In this, our inaugural Controversy column—the kickoff to a compelling series aimed at untangling hot-button issues in aesthetic medicine—we’ll be unpacking an ongoing debate, one embroiling providers of every kind and affecting millions of patients: who to trust with fillers and toxins. Much of the discord between leaders in the field springs not from ego or sensationalism, we should note, but a passionate, evidence-based desire to deliver results that are beautiful, bespoke, and above all, safe. Our experts have unique viewpoints and experiences—each worthy of respect and consideration. Our goal is to present all sides in hopes of carefully informing your beauty decisions.
The International Society of Aesthetic Plastic Surgery (ISAPS) recorded more than 8.5 million injectable procedures worldwide in 2017. (Injectables as a category encompass both muscle-weakening botulinum toxins and various kinds of fillers used to restore youthful volume and contours.) In the U.S., demand for such shots soared nearly 40 percent between 2014 and 2018, according to The Aesthetic Society. These figures, bear in mind, reflect only the number of treatments performed by plastic surgeons who are members of the aforementioned organizations. Factor in injections given by unaffiliated plastic surgeons, dermatologists, and dermatologic surgeons; plus “extenders” like physician assistants (PAs), registered nurses (RNs), nurse practitioners (NPs); and add to that doctors from specialties unrelated to aesthetics and even non-healthcare providers—the entire spectrum of injectors—and the tallies turn astronomical.
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“One of the reasons why injectables have become so popular is because they have an excellent safety profile,” says Vancouver dermatologist Shannon Humphrey, MD. However, she explains, as the scope of providers has expanded beyond core aesthetic physicians to include people of myriad backgrounds, and as technique and treatment patterns have evolved, requiring injectors to venture into deeper planes of the face to achieve more of a three-dimensional remodeling (rather than a superficial line-plumping), these procedures have grown more dangerous. “I often get calls from doctors concerned about potential complications,” says Chicago facial plastic surgeon Steven Dayan, MD.
While side effects common to both toxins and fillers include bruising, swelling, soreness, asymmetries, and otherwise unsatisfactory outcomes—issues that resolve on their own or can be corrected—fillers, in particular, can carry more serious risks. The most catastrophic is vascular compromise, which occurs when the injected material enters a blood vessel, or compresses it from the outside, impeding circulation to the skin or eyes, and potentially causing tissue necrosis (skin death) and vision loss respectively. “We’re seeing an increasing number of these vascular complications—most arising from untrained injectors,” says Marina del Rey, CA plastic surgeon W. Grant Stevens, MD. (To be clear: Toxins cannot clog arteries. An overdose or misdirected jab could drop a brow or slur one’s speech for a few weeks to months, but the damage isn’t usually irreparable.)
BREEZY AS A BLOWOUT?
Vascular events, while on the rise, are still quite rare. With published rates of skin necrosis hovering around 0.09 percent, and 146 reported cases of filler-induced blindness in the scientific literature (only 10 of which were completely reversible), these devastating side effects tend to fly under the radar. Further obscuring the possible perils, certain spas and “injectable bars” are actively aiming to demedicalize the shots by likening them to blowouts—served with an Insta-friendly vibe and fizzy refreshments—a comparison many board-certified plastic surgeons and dermatologists find outrageous. “It turns my stomach,” says Dr. Humphrey. “It reduces cosmetic dermatology to the lowest common denominator, prioritizing profit over patients.”
New York dermatologist Doris Day, MD has repeatedly taken to social media to remind her followers that injectables are, indeed, true medical treatments with real risks. But convincing the public “has been a struggle,” she says, mainly because the industry as a whole has “gone out of [its] way to make patients feel comfortable with these treatments.” Many injectors’ Instagram feeds are looping reels of seemingly effortless filler transformations—and “this is part of the danger of injectables,” explains New York plastic surgeon Lara Devgan, MD: “They look far easier than they actually are, especially on a time-lapse video, and this breeds a certain amount of cavalier braveness.” Before any provider sticks a needle into someone’s face, she adds, they should know the three-dimensional vascular anatomy well enough to draw it from memory. Integral to this understanding is also recognizing that “anatomic variation is real,” says Dr. Humphrey—“knowing the most common anatomical patterns, but also respecting that there’s considerable diversity among patients.”
While surgeons may have a bit of an edge here—“we’re working in and around the muscles, nerves and blood vessels every day,” says Miami plastic surgeon Adam J. Rubinstein, MD—all doctors take a year-long anatomy course in medical school, complete with hands-on cadaver dissections, notes Los Angeles facial plastic surgeon Kay Durairaj, MD. Physicians specializing in aesthetic medicine then receive injectables training through residency and cosmetic fellowship programs. Extenders, on the other hand, typically learn to inject by shadowing MDs and taking voluntary classes, but “there’s no formalized or regulated injectables certification for nurses and PAs,” says New York dermatologist Paul Jarrod Frank, MD.
More concerning, adds Dr. Dayan: “There’s a flaw in our industry-based teaching. Barring aesthetic MDs, the majority of new injectors are learning from experts who are teaching based on FDA-approved indications, which aren’t necessarily the safest, and aren’t always what we follow in clinical practice.” These instructors cannot, for instance, demonstrate how to reverse a hyaluronic acid filler with the injectable enzyme hyaluronidase, because this is considered an off-label use of the drug. And, yet, this skill is vital to patient safety.
WHO SHOULD YOU TRUST?
The “core four” (board-certified dermatologists, plastic surgeons, facial plastic surgeons and oculoplastic surgeons) argue that they have the advanced education and anatomical training to keep us safe—not to mention unrestricted access to aesthetic medical journals and meetings for up-to-the-minute news and advances. (As an example, two doctors cited a just-out study showing large-bore 22-gauge cannulas are less likely to enter vessels than smaller, more routinely used cannulas and needles.) Nurses and PAs contend that experience—injecting dozens of patients a day for many years—and an artistic eye are equally crucial credentials, and that continuing medical education courses keep them current.
If it’s a toss-up, government isn’t breaking any ties: “The laws [regarding cosmetic injections] vary state to state,” says Dallas healthcare attorney Michael Byrd, who advises the aesthetics industry. They’re murky and a bit convoluted, but generally speaking, he adds, “only MDs, PAs and NPs can make diagnoses and determine treatment plans. Most states allow RNs to administer injections under proper delegation, and some states allow delegation to anyone whom a doctor believes to be appropriately trained.” (Did you catch that last part? This is the loophole that enables non-healthcare providers, such as aestheticians, to inject in states like Texas and Colorado.) Legislation often provides NPs with more independence. “In more than half the country, those who have met certain requirements can practice without a physician overseeing them,” says Alex Thiersch, director of the American Med Spa Association.
Given these regulations, how is it that an injectable bar can be manned exclusively by RNs? “The legal way to do this is to use telemedicine for the diagnosis and treatment plan,” explains Byrd. In many states, a supervising physician need only be available by phone. “Their physical distance from the practice they oversee is something of a gray area,” says Thiersch. And that doctor needn’t have any aesthetic training, which is a frequent phenomenon, notes Dr. Frank: “A nurse in New York City will FaceTime with an anesthesiologist in Jersey, who receives a kickback to basically sign off on the procedure.”
THE DOCTOR’S-OFFICE ADVANTAGE
Others interpret the law more stringently. Dr. Durairaj meets every patient her nurse practitioner treats. “I check her markings and approve her treatment plan—I’m always on site, ready to step in if there’s an issue,” she says. And plenty of nurses and PAs prefer this hierarchy—its built-in backup—to the relative autonomy of unsupervised spas. “It’s safer, it’s better for the patient, and I sleep well at night knowing I have at least three physicians in the office at all times,” says Salt Lake City aesthetic nurse Inna Prokopenko, RN, who’s been injecting upwards of 35 patients a day for nearly 20 years.
Degrees aside, the best injectors possess two invaluable resources: An intimate familiarity with risk, first and foremost—knowing, for instance, that the nose and glabella are most highly associated with vision loss and skin necrosis, and that such shots have to be placed in precise spots and at specific depths. And secondly, the expertise to immediately recognize and manage filler complications—to be able to discern a common bruise from the earliest signs of necrosis; to know exactly how to respond to a patient with eye pain and blurry vision. “This is where inexperienced, inadequately trained injectors are going to fall short,” says Dr. Humphrey.
When problems arise, preparedness is everything. “Injectors should have at least 1,000 units of hyaluronidase on hand,” says Dr. Dayan. The dissolvent can be expensive, however, and it expires quickly, so not everyone stocks it, he adds. But it’s the only surefire way to restore blood flow to the skin. And when blindness threatens, a shot of hyaluronidase into the eye socket has been reported to save vision (though its efficacy here is controversial, with pros viewing it as more of a “Hail Mary” than a guaranteed fix). “Injectors should either be comfortable performing this retrobulbar hyaluronidase technique, or have an ophthalmologist available in the event blindness does occur,” says Nashville oculoplastic surgeon Brian Biesman, MD. In such scenarios, “patients can’t wait in an ER for hours,” adds Vancouver dermatologist Katie Beleznay, MD, lead author of a new study on filler-induced blindness in the Aesthetic Surgery Journal. The retina can’t survive more than 90 minutes without blood; some reports suggest a much tighter window of only 12 to 15 minutes.
The bottom line: It may not always be possible to have a core-four specialist personally inject your fillers and toxins, but injectors should always be licensed healthcare professionals “functioning in a level-appropriate manner with adequate oversight,” Dr. Devgan says. If being treated by someone other than an MD, ask to meet the supervising physician to ensure a qualified aesthetic doctor is there, in the flesh, should anything go awry.
4 Questions to Ask Your Injector:
1. How often do you inject this type of filler?
You want someone who does this full-time, not as a side hustle. “If they tell you five times a week as opposed to 20 times a day, find a more experienced provider,” says Dr. Frank.
2. Will you be my injector at every appointment?
With different providers, you can “end up with multiple types of fillers and unknown doses of toxin,” says Seattle plastic surgeon Lisa Sowder, MD. “Find a good one and stick with them.”
3. How do you handle complications?
Do they have hyaluronidase on hand? Do they know how to flood the treatment area to reverse a filler? How would they manage the rare retinal artery occlusion?
4. How can I follow up with you if I have a question?
“Good injectors will send you home with a contact number, and check in with you the next day,” says Dr. Humphrey. Don’t leave the office without a way to connect after hours.