Regenerating aesthetics

Editor Anna Dobbie visits Dr Ali Ghanem at his new premises to discuss how he incorporates science, art, and philosophy into his holistic approach to aesthetics

The prestigious Ghanem Clinic on Upper Wimpole Street is recognised as a world-class centre of excellence in plastic surgery and cosmetic medicine. The premises also hosts the Cranley Clinic, established in the UK in 1992 by Professor Nick Lowe, who is credited for contributing to the first paper showing the efficacy and safety of botulinum toxin in aesthetic indications, as well as bringing botulinum toxin across the pond.

“That seminal paper made aesthetic medicine,” says Mr Ali Ghanem, world-renowned and award-winning consultant plastic surgeon, and the founder of The Ghanem Clinic. “He came from the University of California, Los Angeles, to establish aesthetic medicine in the UK and we maintain the same very high academic rigor that he introduced in 1992. Aesthetic medicine was born there and that heritage carries on in our clinic at the new site because we have put both the non-surgical heritage of Prof Lowe and the surgical aspect of myself and my associate surgeons, who are trying to push for a global standard in aesthetic surgery in the UK.”

Before moving to the new premises in May 2023, The Ghanem Clinic was on Devonshire Place and The Cranley Clinic was on Harley Street, while the Upper Wimpole Street building hosted the London Vein Institute, a vascular surgery practice, since the 90s.

“The practice moved on, the founders retired, and we took this venue a year ago. We achieved the step below a hospital, in the eyes of the Care Quality Commission, registration and regulation.”

Mr Ghanem feels that, by coming together, the practices have created a unique offering, the “UK’s only onestop-shop” in aesthetic and regenerative medicine and surgery. “Many plastic surgeons confine themselves to surgery. They do amazing work on tissue laxity, body contouring, etc, but they rarely offer non-surgical interventions. Although there were some sporadic collaborations between surgical and non-surgical aesthetics, that was always limited, since the surgeons focused on their surgery, and the nurses, dentists and general practitioners developed the non-surgical domain.”

PATIENT NEEDS

Mr Ghanem believes that a lack of communication and understanding between surgical and non-surgical colleagues can lead to patients feeling disappointed and result in a lack of trust. For example, if a patient who needs surgery has unnecessary non-surgical work performed it may cause under-the-skin scars that could affect future surgery. Equally, if a patient with severe sun damage goes to a surgeon who doesn’t treat the skin first, it could lead to a relapse,” he adds.

Collaborating with colleagues is therefore key. “Through this collaboration, Professor Lowe and I have developed many first-in-the-world interventions with multi-laser treatments of the skin that will hugely enhance my surgical practice.”

Mr Ghanem is also utilising his background in stem cell biology to harness the expansion of regenerative interventions: “I don’t want to just pull or heat the tissue to look as if it is younger. I want it to improve the skin on a molecular, tissue, and cellular level.

“I have found that when we work holistically on the patient, we end up with harmony. If you were to hire five workmen unfamiliar with each other to work on a house, each one would have a different style, and you would end up with a slight collage. However, if we look at the human face, body, and psychology through the eyes of one team, often the outcome is far superior.”

THE CHILD WITHIN

Mr Ghanem developed his passion for facial aesthetics and his holistic ideals from his time with the national service, working around the world with children with malformations: “I trained as a cranial and paediatric malformation surgeon, and I realised two things.

“First, when members of the multidisciplinary team looking after a child are sitting in one place and speaking the same language, rather than the child being seen in tandem and in a sporadic way, the patient will have a much better outcome.

“ Secondly, suppose you don’t consider aesthetics in facial malformation. In that case, you will have a child who can swallow and speak without stigma, but the psychological burden later as a teenager or young adult will be enormous. In public health care services, aesthetics isn’t very well developed, people mostly think about the function and the reconstruction.

“Any patient who comes to me with a concern about their facial appearance I see like a three-month-old child with a cleft lip. A child of that age does not have the autonomy to consider their aesthetic outcome. Similarly, I must provide the patient with a facial concern with the most holistic and wide option of care, so that they can make an informed decision.”

According to Mr Ghanem, people are moving away from “that single modality, one-size-fits-all approach to aesthetic medicine of over-filled, pillow faces”. “Often, I have patients with post-traumatic stress syndrome-like avoidance of certain products, saying ‘I don’t want any fillers’,” he adds. “They speak as if they have been bitten or burned by a previous experience and, while I believe that filler is a great tool to address minor volume losses, it is very important to use it in a context of a holistic approach.”

SCIENCE AND ART

“Whether we like it or not, both science and art are essential parts of a good practice and a healthy approach to aesthetic medicine,” says Mr Ghanem. “However, I would add a third point to this: psychology. Without the medical sciences foundation, without a very strong understanding of the aesthetic ideal and what is beautiful, and without a good understanding of human psychology, there is no aesthetic medicine and there is no aesthetic surgery. It’s all in the title.

“When we say aesthetic medicine or surgery, we are referring to art. ‘Aesthetic’ is never related to disease, we are not talking about abnormality.”

But, psychologically, isn’t the reason that we find certain traits aesthetic based on an inherited belief that they represent a ‘healthy’ person?

“There have been some links between beauty and health, but the most accepted definition of beauty is an attempt to detract distraction and move to a central point. If we have five pictures of individual female humans, and we ask the computer to merge them, the resulting image is normally perceived as more beautiful than any individual human being.

“For example, when we do an operation to correct a facial malformation, the objective measurement might not show that they became closer to a particular standard, they might even become worse in this measurement.

“There are so many different philosophies on beauty because human psychology has not yet even been fully explored on the surface. While a liver surgeon can take an x-ray, do an enzyme study, or take a blood test and appraise the outcome for the patient after a medical intervention, in aesthetics, we can have fantastic results according to the doctor which fail to satisfy the patient. Although we are working on objective things, such as bone or muscle or flesh or skin, we are judged not on objective measures, just on feelings, so that’s why psychology is extremely important here.

“I have always thought it was bizarre when I was a trainee and a student observing practices in aesthetic medicine and surgery. You wouldn’t imagine a cardiologist without a stethoscope, or a blood pressure machine to check a patient’s blood pressure. I observed so many aesthetic practitioners as a trainee who don’t practice with a 3D camera, for example. It’s difficult sometimes to appreciate the changes that come with an iPhone fisheye distortion lens that most practitioners use, but unfortunately, aesthetic medicine is unregulated. Even governments around the world consider it an extension of spa culture and nail and hair salons, but it is not.

“When we are talking about aesthetic medicine and surgery, we are talking about quality of life impacts that are as profound as in any other branch of medicine and surgery. It’s not trivial, it is not superfluous, it is not about vanity.”

INTERIOR DESIGN

Mr Ghanem wanted the new premises to mirror his core values of art, science, and psychology holistically. The clinic, which officially opened in May 2023, fully complies with the Care Quality Commission requirements and has received positive feedback from patients and visitors alike.

“Art is very important,” says Mr Ghanem. “We have real sculptures by renowned artists from the UK and beyond. The artists who designed the clinic have taken into consideration psychological health. They are experts in designing spaces such as hotel rooms and conference centres. Because of my Middle Eastern heritage, I wanted to have a bit of my roots represented here, so we asked an important Middle Eastern architecture and art firm, and the outcome is quite unusual for a London Victorian traditional medical facility!”

REGENERATIVE MEDICINE

Mr Ghanem was one of the first to graduate with a PhD in Developmental and Stem Cell Biology from the University College London.

“The programme started in 2006,” explains Mr Ghanem. “At the time, most healthcare professionals around the world, even in the UK, thought that regenerative medicine was something futuristic, related to Dolly the Sheep and splicing embryos. There was a lot of ethical concern because stem cells came from our understanding of embryo development; I studied the subject because I’m interested in child malformation, which can develop when the embryo is a mere few days old.

“Any errors at a very early stage of embryo development will result in the diseases and deformities that we see later in life. When Dr Tunc Tiryaki and I curated the first regenerative surgery meeting in London just before the Covid-19 pandemic, we didn’t do any major surgery. We only applied treatments to help regenerate the dermis, the skin, and the different layers. Less than four years later, we now have off-the-shelf molecules like exosomes, recombinant growth factors, polynucleotides, polypeptides, molecules such as polycaprolactone, polylactic acid, calcium hydroxyapatite, that a therapist can apply with a little bit of micro-needling. They don’t require taking even a single cell from the patient, and they have a regenerative effect that has been established scientifically. Not as strong a regenerative effect, but an effect, nonetheless.”

Mr Ghanem compares the regenerative market now to the industry before hyaluronic acid was discovered: “Before hyaluronic acid, there was a major problem for volume restoration. Collagen was used, which was associated with anaphylactic shocks, as, because it’s a protein, any contamination can lead to allergies and granulomas. It was a horrible journey for collagen. Also, some of the permanent fillers led to fibrosis. When they got infected, it was catastrophic. We had very few safe treatments, beyond fat transfer, free tissue transfers or silicone implants in different parts of the body, to restore the volume. When hyaluronic acid was first created, we had inappropriate usage, where you would hear people talking about a liquid facelift, which stemmed from irresponsible or unethical communication.

There are lots of motivations in human behaviour: some financial, some commercial, some egoistic. Suddenly, we have seen an emergence of industry-supported conferences where colleagues who have never studied stem cell biology or regenerative medicine jump on the bandwagon and start talking about very simple creams or interventions as if they are the Holy Grail and the regenerative solution to all problems.

“Even though now we are in a very transparent time, we also have a lot of misinformation and overwhelming marketing machines. The problem is, if the blind are leading the blind, they will have a misunderstanding of what regenerative medicine is, what tools are available, and what these tools can do. Our patients deserve to know the truth”

When he first started looking into some of the molecules, Mr Ghanem admits that he didn’t know how effective they would be and for how long: “There was nothing in the literature, there were no peer-reviewed articles apart from a few sporadic case reports and some opinions, so I engaged myself in careful evaluations of some of these molecules in my patients, in a self-audit. I found out what their limit is, and I have made an informed decision of how I can offer them to my patients based on my results.”

Dr Ghanem is collaborating with Aesthetic Medicine and will be hosting a regenerative education stream at Aesthetic Medicine Live on May 10-11, 2024 at London Olympia. “We will bring true knowledge, authorised and peer-reviewed, based on the latest available evidence-based interventions in regenerative medicine to our fraternity in the UK and beyond, so that our colleagues know the true potential exactly, plus the limitations, and the precautions that they should consider when they are communicating with their patients.”