for seeking lip fillers vary, but most subjects described social media impacting perceived aesthetic norms. A process of perceptual drift occurs whereby mental schema encoding expectations of "natural" facial anatomy can adapt through repeated exposure to enhanced images. The results can inform aesthetic practitioners and policymakers seeking to understand and support those seeking minimally invasive cosmetic procedures.

Developing Consensus-Based Guidelines for Case Reporting in Aesthetic Medicine: Enhancing Transparency and Standardization.

Clinical case reporting plays a vital role in sharing detailed patient narratives, providing insights into rare conditions, innovative treatments, and unexpected outcomes. However, existing reporting guidelines in aesthetic medicine fail to capture the specific nuances of procedures and outcomes in this field. The authors' objectives were to develop comprehensive guidelines for Case REporting in Aesthetic Medicine (CREAM). The study employed a 3-phase consensus process, including a literature review, expert interviews, and a consensus meeting. A diverse group of 10 expert participants (plastic surgeons, dermatologists, noncore specialists, evidence-based medicine expert, and research scientist) in Phase I and 30 experienced aesthetic practitioners in Phase II contributed to the research. Statistical analysis was conducted to assess agreement levels among participants and explore associations and variations within the data. The participants represented various specialties, genders, LGBTQ+ identities, and ethnic backgrounds. The research resulted in the development of the CREAM guidelines, consisting of a 16-item checklist. The guidelines covered essential aspects of case reporting, such as patient and practice information, procedure details, clinical assessment and outcomes, adverse events, and ethical considerations. Statistical analysis indicated a high level of consensus among participants, as well as significant associations between checklist items. CREAM guidelines represent a step toward enhancing transparency and standardization in case reporting in aesthetic medicine. Adhering to these guidelines will allow authors to contribute to a robust evidence base, prioritize patient safety, and drive advancements aesthetic medicine.

Introduction of the Lip Classification of Tubercles: A Novel Approach to Minimally Invasive Aesthetic Lip Treatments.

Lip enhancement procedures involving dermal fillers are one of the most sought after nonsurgical aesthetic treatments. However, current trends are associated with unnatural results and involve increased risks of complications and compromise to normal function. It appears that lips may be classified according to the presentation of their tubercles and this may be used to guide minimally invasive techniques which aim to preserve individual lip shapes and normal function. To test the reliability of a classification system based on lip tubercle morphology, named the Lip Classification of Tubercles (LCT). To test the reliability of the LCT, a total of 214 high-definition photographs of patients' lips with no previous histories of lip treatments were classified independently by 4 experienced aesthetic practitioners on 2 separate occasions 3 months apart; the second followed a more detailed explanation of the classification. When inter-rater reliability was calculated for the first attempt, the results were 36% and 43% for upper and lower lips, respectively. The second attempt following an education process resulted in 79% for both lips. When 1 practitioner was considered the standard, the average score for the remaining 3 showed some individual variation but improved significantly from 58% to 85%. The LCT is a reliable way to classify lip types based on the morphology of tubercles.

Considerations for Laser Therapy, Microneedling, and Chemical Peels When Treating Patients With Skin of Color.

Over the past 10 years, we have seen exponential growth in the aesthetic industry. With this growth, we have also seen an influx of patients of differing ethnicities, in all varying shades of color. Some clinicians may not have the necessary knowledge and skill to appropriately treat these patients using modalities such as laser therapy, microneedling, and chemical peels. The aesthetic industry provides courses, conferences, and educational guides for helping aesthetic practitioners determine which patients are eligible to undergo these treatments. However, there is a considerable lack of information available for clinicians about treatment modalities that can be safely and effectively used on patients with Fitzpatrick skin types IV-VI. As the population of patients of various ethnic origins seeking aesthetic treatments continues to grow, it is imperative for clinicians performing these treatments to increase their knowledge and skill related to treating patients with skin of color. The purpose of this article is to educate aesthetic clinicians about appropriate treatments, procedures, and protocols for preventing adverse reactions in patients with skin of color who are undergoing aesthetic treatments using lasers, microneedling, and chemical peels.

The PEAK Aesthetic Consultation.

Aesthetic practitioners work diligently to perfect the depth of the needle injection, find the right products regimen, and create a perfect before and after visual. However, the true work of an aesthetic nurse lies in the conversations we have with our patients. Consultation may be overlooked by practitioners who are starting out and consultation is almost always the first item to be put aside by patients seeking aesthetic treatments. It is imperative for aestheticians to incorporate an effective consultation into the patient experience. The longevity of your career lives in the effectiveness of your patient consultation. This article explores the aesthetic consultation process and evaluates the importance of providing meaningful conversation that includes the patient while also managing patient expectations and creating a long-term care plan. Here, I share my own concept regarding aesthetic consultation. This concept allows me to consistently create a plan of care for my patients, while building trust and longevity in my practice. The PEAK Aesthetic Consultation process incorporates four elements: Prioritize the patient story; Education and expectations; Aesthetic treatment; and Kinetic plan.