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 placed 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 the 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 a medical 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 our clinics thriving but not at the expense of patient well being.

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. Prevention is always better than cure.

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 aesthetic medicine. 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 approved dermal filler for tear trough correction.

About the author

Helen Bowes

RGN, BSc (Hons), NISP, AMAP

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 wrinkle relaxing injections, dermal fillers, IV nutrition and PDO thread lift treatments in Exeter Milton Keynes Bristol Coventry Swansea Warwick 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 or 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 regulation. 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 honour 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 cheeks.

About the author

Helen Bowes RGN BSc (hons) NISP AMAP is a Registered Nurse Prescriber, certified Advanced Medical Aesthetics Practitioner and industry expert Key Opinion Leader for PDO thread lift.



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