Clinical-perspectives
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Clinical Perspectives
A different kind of reading - reflections from our Surrey Clinic
Clinical Perspectives is a little different from the rest of our site. You will not find treatment guides or procedure explainers here. What you will find is a collection of essays and reflections on some of the broader questions that sit behind aesthetic medicine.
These pieces are wholly text-based and deliberately unhurried. They are written without the of imagery because the intention is that the ideas carry the weight, not the presentation. If you are someone who is curious about the quieter, more considered side of aesthetic medicine, we hope you find something here worth returning to.
The views expressed here are Dr Forrester’s personal opinions — formed over 45 years of medical practice and refined through thousands of patient conversations. They do not represent an industry position or a commercial one.
Filler-induced occlusion is not a theoretical risk. It is a documented, recurring complication that affects practitioners across all experience levels. A practitioner who has the appropriate materials to hand and has the management protocol is in a position to act effectively. One who has not is not. The difference in outcome between these two practitioners can be the difference between complete resolution and permanent vision loss.
Every prescription medicine has a dose-response relationship. Botulinum toxin is no different. And yet the between dose, effect, and duration in aesthetic practice is rarely discussed with the rigour it deserves — partly because the consequences of under-dosing are commercial rather than immediately harmful. Here is what the evidence says.
Any practitioner who has treated the same patients with botulinum toxin over a number of years will have noticed the . Early in treatment, results last three to four months. Over time, the interval extends. The effect is real, consistent, and well recognised in clinical practice. What deserves more attention is why it happens — and one of the proposed mechanisms has been sitting in plain clinical sight for twenty years.
Professor Andy Pickett is not a . He has never injected a patient. But for thirty years he has done something the aesthetic industry rarely welcomes — applying rigorous to its most widely used treatment and challenging the myths that have accumulated around it. Here is what he found.
Over 140 dermal fillers are CE-marked for use in the European market. The United States has fewer than 25 FDA-approved products. That disparity is not a reflection of greater European innovation. It is a of fundamentally different regulatory philosophies — and understanding those philosophies has genuine implications for every practitioner working in UK medicine.
Approximately 8 million cosmetic botulinum toxin procedures are performed worldwide every year. In over three decades of licensed use, the treatment has never caused a single confirmed death. In counterfeit and unlicensed use, patients have required mechanical ventilation. The difference is not the molecule. It is everything that surrounds it.
Zein Obagi spent two years as what he called an "aesthetic detective" before developing the Nu-Derm System in 1985 — a physician-dispensed skin transformation protocol that brought tretinoin into mainstream cosmeceutical practice and established a the entire subsequent industry has followed. This is his story.
The patient sits down, reaches for their phone, and turns the screen towards you. On it is a photograph — a celebrity, an influencer, a stranger encountered on Instagram — and the request is clear: I would like to look like this. It is one of the most common moments in practice. It is also one of the most clinically significant — and what next matters more than most practitioners acknowledge.
The idea that gut health influences skin health is not new. What is new is the mechanistic understanding of how these connections work — and the growing evidence that the gut microbiome influences not just specific skin diseases but skin health, skin ageing, and skin barrier function in a more general and clinically significant way.
The clinical conversation about photodamage has historically been dominated by prevention. What has received considerably less honest clinical is what can be done for damage already accumulated. The answer is more encouraging than most patients are told — and more nuanced than the aesthetic industry's marketing tends to acknowledge.
If a patient asked us to identify the single intervention with the greatest evidence base for preventing skin ageing, the answer would not be a retinoid or a . It would be daily, broad-spectrum, high-factor sun protection — consistently, without exception, regardless of weather or season. Everything else in a skincare is built on that foundation.
Aesthetic medicine has historically been uncomfortable with its psychological dimension — presenting itself in purely physical terms as though the motivation behind treatment were irrelevant to the clinical picture. It is not. The that appropriate improves psychological wellbeing in suitable patients is real. So is the evidence that it cannot resolve deeper psychological distress. Both deserve to be examined honestly.
The degree of dehydration required to produce visible skin changes is pathological. It represents a fluid deficit that would, in any otherwise healthy person, produce intense thirst long before the skin showed any observable change. The hand turgor test is a tool for assessing clinically unwell patients — not a guide to the skincare habits of the well.
is frequently as a relatively recent innovation. In fact, the concept of using controlled skin injury to stimulate production predates most of the treatments that now share its clinical space. The modern dermaroller was developed in the mid-1990s by Dr. Desmond Fernandes, a South African plastic surgeon, whose observations have since been characterised in considerable scientific detail. Here is an honest account of what the evidence actually says.
Before examining any topical ingredient on its own terms, there is a prior the industry consistently fails to ask loudly enough. Does it penetrate the skin barrier in a biologically active form, in sufficient concentration, to reach the tissue where it is to act? That question is the lens through which everything that follows should be read.
No topical skincare ingredient has been studied as thoroughly, over as long a period, or with as consistently results as retinoic OnabotulinumtoxinAAbobotulinumtoxinAIncobotulinumtoxinAPrabotulinumtoxinALetibotulinumtoxinARimabotulinumtoxinBHyaluronic Acid FillersCalcium Hydroxylapatite FillersPoly-L-lactic Acid FillersPolymethylmethacrylate FillersAutologous Fat GraftingForehead Lines TreatmentGlabellar Frown Lines TreatmentCrow's Feet TreatmentBunny Lines TreatmentChemical Brow LiftLip FlipGummy Smile CorrectionMasseter ReductionJaw SlimmingDimpled Chin SmoothingCobblestone Chin SmoothingNefertiti Neck LiftMicro-BotoxMesotoxHyperhidrosis TreatmentChronic Migraine ReliefBruxism TreatmentTMJ TreatmentCervical Dystonia TreatmentNeck Spasm TreatmentBlepharospasm TreatmentLip AugmentationLip ContouringCheekbone EnhancementTear Trough FillersNasolabial Fold SofteningMarionette Line FillersLiquid RhinoplastyNon-Surgical Nose JobJawline ContouringJawline DefinitionChin AugmentationTemple VolumisingHand RejuvenationAcne Scar Subcision Filling and its derivatives. When a patient asks whether a new topical ingredient might be as as their retinoid, the honest answer almost always begins with an acknowledgement that nothing has had the time, the research investment, or the clinical validation to make that comparison confidently.
The phrase "skin barrier" has entered mainstream skincare vocabulary to the point where it has begun to lose its meaning. This piece is about the barrier in precise clinical terms: what structures comprise it, what they do, what causes them to fail, and what the evidence says about them. Understanding it at this level is not merely academic. It informs every clinical decision about topical treatment.
The patient who has lost significant weight has typically worked hard to do so. The body looks better. And then they look at their face. What they see is not always what they expected — a face that looks older, more gaunt, more depleted than it did before. This is a predictable and increasingly well-documented consequence of significant and rapid weight loss. It deserves to be understood clinically with the same seriousness as the weight loss itself.
A subset of consultations feels different from the moment the patient sits down. She is a barrister, a senior executive, a presenter. Her appearance is not merely something she thinks about in the mirror. It is something presented to the world professionally, assessed in contexts that carry real consequences, and against a standard that would not apply to a male colleague in an equivalent position.
The phrase "non-surgical facelift" promises the outcome of a surgical procedure without the recovery, the risk, or the cost that surgery entails. It is, in almost every clinical application, a considerable overstatement. This is not an argument against non-surgical aesthetic treatment. It is an argument for honesty about what those treatments can and cannot do.
When a woman presents for an aesthetic consultation shortly after a divorce, there is an assumption that floats, largely unexamined, in the background. She wants to look her best for a new . In our experience, this assumption is almost always wrong — and what these patients are actually seeking is considerably more interesting and considerably more human.
Most patients say they want to look . But spend a little time with that answer and it begins to unravel. Younger than what? And is looking younger really the goal — or is it something else entirely, something that looking younger is simply the shorthand for?
Most women in their late forties describe the same experience. The changes they could previously attribute to the slow accumulation of years now feel different — more pronounced, more rapid, and less easily explained by lifestyle factors alone. They are right to notice the difference. has changed. And it has a name.
Sculptra and Radiesse are frequently discussed as though they were essentially interchangeable; different brands offering the same biological effect through slightly different formulations. That framing is convenient but misleading. The mechanisms by which these two treatments drive neocollagenesis are meaningfully different at a cellular level — and those differences have genuine clinical implications.
Eighty percent of women saw an improvement in fine lines in two weeks. Consider what this does not tell you. It does not tell you how many women were in the study, whether there was a control group, or how it is possible to meaningful collagen improvement in fourteen days when we know that true neocollagenesis over months. The statistic tells you, with considerable confidence, that the company selling the wanted you to feel impressed. Beyond that, it tells you very little.
There is a particular quality to the consultations we have with patients in their late forties. They have been noticing for a while — a gradual divergence between how they feel and how they look — and they have reached the point where they want to understand it better before deciding what to do about it. They are asking the right question. This piece is an attempt to provide a serious answer.
I started using polynucleotides with my scepticism intact. Almost hoping, if I am honest, to confirm what I suspected; that this was another treatment whose promise would not survive contact with real patients. The early results gave me pause. They were better than I expected. But I am not yet ready to set my scepticism down entirely — and I think the reasons why are worth examining carefully.
The aesthetic industry owes a genuine debt to celebrity culture for the normalisation of treatment and the removal of stigma. The acknowledgement should come with a significant caveat. The relationship has never been straightforward — and its influence on patient expectations has been considerable and largely negative.
Subtlety is not a trend. It is a standard. The fact that it requires announcing as though it were new tells us more about how far the industry lost its way than about where it is now heading.
The most criticism of oral collagen supplementation has always been the absorption question. The traditional sceptical argument has been that what reaches the bloodstream is simply amino acid building material, no from eating a piece of chicken. The science has moved on — but the picture is considerably more complicated than the supplement industry acknowledges.
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