Sunday, 9 November 2014

Why dermal filler injuries and corrective procedures are on the increase in UK

Injuries from dermal fillers and corrective procedures - are they on the increase in UK?

Expert medical aesthetics practitioner Helen Bowes explores the notion that corrective dermal filler procedures resulting from injuries and bad practice are on the increase. We look at two case studies from UK doctors who misplaced injections causing the client trauma and discomfort.

Client 1

This lady visited our Exeter skin clinic with a badly overfilled face and asymmetrical cheeks.

She had been treated by an Exeter based female doctor who had misplaced the dermal filler for a nasolabial fold treatment, overfilling the area in the process. Not only was it the wrong treatment for the client's needs but also poor product selection (i.e the wrong dermal filler). It was also overprescribed and incorrectly administered too.

The resulting bad treatment had traumatised the client. The overfilling caused pain and discomfort, putting pressure on the internal carotid artery. This in turn restricted nasal breathing on her left side and gave symptoms of tightness on the left side of the face. I advised the client to return to the clinic and ask that the treatment is corrected. Unfortunately, she was wrongly advised by the doctor into thinking that the dermal filler would even out over time.

The next time I saw the lady she had been seen by the doctor who attempted to dissolve the dermal filler with hyalase. This wasn't done correctly either as the client's cheeks were still asymmetrical. The client then told me that the doctor informed her she had never used hyalase before.

As you can see from the left hand image the face was left looking asymmetrical, causing the client both physical discomfort and emotional trauma too.

The right hand image shows how the client looked immediately following the correction procedure at our Exeter clinic.

Notice how the lips are poised in the two images. In the left hand image the pressure from overfilling weighed on the upper lip. In the right hand image with the filler dissolved and the pressure released, the lips return to normal

Client 2

Tear trough filling has become one of the most popular procedures at our Exeter clinic. Sadly, for some clients who have visited a certain female doctor in Exeter they have had to endure injury and temporary deformity before calling on us to correct things.

My second case study is a client who came to our Exeter clinic having visited the same GP as in case 1 for a tear trough correction procedure. Unfortunately, we have not yet obtained consent to use images from the treatment (as with the client above), but will update the blog if and when that changes.

When I first met the client she knew that the treatment had not been performed correctly. Again, I suggested that the practitioner should rectify this, but the client had been upset by the practitioner's hostile response when she previously requested remedial work for the bad treatment.

The dermal filler had been so badly misplaced that it was actually outside the peri-orbital area, causing swelling and discomfort to the entire area.

In my assessment the doctor was afraid to inject along the orbital rim, and close enough to the eye as she did not understand tissue she was injecting nor the consequences of her injection placement and so decided to cautiously inject further away. This may seem sensible at first but when one considers that the placement of the doctor's injections were in the suborbicularis oculi fat pad, which is between two ligaments then it is easy to understand how this caused pressure on the eye and a restriction of movement along with pain and discomfort too. Filler has to be accurately placed in the tissue close to the tear trough and any slight circling under the bottom eye lid. It should never extend out to the suborbicularis oculi fat pad.

Why do injuries and bad practice occur with 'qualified' doctors and practitioners?

Here is some food for thought...

Is a qualified plumber the same as a qualified gas engineer? After all they both plumb and with the same tools, and, both attend to your hot water system. The answer is a resounding NO!

So why would one expect a general practitioner to be the same as an aesthetics practitioner? The principal is identical. Of course many plumbers also happen to be CORGI registered gas engineers as do many doctors also happen to be qualified medical aesthetics practitioners. It just so happens that one does not automatically imply the other.

As a paying client you need to see evidence of training and certification in medical aesthetics but you also need to see evidence that the training translates into properly performed procedures.

It is not a foregone conclusion that any practitioner who has been trained in medical aesthetics can perform any treatment you ask for perfectly. Training standards vary and many practitioners consider 'working with a doctor' or working as a nurse alongside a plastic surgeon' to qualify them as an authority in medical aesthetics.

It's really quite simple: if you want a tear trough filler treatment then ask to see evidence of the practitioner's work in tear trough filling with a dermal filler.

Are injuries and corrective procedures a UK wide problem?

The most plausible answer here is  'probably.'

I practice at 10 clinics across England and Wales and have treated clients requiring corrective procedures in most if not all of these clinics.

There are variances between clinics both in terms of the numbers of corrective procedures and the areas requiring correction. For example, at our Exeter clinic business is thriving, and particularly for corrective procedures to tear trough filling.

I alone have corrected 3 bad dermal filler treatments in the past month from the same Exeter based female doctor (GP). I won't attempt to name either the doctor or the Exeter skin clinic she practices at but just to remind potential clients to always ask two vital questions of the practitioner:

1. Are your trained and certified by a recognised medical aesthetics training company in the exact procedure I require, and can I see evidence to that effect?

2. Can I see evidence of your work and results from previous identical procedures?

As a practitioner we all want to see a thriving clinic but not at the expense of patient wellbeing.

Give your doctor nowhere to hide

The old saying "trust me I'm a doctor" has absolutely no place in medical aesthetics. No doctor is trained in this field as part of a medical degree.

There are increasing numbers of clients who want to have cosmetic treatments but are too afraid based on perceived risk and who are also afraid to challenge or question a doctor.

I want to encourage the public to translate that fear into a determination to put doctors and other practitioners on the spot, asking difficult questions about their qualifications and ones which they cannot hide from.

Doctors are not experts in medical aesthetics by right. They certainly do not have any automatic right to use a medical degree as a status for providing medical aesthetics treatments.

Doing things correctly for the sake of our clients

So, what exactly should you look for in a practitioner?

Obviously, you want them to have at least a medical or health care background. If you were to suddenly react to a substance injected into your skin then you would want to be sure they know how to address it quickly and safely.

The practitioner should be trained and certified by an expert in the exact procedure you are enquiring about. In addition evidence of both the certification and of the practitioner's work should be available to you.

It is not an inconvenience to the practitioner in asking for such evidence but an absolute right of the client.

...and in your own practice?

My own prescribing qualification was gained in the study of medical aesthetics. Doctors, dentists and most nurse prescribes only have prescribing in General practice or other clinical roles.

Remember, medical aesthetics is not a part of general medical, dental or general nursing practice.

As a matter of principle I only ever treat conditions or provide cosmetic treatments that I have been independently trained and certified for.

So, if you are seeking a tear trough filler then please ensure that the practitioner you choose is trained and certified for Teosyal Redensity II the word's only FDA approved dermal filler for tear trough correction.

About the author

Helen Bowes


Clinical Director at Skin Beautiful Medical and Cosmetic Clinic

A Harley Street certified advanced medical aesthetics practitioner, Registered nurse prescriber (medical aesthetics) and registered general nurse.

Pioneer of ADFS advanced dermal filler systems for lips, cheeks and non surgical facelift, the UK only clinically developed dermal filler systems.

Helen holds 10 medical & cosmetic skin clinics across England and Wales at Exeter Milton Keynes Bristol Coventry Swansea Warwick Daventry Carmarthen Llanelli and Neath

Saturday, 4 January 2014

Botox & dermal fillers : regulation & accountability of nurses, doctors and dentists vs beauticians & therapists

Skin Beautiful Medical and Cosmetic Clinic is a specialist medical aesthetics skin clinic for advanced Botox and dermal fillers treatments in Exeter Milton Keynes Bristol Coventry Swansea Warwick Leamington Spa Milton Keynes Daventry Carmarthen Llanelli and Neath

If beauticians, therapists and any other person (e.g self acclaimed 'skin specialists') who are not medical and/or health care professionals are permitted to administer Botox and dermal fillers following the impending government legislation then two questions need to be addressed: Should there be a single governing body that regulates both therapists and medical/health care professionals? Should they be regulated under a separate governing body that makes concessions on the basis of their non medical backgrounds?

Should medicines and medical devices such as Botox
and dermal fillers be administered by unregulated persons? 

Why does regulation and accountability matter?

Regulation exists to protect the public against malpractice in the medical and health care professions. However, rather than being a useful tool to the public and one that hinders practitioners and practices it is actually a very helpful professional tool in our industry. It helps us to meet client expectations, to do things more efficiently and to practice in the safest and most ethical manner possible.

Thanks to regulation clients know what to expect from their practitioners, and, where there is uncertainty over how things should be done then medical and health care professionals can point to appropriate regulatory guidelines.

Could non medical/health care personnel ever be trained and qualified sufficiently to deliver cosmetic injectable treatments?

There is both enthusiasm and animosity, confusion and condemnation throughout the medical aesthetics industry over this very question. We owe it to the public as practitioners to be able to demonstrate clearly and unambiguously that we have every necessary skill and experience from the first initial contact with the patient, through consultation, patient selection, choice of product or therapy and the treatment itself to meet or exceed a basic minimum standard every time.

For beauticians, who is going to train them and to what standard? What knowledge must they possess? Surely they would require the very same knowledge as a medical or health care professional to deliver these treatments, unless we are to accept an industry with double standards?

Undermining medical and health care qualifications

There has been talk throughout the beauty industry that beauticians (with the right training) should be permitted to administer prescription only medicines such as Botulinum toxin type-A. The beauty industry, lead by calls from Molly Hanson Steel believes that 'therapists' with as little as NVQ level 3 in beauty therapy and basic anaphylaxis training are safe and sufficiently qualified to practice medical aesthetics. So what is wrong with this approach?

Firstly, to suggest that an NVQ in beauty therapy somehow equates to a medical, nursing or dentistry degree in delivering treatments that fall under the categories of medicines and medical devices is frankly degrading and discourteous to those who hold such degrees.

Secondly, if these kind of treatments were intended to be delivered through the beauty medium then why are they not part of the criteria for advanced beauty therapy training? The answer here is simple: Who is going to supply prescription only medicines found in the BNF (British National Formulary) to beauty therapists for the purpose of training? The answer is in the question. Furthermore, when one considers that none of the manufacturers or UK distributors of aesthetics medicines or medical devices will supply any of their products to beauticians and therapists and even actively investigate any third party source supplying their products to non medical and health care professionals, then it becomes clearer still that these products should not be handled by non medical or health care professionals.

Of course, for a doctor, dentist or nurse to enter medical aesthetics via the back door (i.e. with no certificates in the field and with no experience of the products or procedures that are to be used in practice) is no less honourable than the beauty path. However, a medical or healthcare degree does provide a correct foundation for specialised medical aesthetics training. It is even a prerequisite with some training providers.

Can a beautician, therapist, hairdresser or any other non medical professional ever be held accountable in the same way as a nurse, doctor or dentist?

These is no simple answer to this question. In short, the answer is no, because beauticians and therapists are not regulated in any way by a recognised governing body and cannot possibly be held accountable by a governing body of an organisation to which they don't belong. Even if it were possible, then regulation would have to somehow excuse beauticians/therapists for not understanding certain principles of professional clinical practice.

There is one other option, albeit a far cry from medical regualtion. Do we become a nation whereby non surgical medical procedures are carried out under different criterion and even to differing standards; i.e. one may visit an aesthetic salon to undergo an aesthetic beauty consultation, to be treated by an aesthetic therapist administering an aesthetic injectable beauty treatment? Notice the deliberate omission of the term 'medical.' By comparison, clients may also visit a medical aesthetics clinic to undergo a medical aesthetics consultation, to be treated by a doctor, dentist or nurse administering a medical aesthetic treatment.

We simply cannot refer to the same treatment or group of treatments under two different names because of the differing qualifications and backgrounds of those administering the treatments. Allergan inc. the manufacturer of BoTox™ would only ever refer to their product as a prescription only medicine, medicine or drug. Under no circumstances would they ever supply it to a non medical professional thereby effectively ruling out the

Can a single governing body possibly regulate both medical/healthcare professionals and non medical/healthcare professionals for the handling and administration of prescription drugs and medical devices?

Surely the answer has to be no! The very purpose of a governing body is to regulate the practice, behaviour, training and development of its members. Thus, we have separate governing bodies for doctors, dentists and nurses even. Why? Simply because their roles, and therefore their responsibilities differ from one another as do their fields of practice.

If there is currently no recognised governing body for non medical/health care professionals in beauty therapy then it would be necessary either to create one for the very purpose of administering medicines and medical devices (something that would be very costly and many existing governing bodies such as the GMC, NMC, GDC would most likely not be keen to partake in) or therapists would have to be governed by an existing body with certain concessions being made.

Is the current regulation sufficient for doctors, dentists and nurses to practice medical aesthetics?

Certainly not! We need a professional register of 'qualified' medical aesthetics practitioners. That is, a register that lists only those doctors, dentists and nurses whom have specialised qualifications in medical aesthetics and, ideally, have undertaken specialised training and qualifications in prescribing the drugs and medical devices found in medical aesthetics.

Regulation must, for the sake and safety of the general public not permit 'have a go hero' types of GP's, dentists and nurses. These types walk into aesthetics with no training or certificates, then simply pick up a needle and begin injecting. Worse still, many then themselves with new titles such as "aesthetic doctor", or "aesthetic nurse practitioner", etc.

The public needs to know, beyond any doubt whatsoever, that every practitioner on the register has the same aesthetics qualifications, ability to consult and prescribe aesthetics drugs and medical devices and that their skill level is reflected in the treatments they offer.

Other areas of concern

One of the most strikingly repetitive scenarios I find in my own medical aesthetics practice is when meeting with a new client whom comments either about poor experiences with other practitioners or regarding a scare story that has been read via an online forum or social media site. Although it is something I have become used to I still find it hard to accept that some of these poor clients actually believe it is the norm to receive severe bruising or other injury, for an eyelid to drop or for slurred speech to occur following a treatment.

A lady client I treated last month for the first time told me she had taken a week of annual leave from work to have a dermal filler cheek augmentation. Out of curiosity I asked her why she needed a week off and she replied "for the bruising to go down!" I was dismayed! In my own practice this is unheard of. However I do often hear this from first time clients. The lady told me that this was her experience the last time she had a cheek enhancement.

Her expectations had been lowered to such a degree that she avoided all clinics for several years following her previous experience. Needless to say she was surprised when she looked in the mirror the next morning and saw a bruise free complexion and high contoured cheekbones.

About the author

Helen Bowes RGN BSc (hons) AMAP is a certified advanced medical aesthetics practitioner, medical aesthetics researcher and pioneer of the clinically developed advanced dermal filler system ADFS by HELEN BOWES®

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Sunday, 16 June 2013

Why other clinic's lip fillers (lip enhancements) are only half the job

Lip augmentation (plumping) without proper contouring can leave the lips looking like fat sausages. A practitioner or clinic offering only a lip augmentation is offering only half a job!

Skin Beautiful Medical and Cosmetic Clinic provides expert advanced dermal filler treatments at clinics in Exeter Milton Keynes Bristol Coventry Swansea Warwick Daventry Evesham Carmarthen Llanelli and Neath.

Fuller lips, lip plumping, lip fillers, lip enlargement, lip injections, etc, etc are all offered by cosmetic clinics across the UK. These treatments are nothing more than adding volume to the lips. Surely that is what every client seeking a lip enhancement wants, isn't it?

If I tell you that these treatments can result in loss of definition, natural shape or symmetry then you may think a little differently about these advanced dermal filler treatments. To "plump up the lips" changes their dimensions. A little saying I often use to explain this to clients:

"As we change the dimensions of the lips then we must also redraw the contours."

Introducing lip sculpting, shaping, contouring and outline definition!

Lip plumping is only half the job

What happens to a balloon when one adds water to it? It changes shape and size. In other words its outer perimeter contours are altered to compensate for the volume of water contained within them. This is very much the same with the lips when liquid gel hyaluronic acid dermal fillers are injected into them. Clients are left with larger, fuller lips but in some cases the outline of the lips have been eroded. In these cases the client has literally gained a fuller pair of lips at the expense of them losing their shape. This is only half a job as the lips have not been finished off correctly.

What is lip contouring and why is it important?

Lip contouring is particularly important as part of a lip enhancement procedure because it redraws the natural contours of the lips, particularly the upper lip. When volume is added to the lips the contours can then be redrawn using advanced needling techniques.

The diagram below is from a previous lip enhancement treatment performed at our clinic. It shows the particular points of interest that together make up the contours of the lips. Notice how the natural contours have been redrawn after the lips have been augmented (plumped). Without lip contouring the lips would just look like fat shapeless sausages!
Diagram of the lips showing points of interest
Lip contouring is about the areas around the border outline of the lips

Sausage lips, balloon lips and the trout pout!

Many young women desire fuller lips and realise how easy it is to get treatments for them at high street cosmetic clinics throughout the UK. Clients I have consulted with generally have no prior knowledge of lip enhancement other than to have larger lips. When I consult I explain that the contours will change once the lips are enlarged (augmented). Of course any client is quite welcome to have just a lip augmentation treatment at our clinics, but many choose to have them contoured too.

I have spoken with several clients whom, having had consultations with other clinics have been offered only lip plumping and so their understanding of lip enhancements goes no further than the size of the lips. Some practitioners make the mistake in over filling the lips as a way to reintroduce shape. This is not the correct way to redraw contours and will only make them look like ugly, fat sausages or over inflated balloons. This is commonly referred to as the "trout pout!"

Advanced lip enhancement procedures

Advanced lip enhancement treatments involve lip sculpting, shaping, contouring and definition. this is quite different from the basic lip augmentation (plumping). I always advise clients to get the best for their money when considering dermal filler treatments. At the basic end a client pays for one, two or more syringes of dermal filler. The vital question then is what is the practitioner going to achieve with that syringe of dermal filler? If they cannot perform advanced treatments because they don't know the necessary advanced techniques then the ceiling for potential creativity is instantly lowered and the client is not going to benefit from the true potential of the dermal filler.

Advanced needling techniques - Lips created by Helen Bowes!

For every two syringes of dermal fillers a client pays for then some of this filler must go into contouring. Clinics that charge for lip augmentation and do not contour may be wasting a client's money. I am not about to give away my knowledge of advanced needling techniques and procedures for other practitioners to attempt in their clinics but the video below demonstrates how advanced needling can really make a difference to a client both in terms of discomfort and precise results

Expert lip augmentation - No bleeding, bruising, lumps or bumps.

Watch Helen Bowes RGN, BSc (hons) AMAP perform the perfect lip augmentation

I don't use a cannula or dental block! A cannula is not a good tool for precision in lip contouring and sculpting. Patient discomfort is kept to a minimum by advanced needling techniques.

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Links to our lip enhancements:
All of our other lip enhancements
Lip augmentation (plumping & volume)
Advanced lip sculpting, shaping contouring and definition

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Skin Beautiful Medical and Cosmetic Clinic homepage
Treatments available at our clinics
Dermal fillers and advanced techniques

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Saturday, 27 April 2013

Who wants a wrinkle free sagging face?

Could filling wrinkles with dermal fillers really leave you with a sagging face? Find out why facial contouring and advanced dermal filler procedures matter.

Skin Beautiful Medical and Cosmetic Clinic provides expert advanced dermal filler treatments at clinics in Exeter Milton Keynes Bristol Coventry Swansea Warwick Daventry Evesham Carmarthen Llanelli and Neath.

Wrinkle free sagging face anybody?

No, I didn't think so. The point being made is that whilst cosmetic treatments such as dermal filler injections with Juvederm, Restylane, Radiesse and Teosyal can certainly correct lines folds and wrinkles they can offer so much more. You pay for the product so you should not be limited by treatment options just because a practitioner cannot perform the more advanced treatment(s) for your needs.

As a paying client it is the duty of your medical aesthetics practitioner to offer honest and appropriate advice about the cosmetic treatment options available to you. If you have deep nasolabial folds (laughter lines or nose to mouth lines) then it may not be money well spent to have these treated alone. Why? Because they are likely to be a symptom of another problem not the direct cause.

What are advanced Botox or dermal fillers techniques?

Advanced Botox & dermal fillers techniques may be defined as any treatment which adds volume, lift or definition to the face (e.g facial contouring) or, cosmetic Botox and/or dermal filler treatments other than to correct lines & wrinkles. Some examples are: Botox for eyebrow lift; dermal filler treatments for cheek augmentation, lip enhancement, jaw definition, jowl lift and non surgical facelift.

What am I paying for?

In my own medical & cosmetic practice: Skin Beautiful, we charge for most dermal filler treatments by the syringe. Clients literally pay for the product according to the treatment being given. So, for example a syringe of Restylane or Juvederm may be used for one treatment or another all at similar prices. Where a client presents themselves with visible lines and wrinkles it is appropriate to look under the surface, so to speak. Often the lines are accompanied by visible signs of loss of fat or volume in the face. In such cases it may not be appropriate to offer treatment for lines and wrinkles. I tell my clients "you are paying for the product so you should get the best treatment available for your needs."

Consider all treatment options

During consultation with clients I take time to explain the properties and potential uses for a range of dermal fillers. For example, a lady client came to our clinic last year with multiple lines and wrinkles around the eyes, cheeks and mouth. Her expectation was to pay for several areas of lines and wrinkles treatment. When she explained that other clinics had quoted her for 4 areas of treatment I advised her that this was the wrong way to treat her condition and that all areas could be treated under a single treatment. Yes, the lines were indeed visible and there was a genuine need for treatment. However, the previous clinic clearly did not understand that loss of volume was the cause of her wrinkles. In my experience it was a case of treating the cause not the symptoms. After all, who wants a wrinkle free sagging face?

Getting the best treatments for your money

Case example: Lip plumping

I've seen many clinics offer "lip plumping" or "lip filler" treatments. This is simply no more than an inflation of the lips. Yes, it will make them larger, but may also destroy their shape, contours and symmetry. The lips are an incredibly beautiful feature of the human face with very intricate contours. A lip enhancement procedure should respect these contours. In other words, as the dimensions of lips are enlarged then the contours must be redrawn.

Sausage lips!

Some of the very worst lip enhancements i've seen literally resemble "sausage lips!" That is, lips that have undergone a lip augmentation and have been inflated to look like fat sausages with absolutely no shape or contours whatsoever. This is a very bad waste of a client's money. Furthermore, I doubt the practitioner consulted with these clients properly.

The very same syringe of dermal filler could have yielded much better results for a similar if not identical cost. It is down to the ability of the practitioner with the syringe in hand to effect these results. Nobody wants to pay to lose their natural lip contours at the expense of sausage lips, but this practice is quite common amongst clinics with poorly trained staff. They simply do not know how to use lip fillers beyond basic augmentation.

Lip augmentation with beautiful contours

The images below represent a treatment I performed in 2012 (hence the copyright). Notice how the vermilion border of the upper lip and has been raised and philtrum to lip border has been redefined relative to the size of the upper lip. This is an advanced dermal filler technique known as lip sculpting (also referred to as lip shaping, lip contouring or lip definition). In addition, the treatment has also improved symmetry between top and bottom lips.

Lip enhancement before treatmentLip enhancement after treatment

*N.B. a cupid's bow definition has not been performed on this client. The illustration is to show the relative position of the cupid's bow to neighbouring areas.

For further details of advanced lip enhancement treatments and techniques including shaping and sculpting please visit the following pages on the Skin Beautiful website:

Lip enhancement treatments: Advanced techniques with dermal fillers
Lip augmentation treatments (plumping, enlargement)
Lip contouring treatments (Advanced sculpting, shaping & definition)


Advanced lip sculpting, shaping and contouring treatments are just one example of getting the best from a syringe of dermal filler. Many of the advanced cosmetic treatments with dermal fillers often use the same or similar products as used for more basic volumising, augmentation and wrinkle filling treatments.

In essence it's all about the level and understanding of the practitioner. A good practitioner with skill in advanced procedures will take time during consultation to explain all treatment options. Clients are often at the mercy of practitioners as many charge by the syringe for basic dermal filler treatments. "Lip fillers" is not a treatment. In fact it isn't a product either. There are various categories of lip enhancement.

Please see our other blog titled "Good practice begins with a proper consultation" to find out what constitutes a good consultation.

Blog author: Helen Bowes RGN, BSc (hons), NISP, AMAP

Helen Bowes is the pioneering developer of the first advanced dermal filler systems for lips, cheeks and non surgical facelift. She is a qualified advanced medical aesthetics practitioner, registered general nurse and nurse prescriber. Helen holds regular clinics at over ten locations across England and South Wales.

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Skin Beautiful homepage
About Helen Bowes and Skin Beautiful

Botox & dermal fillers treatments
Advanced Botox treatment for eyebrow lift
Advanced dermal fillers treatments for cheek augmentation
Advanced dermal fillers treatment for jaw definition & jowl lift
Advanced dermal fillers treatment for Non surgical facelift

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Sunday, 17 February 2013

Botox Treatment - Getting The Most From It

How long can a Botox treatment really last? How can I get the most from my treatment? This article explores some Botox myths and offers practical advice for clients.

Skin Beautiful Medical and Cosmetic Clinic provides expert advanced dermal filler treatments at clinics in Exeter Milton Keynes Bristol Coventry Swansea Warwick Daventry Evesham Carmarthen Llanelli and Neath. 

Getting the most from a Botox treatment and ensuring it lasts for as long as possible is an area that clients must take responsibility for.

In my own practice many first time clients present themselves with differing expectations as to how Botox (Botulinum toxin type A) works and how long its visual effects will last. This is one half of equation.

Putting the record straight

1. How long can I reasonably expect Botox to last?

In facial aesthetics Botox is the essential ingredient in removing facial lines and wrinkles (albeit temporarily). For those of you that are interested in calculating costs based on longevity then a rule of thumb is three months. Yes, that's right, only three months. This is the average time it takes for neuromuscular contractions to resume. Remember that creases, lines and wrinkles are visible as a result of muscular contractions. Once the Botox has ceased to block muscle contractions then there is 'X' amount of time before those lines become visible again.

A common misconception amongst clients is that Botox works on the skin and that there is a direct relationship between Botox and lines and wrinkles. This misconception in turn leads to the belief that if wrinkles are kept at bay for 5 months then the Botox works for 5 months. The scientific response should be that Botox works on local groups of muscles and has no direct effect on the skin whatsoever. Botox will stop certain muscles from contracting for approximately 3 months. In fact that's all it does. The interesting thing here, and one of the many wonders of science is that there can potentially be a delay between the time muscle contraction resumes and lines and wrinkles become visible once again.

2. How soon after Botox stops working will lines and wrinkles become visible?

it is scientifically impossible to give an objective answer to this question, and here's why. Once muscle contractions have resumed then Botox is no longer governing the behaviour of those muscles. In a sense it is retiring and handing the job back to the neuromuscular system. So, if the time it takes for the lines and wrinkles to reappear from this point forward is not determined by Botox it must be determined by something else. Indeed, it is determined by your own body, its metabolism, physical state and a whole conundrum of other factors.

3. I've had my Botox treatment. Now what?

There are clients whose perceptions of Botox is that they visit a clinic, receive their Botox injections and will not see any lines or wrinkles for around 6 months. Botox is a drug, and drugs go through the stages of absorption, distribution and metabolism within our bodies. Hence, the speed and effectiveness with which a drug is absorbed and then distributed is largely dependent on the environment in which the drug has to work. Similarly, metabolism is an important factor in the effectiveness and longevity of the drug too.

It's all about shared responsibilities. Where the practitioner has a responsibility to advise it is the responsibility of the client to action post treatment advice at a personal level and, where longevity and effectiveness is a priority then to create the right environment for Botox.

4. Are there any possible reasons why Botox wouldn't last three months?

Yes there are. Although, at the time of writing there remains inconclusive evidence to support the many theories out there. We need further scientific evidence in order to better inform our clients. There are those in the industry who believe the effectiveness of Botox in temporarily correcting facial lines and wrinkles may be reduced by alcohol, smoking, recreational drug use, sports activities, stress, diet, environmental factors, sleeping patterns, etc, etc.

Whilst it is generally recognised that a healthy, active lifestyle leads to better metabolism in the body certain physical activities may lead to problems elsewhere. For example, through exertion we often use our facial muscles more than at rest. A good example might be weight lifting. The activity in itself is unlikely to have a negative effect on the longevity of Botox. However, the tightening of facial muscles that accompanies exertion when lifting very heavy weights results in overuse of certain facial muscle groups. This in turn could be a factor working against the effectiveness of Botox.

In a different way alcohol and smoking may affect the absorption and metabolism of Botox within the body. Other factors such as excessive exposure to sunlight may cause the skin to appear more wrinkled than it would otherwise do so.

5. What advice can you offer to help me get the best from my Botox treatment?

Much of the advice given to clients is centred around research conducted by drugs manufacturers. For example, I always provide general advice to clients regarding alcohol consumption, exercise, flying and head position but I like to go further in offering advice too.

Following treatment it may take up to or even beyond 14 days for Botox to take full effect. My personal belief is that advice to refrain from alcohol for a period of just 6, 12 or even 24 hours post treatment is not sufficient. That is not to say that if a client consumes a small glass of good quality wine then he/she will see no visual effect with the Botox on the treated area. My advice is based on effectiveness and optimisation. For Botox to be as effective as possible then it is important to create the right environment to support its distribution and metabolism within the body. Furthermore, the process is also dependent on how the body metabolises alcohol.

For anyone interested in optimising the effectiveness of their Botox treatment then a sensible course would be to look after one's skin and neuromuscular system. For the skin it is better to stay away from excessive strong sunlight than to receive exposure to it and then apply creams or lotions to counter its effect later on. As mentioned above, exercise that puts stress on facial muscles is also something that should be avoided as much as possible.

About the author:
Helen Bowes RGN, BSc (hons), NISP, AMAP
Registered Advanced Practitioner No. MD1248/12

Helen is a qualified advanced medical & cosmetic aesthetics practitioner, specialising in advanced Botox & dermal fillers treatments. She practices regularly at Skin Beautiful clinics in Exeter Milton Keynes (England) Bristol Coventry Swansea Warwick Daventry Evesham Carmarthen Llanelli and Neath.

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Wednesday, 31 October 2012

The Myths About Botox & Dermal Fillers

Botox and dermal fillers: myths and important client information

Skin Beautiful Medical and Cosmetic Clinic provides expert advanced dermal filler treatments at clinics in Exeter Milton Bristol Coventry Swansea Warwick Daventry Evesham Carmarthen Llanelli and Neath.

From every corner of the non surgical aesthetics industry there exists a multitude of myths regarding the uses, properties, legalities and ethics of Botox & dermal fillers. Some are quite surprising and none are limited to any one particular group.

In an attempt to provide the discerning public with the most accurate information possible, this article aims to clear up many of the most common myths.

Who can administer Botox injections?

Although there is widespread disparity in answering this question, the answer is a very straightforward one. At the time of writing, and under current UK law, any person can administer Botox injections, so long as certain criteria have been met. Botox is a prescription only medicine (POM). This means it must be supplied by prescription. A prescription must be obtained following a face to face consultation with an appropriate person. Therefore, if a doctor is willing to give a direction to a beautician to administer Botox there is currently no UK law prohibiting this.

Who can prescribe Botox?

I have seen several articles where doctors claim that nurses are not allowed to prescribe Botox or other botulinum toxin type-A drugs. This is quite simply a distortion of the facts. Any nurse holding a nurse independent and supplementary prescriber qualification (NISP) can prescribe Botox independently of a doctor or dentist. An NISP may also prescribe for others and give a direction for others to administer Botox too.

Who is qualified to do what?

I have seen several doctors (general practitioners) claiming to be 'best placed' or 'most suitably qualified' to deliver non surgical facial aesthetics treatments. I am sceptical that this advice is not in the best interest of the general public for several reasons:
  1. A doctor is highly knowledgeable in medicine and disease. However, no aspect of doctor training covers any part of facial aesthetics, nor does it cover the technique of injecting Botox or dermal fillers.
  2. Many doctors have absolutely no aesthetics training, qualifications or certification whatsoever. That's not to say that doctors don't make good aesthetics practitioners. There are many good aesthetics practitioners with medical backgrounds. However, to claim to be most suitably qualified on the basis of a medical degree, without having had any professional aesthetics training is perhaps misleading.
  3. Over 70% of all injections in the UK are administered by qualified RGN or RN nurses. Many doctors rarely inject patients in daily practice, but instead give the direction to practice nurses to administer injectable drugs.
  4. Specialist medical aesthetics training course for doctors, dentists and nurses are readily available, leading to certification in all manner of non surgical cosmetic and medical procedures. A medical aesthetics certificate is evidence that the practitioner can perform the given procedure safely and correctly, and, independently of any medical, nursing or dentist training and qualifications.
In my own experience, I have been told of several doctors, nurses and dentists who have injected incorrectly leaving a client(s) with bruising and other undesirable effects following treatment.

My advice to the client is: ask several questions of your practitioner. Find out exactly what training and qualifications they have, and ask whether they have evidence that they can perform the treatment you require effectively. Always ask to see professional cosmetic insurance, which is independent of any other medical practice insurance. The best cosmetic insurance available will only cover doctors, dentists and nurses who are also qualified aesthetics practitioners.

The Frozen Look!

It is not good practice to inject a client's face leaving a frozen look. Scientific literature from both independent studies and drug manufacturers state that Botox Cosmetic (and other botulinum toxin type-A drugs) should 'relax', 'reduce' or 'weaken' muscle contractions. Botox is not supposed to be administered to the extent that muscles become completely, albeit temporarily paralysed. In my own practice I refuse to attempt the 'frozen look' on the basis of such scientific evidence. Botox is supposed to achieve a reduction in the visibility of facial lines and wrinkles, not a visibly stiff face.

What is the difference between Botox and dermal fillers?

I often get asked this question by clients. For many 'Botox' has become a generically used term to describe all facial aesthetics injectable treatments. In terms of the physical and pharmacological properties of the two Botox and dermal fillers are very different.

Firstly, Botox is a prescription only medicine (POM) whereas dermal fillers are medical devices (non POM). Botox cosmetic is a drug that is injected beneath the skin to temporarily correct lines and wrinkles caused by the contraction of particular facial muscle groups. It does so by blocking the release of acetylcholine, a neurotransmitter. This in effect inhibits localised muscle contraction.

By contrast, dermal fillers have no effect on muscle contraction or in neuromuscular function. Instead they work by replacing lost volume in the skin's matrix. The active ingredient in most dermal fillers is hyaluronic acid, a substance that occurs naturally in the body. In the skin it aids hydration by holding water, which in turn gives volume to the skin. Through ageing, our skin loses its ability to hydrate itself and the resulting loss of volume yields characteristic deep lines and folds. Dermal fillers can replace the lost hyaluronic acid and allow the skin to rehydrate itself once more.

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Monday, 1 October 2012

Botox & dermal fillers - The Keogh Review

The Keogh Review: Botox and dermal fillers in the UK

Skin Beautiful Medical and Cosmetic Clinic provides expert advanced dermal filler treatments at clinics in Exeter Milton Keynes Bristol Coventry Swansea Warwick Daventry Evesham Carmarthen Llanelli and Neath.

The Keogh review, once concluded, will likely change the way in which non surgical cosmetic treatments such as Botox and dermal fillers are administered in the UK. Read this article to find out more.

At the request of the then health secretary Andrew Lansley MP the NHS medical director Prof. Sir Bruce Keogh is heading a review into the practices of both surgical and non surgical cosmetic procedures. A review was deemed necessary by Mr Lansley following the scandal of PIP breast implants. However, the review is to consider a much wider scope including all non surgical aesthetics procedures to include the prescribing and/or administration of all Botox (botulinum toxin) and dermal fillers products.

The review is currently at the consultation stage with both the medical profession and the wider public being encouraged to comment on and provide evidence of various aspects pertaining to (amongst other matters) cosmetic injectable treatments. It is set to conclude in March, 2013 soon after which many of my colleagues and I expect regulation to become a part of a largely unregulated industry.

As a qualified advanced medical aesthetics practitioner I give my full support to regulation within the industry. Not least as I consider patient safety to be fundamental in any cosmetic procedure (either surgical or non surgical), but also because I believe the cosmetic industry, and, in particular non surgical aesthetics must be better defined, allowing the public to be better protected and better informed.

Possible implications for Botox & dermal fillers in UK

There are several possible outcomes following the conclusion of the Keogh review. These range from a ban on beauticians administering prescribed, injectable Botox (botulinum toxin type A) and/or injectable dermal fillers such as Juvederm, Restylane, Radiesse and Teosyal to an outright ban on all but registered physicians from administering either Botox or dermal fillers. The latter is perhaps unlikely, and more in line with other EU member states where only doctors are permitted to administer injectable botulinum toxin type A.

Between these two opposing states lies a whole conundrum of other possibilities for the aesthetics industry. For example, in the UK many nurses are permitted to prescribe, both as part of a team and also independently, drugs such as Botox. This is an exception within the EU where nurses do not have such roles.

There are further options, both along the lines of autonomous practice and regulation. One it has been decided who can and cannot administer cosmetic injectables such as Botox and dermal fillers then it must also be decided where the boundaries lie between 'practice' and 'autonomous practice.'

Botox - The current state of affairs

Currently, it is necessary only that all injections of botulinum toxin type A must be preceded by a face to face consultation with a qualified prescriber. That is to say there are no regulations governing who can and cannot administer the treatment so long as the prescription was obtained as described above.

Needless to say, the UK is severely lacking in regulation. This has led to beauty salons across the country offering "Botox injections", "anti wrinkle injections", "skin rejuvenation" and "muscle relaxing injections" as part of their beauty portfolio. In light of the Keogh review questions must be asked as to whether a prescribed drug with potentially severe consequences should be administered by a person(s) who has no medical or health care training, and, therefore no knowledge of dealing with possible complications as a result of injecting.

Prior to the announcement of the Keogh review, and despite there being no current supporting regulations in place many organisations in the UK already have strict rules effectively excluding certain groups concerning the acquisition, and administration of Botox and dermal fillers and the insurance covering such interventions. For example, my own cosmetic insurance company sent letters to all members stating that it will not renew existing policies where the insured is not a qualified nurse, doctor or dentist. Similarly, none of the pharmacies or aesthetics manufacturers that I deal with will sell or market either Botox or dermal fillers to anyone other than a nurse, doctor or dentist.

Injectable Botox & dermal fillers - How should regulation be applied?

There is little doubt that the Keogh review will ultimately lead to regulation being implemented across the cosmetic industry, but how should this apply to non surgical aesthetics such as Botox & dermal fillers?

In my own view as an experienced RGN and qualified advanced medical aesthetics practitioner any regulation must ultimately provide universal protection for the public seeking cosmetic treatments. It must also go further in addressing public awareness. When one considers a GP it is common knowledge in the UK that any such person is suitably qualified and knowledgeable to diagnose and treat illnesses. I believe it should also be common knowledge that any person administering Botox or dermal fillers is a qualified medical and/or health care professional with professional aesthetics training.

In summary, my own suggestions put forward to the Keogh review include the following
  • Botox & dermal fillers should only be administered by a practicing qualified medical or healthcare professional.
  • In addition to a medical, dentistry or nursing degree all practitioners should have suitable independent aesthetics training and qualifications and should only perform the treatments they have trained for.
  • All practitioners must hold separate professional cosmetic insurance.
  • All practice should be performed either by a qualified prescriber, or, at the very least by a qualified health care professional in connection with a prescriber.

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