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Diversity in Aesthetics: Dr Soul Mugerwa

Next up in the Diversity in Aesthetics series is the brilliant Dr Soul - GP, aesthetic doctor and medical director at Nouvelle Aesthetix. He explains why there's no cookie cutter approach to aesthetics, and gives his advice on how aesthetic practitioners can become more confident treating patients of colour.

Thanks for joining us, Dr Soul. Tell us about your journey into aesthetics.

My journey into aesthetics started due to my very own skin issues. Throughout my 20s I had ongoing issues with acne and uneven skin tone. I tried everything I could to get the acne under control, and this was relatively unsuccessful. The uneven skin tone was my main problem, though and, like many people who seek aesthetic treatments, I knew there was a problem but I didn’t know how it could be treated, or even who could help. I went to a couple of skin clinics at the time who, essentially, told me they couldn’t do anything to help, mainly because they had little experience in dealing with African skin. I thought it was something I’d just have to live with, and I didn’t seek help again for at least 10 years.

However, it continued to bother me. I would often shy away from having my picture taken because of how my skin looked in photos. Ten years had passed and I thought there surely must have been advancements in treating uneven skin tone. This led me to do my own research, and I realised I had melasma - strange, I know, since it mainly affects women. I tried various clinics who offered different peels, creams, microneedling, etc, but nothing really made a significant impact. It was through speaking to a doctor at one of the clinics that got me interested in aesthetics. Before this point I was used to treating skin diseases, and had never considered aesthetics.

Like many people who don’t know much about aesthetics, my perception at the time was that it was all about making people look fake with Botox and fillers, and was just for the vain. I decided to attend a training course just to see if I would like it and what it was really all about. I loved the course and how happy the clients were, as well as the real difference it made to their appearance and confidence. I realised this was really no different to clearing my patients' acne or rosacea. I soon understood that my skin surgery skills were very much transferable to aesthetics and that there was a whole new avenue of medicine that, until now, I hadn’t been aware of. I was eager to learn much more, and it also empowered me to learn more about my own condition and what could help it.

Do you have any particular standout moments when you knew aesthetics was what you wanted to be doing?

This would have to be the first time I trained in non-surgical rhinoplasty. After learning about all of the complex anatomy and techniques, it was time to actually perform the procedure. My first client was a young lady who had always been self-conscious of the bump on her nose, and explained that she never wanted people to see her from the side. Fifteen minutes later, following some delicately placed filler, she couldn’t have been happier. To think you could make such a difference to someone’s confidence in such a short time, without drastic surgery, was amazing and gave me the appetite to explore aesthetics even more.

Incredible! It's apparent that the those in the industry are predominantly white, middle-class men and women. From training materials to clinic websites and product advertising materials, they typically show very little diversity. Do you feel the lack of representation was a barrier to you and other black practitioners entering the industry?

I think lack of representation could definitely be considered a barrier. You can’t aspire to be something you can’t see. I could probably count on one hand the number of prominent black aesthetic doctors who are given a platform in the media. Personally, I didn’t see this as a barrier. It was something I developed an interest in and saw no reason why a lack of representation should prevent me from entering the field. My parents always taught me that you should follow the shining example of others, and if there is no shining example then you should aspire to be that example.

Can you tell me about an occasion where you have experienced racism in the industry?

I have never, personally, experienced racism within the aesthetics industry. But I have certainly witnessed it in my NHS work, both personally and towards others. My partner and I supervise and train other GPs, and one unfortunate recent example stands out. My partner was reviewing a video recording of a telephone consultation between a trainee GP (of Egyptian origin) and an elderly lady. The doctor called the lady and introduced himself, giving his name and asking her how he could help. The lady’s first response was “are there any other doctors available?” We were obviously shocked, as all he had done was politely introduce himself over the phone, and her only clue as to who he was was his accent. So why ask for another doctor? Based on what?

That's awful! Literature regarding aesthetic treatments for different ethnicities doesn’t appear to exist. Is this because caucasian clients and black clients are treated in exactly the same way, with the same volumes, techniques and procedures, or because it just isn’t taught and documented? If it's the latter, what would you like to see done about this?

Literature regarding aesthetic treatments for different ethnicities does actually exist, but it is not easily available to the public, and is indeed very limited. There are papers on treating Asian clients and the different aesthetic ideals, and I also recently read a paper on concerns in the female African American patient.

In aesthetics, there is no cookie cutter approach to addressing patient concerns, and the technique or quantities that are effective in one patient may not produce the same outcome in another patient - even if they are the same ethnicity. Black clients cannot be treated in exactly the same way as caucasian clients due to many intrinsic differences, such as increased skin thickness, musculature, bone density and propensity, or pigmentation disorders. Their skin, therefore, shows signs of ageing, such as skin wrinkling and laxity much later than a caucasian client. A black client is less likely to be concerned about fine lines or wrinkles and skin laxity, and may be more bothered by pigmentation issues.

With the above in mind, it is, of course, essential to adapt the type of aesthetic procedures and the volumes used. For example, it would not be appropriate to use certain peels or lasers on skin of colour due to risk of hyper - or even hypo - pigmentation. Having said that, however, there is clearly a need for training providers to offer significantly more teaching with respect to aesthetic ideals in people of colour - like how their skin differs, and suitable treatments for these clients.

Many non-black practitioners feel they lack knowledge and experience when it comes to treating black skin and facial anatomy. When you undertook training to become an aesthetic practitioner, did you feel adequately prepared to treat black skin and facial anatomy confidently, or did you have to self-teach?

Facial anatomy is not really the problem. Everyone's general anatomy is more or less the same, regardless of race, with some minor variations with respect to the course of blood vessels, etc. The main issue is how black skin behaves when treated. I didn’t feel adequately prepared treating skin of colour after training, as so little time is dedicated to the nuances of black skin. For example, how does it react when you use a chemical peel, laser, or a particular topical product like retinol? What factors may make adverse outcomes like hyper or hypopigmentation more likely? To understand all of this, you have to go and learn personally, through further reading, research or actual physical experience.

I think the other reason practitioners may not be confident when treating skin of colour is the lack of visual safety cues. For example, an early sign of vascular occlusion with fillers is blanching of the skin and skin changes. These may be easily visible in someone with a type I complexion, but less so in someone with dark skin.

What advice would you give practitioners wanting to become more competent and confident treating black clients?

In medical school we were taught to see one, do one, teach one. My advice would be to learn the basics and foundations first. As with anything, if you have a good understanding of the foundation it allows you to better understand why you are doing something, the science and rationale behind it, and also to be able to understand why and where things went wrong - as well as how to correct them. Then, of course, practice is essential. See more people of colour, treat more people of colour, and with time you learn what works and what doesn’t. You're taught a certain way of doing things but with time you realise there are many different techniques to use to achieve different outcomes. Essentially, it's important to not be wedded to one way of doing something.

Given the lack of representation within the industry, do black people, women in particular, see aesthetic treatments as being "for them"? If not, what can we do to address this?

I believe black people may not see aesthetic treatments as being for them for several reasons. I refer back to my earlier point that it's hard to seek out what you don’t see. Aesthetic imagery and advertising is rarely focused towards black people, therefore giving the impression these treatments aren't for them. Black people generally show signs of ageing, such as wrinkles and fine lines, much later in life, so popular treatments like Botox may be appealing to a caucasian woman in her mid-late 30s but not so much to a black woman in the same age group. Also, treatments such lip fillers may not be seen as necessary as black people, genetically, have bigger lips. This isn’t necessarily always the case - often people just want greater definition to the lip contour. There may also be a perception that some treatments, such as lasers and microneedling, can be permanently harmful to the skin, resulting in pigmentation changes, and so these may be avoided by people of colour.

To address this, I feel we would need to show more people of colour in adverts for skincare treatments. There also needs to be more easily accessible skincare advice specifically targeted at people of colour, and more information about what aesthetic treatments are available to deal with complaints and skin concerns that are more common and relevant to them, such as pigmentation issues.

Following the resurgence of the Black Lives Matter movement, I have been seeking out content creators who have helped me begin to understand the experiences of black women in particular. As a black aesthetic practitioner, who are your 'must follows' on social media?

I have to be honest I have never really been very engaged on social media, but I do personally follow Dr Tijon Esho and Dr Chike Emeagi, both of whom have different styles but I see a little of both in myself. I've also more recently started following Dr Ifeoma Ejikeme, who is very impressive.

What are your ambitions for your clinic in the coming year?

To continue expanding our client-base and widening the range of procedures we offer to all types of clients. I love my NHS work in general practice and our Church Road Medical Practice has recently been voted the top rated GP practice on the Wirral, so this is a proud achievement for my partner Dr Neha and all of our staff. I would like to continue to improve our practice and provide better levels of care for our patients, whilst also building our aesthetic practice and learning more about aesthetic medicine in general.

That sounds great! And what overall changes do you hope to see within the industry?

I feel there's definitely a need for aesthetic medicine to be recognised as a speciality in its own right, with strict training and assessment criteria to ensure a certain standard. I find it amazing given the complexity of the facial anatomy and available treatments and techniques that there isn’t greater regulation. You can attend a 1 or 2-day-course and then you're apparently good to go and inject people, and some courses don’t even require you to have a medical background. As a medic, I have trained over decades, undergoing rigorous regulation and repeated stringent examinations to ensure that I am safe and of a certain standard in order to treat people. So I find it very strange that there are no such safeguards in place in aesthetics. I think this would help better reassure people with respect to cosmetic treatments.

I would also like to see greater diversity as I think black people are under-represented, both in terms of training to be aestheticians but also with respect to accessing the treatments themselves.

Well said! Thanks for taking the time to chat with us, Dr Soul.

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