You know you’re on a small plane when row 12 is the last row! I was in Saskatoon this week doing advanced injection training for physicians and nurses in 3 different clinics. As I settled into my seat for the quick flight home, I reflected on a successful day of teaching.
While I, sometimes, teach seasoned injectors about a new product, it is new injectors that I work with most often. Today was particularly interesting as one of the doctors was a psychiatrist who has never injected fillers. Fortunately, he had done quite a bit of research and his product knowledge was great. He also was going to a training course in Vancouver.
It has become so apparent that the Cosmetic Injection industry will continue to expand. As demand continues to rise, the industry draws nurses, physicians, and dentists to jump on board. All of a sudden everyone with a healthcare license is now an expert at what a beautiful face should look like. I had a client this week who was in the External Affairs St Albert location to see me for her Botox treatment and she told me that a co-worker had invited her to a Botox party at someone’s house and the injector was a pharmacist. Seriously?? Now I’m not sure how the Alberta Pharmacists’ Association feels about this, but I do know that The College of Physicians and Surgeons of Alberta, as well as the College and Association of Registered Nurses of Alberta, would not promote the use of a drug combined with an at home party!! Promoting alcohol consumption prior to having a medical procedure is shunned upon. Even tattoo parlors are on to this. Not only will you bleed more, but someone who is under the influence of drugs or alcohol is not in a position to be making an informed decision about a medical procedure. I think people are forgetting that these are medical procedures and have associated risks. Are these risks best cared for in someone’s’ basement? Did you actually read the consent form after that 3rd glass of champagne?
I sometimes ask myself why I took on the position of Advanced Clinical Trainer for Galderma, the pharmaceutical company that makes Dysport, Restylane, and Sculptra. At first, I was really just flattered that they considered my experience and skill set to be worthy of training other physicians and nurses. Once I started visiting clinics from Winnipeg to Vancouver I was further rewarded with accolades of “very knowledgeable” and an excellent style of teaching. Hmmm! Who knew, and it turns out I love teaching! As I travel across the countryside, my eyes have been opened to how things are being done out there. Some clinics are bang on following proper policy and procedures for administering neuromodulator (Botox and Dysport) and HA fillers (Juvederm, Restylane, TeoSyal).
Some clinics not so much. Patients must be assessed initially by a physician or other authorized prescriber who then writes a patient-specific order for the neuromodulators (Botox & Dysport) or HA filler. I really encourage nurses to contact their professional associations to make sure they are following a procedure in their province. Clinics often cut corners to make more money (doctor never comes to the clinic or if he does he signs charts 3 days after the procedure). These rules are put in place for public safety.
The question I hear so often from both clients and other health professionals is “How do you get trained to do Botox and fillers?”
Training is offered sometimes by the drug companies (like what I do) but that is only for clinics who already have basic training in cosmetic injections. There are weekend courses available to MDs, RNs, NDs, dentists, and pharmacists. Typically these courses don’t offer any hands-on training or very little. Students learn just enough to be dangerous. I really believe that teaching the “art” of cosmetic injections takes months and months of practice. I’ve been injecting for over 15 years and I still learn new things every day. I look at the face in new ways. Challenge myself and the products I’m using. This really is medicine and art combined.
When I was trained back in 2002 on Restylane I remember the nurse trainer telling us that they predicted that one day, neuromodulators and HA fillers would be as popular as getting your hair colored. At the time I didn’t believe it but I wouldn’t have believed that every 12-year-old kid would have a cell phone either and that’s happened too! Everything available to us is in direct response to demand and desire!
Over the last 18 months of training, I have been motivated and inspired to develop better training protocols for cosmetic injectors. Both for clinicians outside of our clinic and most importantly, for the team of physicians, physicians assistants, and nurses who are employed at External Affairs Medical Spas in Edmonton and St. Albert. I decided that I needed to develop an apprenticeship program for cosmetic injectors. So I got to work getting all the theory into a training manual. I have to admit that Dr. Briggs, our Medical Director is a stickler for policies and procedures and kinda nagged me (motivated me!) into completing this project. Next step was to develop a well thought out hands-on training program. Our medical team members first shadow with an experienced injector for several weeks. They also have to complete an online training portion which reviews anatomy, physiology, and full face injection demos complete with testing. Then our other staff members (we have over 35 staff now at External Affairs Medical Spas) volunteer their faces for injections. The first month is just Botox and Dysport. The new injectors learn how to properly take photos using our 3D Vectra system. They learn how to communicate with potential patients to really understand their goals. They learn how to see the face and understand all the causes of aging to the different layers of skin. They learn how to create a Treatment Plan exclusive to External Affairs Medical Spas which outlines potential treatments to suit the patients’ budget. They learn all the necessary facts about the medications being injected and the best techniques, placement, and dosing. They learn the importance of patient-specific orders, informed consents, and documentation.
And we haven’t even started talking about the Hyaluronic Acid fillers. Fillers are being commoditized. You can go to the Medi Center, pharmacy, or your neighbor’s basement now. What used to be in the hands of just plastic surgeons and dermatologists is now being done in the back alley. In Asia, they actually have booths on the side of the road!
It seems as though as much thought goes into these procedures as getting a makeup application at the mall (sorry, I am not targeting our clients who take this seriously, as you should). I actually appreciate it when clients are full of questions and fears. It’s our job to address them. Unfortunately, so much is being ignored in the cosmetic injection world.
People worry about Botox but the real worry needs to be the fillers. Botox and Dysport are medications that where injected, block the ability for that muscle to contract. The results in the hands of a well-trained injector are extremely predictable with very low rates of adverse events. Dissatisfaction with these products is usually due to underdosing the area.
Although fillers are classified as “Medical Devices” by Health Canada (as opposed to a class 1 drug like Botox or Dysport), the training required to safely administer fillers, is so underestimated. The public has no idea of the complications that can happen from fillers. Not only is there a higher incidence of swelling, bruising, and pain, but with filler, there is a risk of blocking blood supply to the face everytime you stick a needle into the skin. I’m horrified when I watch Instagram videos of people getting poked 32 times into the lip. Every poke increases the risk. The clinic usually just posts the immediate pictures of the new set of lips but what they don’t show you is how black and blue the poor girl is for the two weeks following her injections. One of the biggest concerns using needles in the lip is the superior and inferior labial arteries. Those lovely blood vessels that feed the lip. And those vessels backflow into the angular artery which can backflow to feed the retinal artery. If you’re following me, I’m telling you that yes….filler in the wrong vessel can be very very dangerous! So it drives me bananas when it’s taken so lightly. How do you reduce the risks of not injecting filler into these arteries? Don’t use needles in the lip!! Use cannulas!!! Cannulas are blunt tipped devices that kinda look like needles but they go around vessels instead of through them.
Now you might be asking why I’m so neurotic about using cannulas as much as possible. It’s because I’ve seen these incidents occur. And when you are injecting a lip and all of a sudden the mouth and nose turn white…it is bad news. As an injector, your heart starts pounding and you feel a bit nauseous. You tell yourself to stay calm…but you’re freaking out. You know you have to reverse this product immediately before it travels up toward the eye. If you are a well-trained injector, you have a full stock of hyaluronidase in your fridge which can be injected into the area to break down the hyaluronic filler and prevent damage to the surrounding tissue. You stay with the patient for an hour, sometimes two…assessing circulation to the tissue. Re-injecting more hyaluronidase until tissue perfusion is satisfactory. You still feel sick because you know your patient is going to have some healing to the tissue, some pain after the lidocaine wears off, possibly sores or blisters to the area. She will recover but it sucks. It sucks when she came in to look and feel prettier and that was not the outcome. Now, this type of situation does not happen very often but it does happen (maybe 1/1000). In our clinic, we do an extremely high volume of injections, so statistically speaking, we see the odd adverse event. The key, is what do we do about it? Are we trained to handle it? Is your neighbor’s basement the best place to get a neuromodulator or HA filler injection?
Fillers are typically taught to be injected with very small needles which come in the same sterile package as the product. It’s been that way for 20 years. Most injectors use needles throughout the face and lip. It’s the easy way to inject but not the safest way. For years we were trained to inject needles right into high-risk areas. Back then, the doctors and nurses doing the teaching didn’t know the risks. They never thought about what would happen if a gel was injected into an artery. Now we all know better but the traditional way of teaching still exists. This is why I am making it my personal mission to contribute to better ways of teaching.
The biggest downfall of a cosmetic injector is the inability to manage client expectations. It’s our job to properly educate about what fillers can & cannot accomplish. We train our team to understand proper proportions that create an attractive face. Also known as the Golden Ratio or PHI proportions, a system of measuring and checking to keep the face in balance and make it look it’s most appealing. Make sure your injector is looking at your full face instead of just a select area, PHI is important for a balanced symmetrical appearance.
In Stephen Convey’s Book Primary Greatness, he describes the principles successful people live by. One of them: Teaching to Learn, is my personal mission. The more I embrace how to teach others better, the more I have to sharpen my own skills. It’s humbling having to admit to others where you have failed so that they may learn quicker. In order for me to be a better trainer, I must continually advance my own skills.
We will continue to see neuromodulators (Botox & Dysport) and HA fillers like Restylane and Juvederm become more popular. As this happens it will be health care professionals like our EA team who need to be the voice for patient safety and insist on properly trained injectors.
In closing, please demand the best from us! And for goodness sake, please reserve home parties for Tupperware and Stella & Dot, not medical procedures!
Aging with Passion & Purpose
Becky Wilkins RN, Clinical Director
External Affairs Medical Spas