Making clinical and ethical decisions as an aesthetic injector

Recently, Dr Tim Pearce welcomed his apprentice winner, Nurse Charlotte to a podcast to discuss her concerns, as a beginner in aesthetics, about key clinical and ethical considerations for botulinum toxin treatments to keep in mind when treating patients.

In this blog, we share the key points from their conversation and Dr Tim explores the clinical decisions and ethical questions that must be carefully considered. They delve into topics including age limits for administering Botox, managing resistance to botulinum toxin treatment, the importance of follow-up appointments in assessing the outcomes of treatment, and topical anaesthesia for dermal fillers.

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Can patients have Botox treatment in their 20s?

Nurse Charlotte raised the question to Dr Tim that aside from the legislation now in place to prohibit the cosmetic treatment of under 18s with botulinum toxin – Botulinum Toxin and Cosmetic Fillers (Children) Act 2021 – whether there is a lower age limit for the ideal patient for Botox treatment to avoid issues related to resistance or general unsuitability, such as those under 25, for example.

Dr Tim explained that age in a factor to consider when evaluating a patient, but a proper medical decision is made based on the individual in front of you and not an arbitrary, or blanket decision to avoid treating anyone under a certain age (within the legal framework). He made the point that had the legislation been enacted around medical practitioners being the only ones performing the treatment, the law would probably not have been needed due to the nature of medical decision making which requires justification of the intervention, and for it to be in the best interests of the patient, no matter their age, but which would usually rule out children and teenagers.

He also raised awareness that if you treat patients who are older than 65 with botulinum toxin for lines and wrinkles, you are doing so off-label, because all the clinical data used for the medical licensing is based on patients below that age; and patients must be informed.

The typical 21-year-old probably does not need this treatment, but there are some people who have hyperdynamic muscles from a very early age and could benefit from intervention post-18. Dr Tim evaluates each patient on their own merits when considering Botox treatment and establishes if they have lines at rest; he is, however, not a fan of using the treatment in a preventative capacity and will decline patients who seek this option and present with no visible lines. He assured Nurse Charlotte that it is likely that one day she will meet an 18-year-old with deep lines who could benefit from a full dose botulinum toxin treatment; she can then use her medical decision making to determine an appropriate time frame and plan for treatment.

Dr Tim concluded that for reputational risk, aesthetic clinicians may choose to impose their own lower age limits (above those set by the legislation) to avoid conflict and defamation in their local area.

Should you change brands when treating patients to avoid botulinum toxin resistance?

Nurse Charlotte was concerned about the often talked about phenomenon of botulinum toxin resistance. She asked Dr Tim if, despite getting good results for a patient with one brand of toxin, should she consider switching them to another brand after some time to prevent resistance for occurring, or just stick with the same product if it works. Dr Tim advocates the latter and suggested continuing with the brand that is working because switching can complicate matters.

Botulinum toxin resistance is not well understood, he explained. The consensus view is that the incidence is very low, and it does not happen as often as practitioners fear, but it does happen. He pointed out that he has four patients who have tried every licensed brand of botulinum toxin available and none of them work for them, which can be very upsetting for the patient. Of course, you can increase the dose, but there comes a point where you are using so much that it is not economic for either party, or you have no explanation for why they now require a higher dose, higher cost treatment than previously. Leaving a longer gap between treatments or finding alternative treatment options can help such patients.

Dr Tim believes that this kind of resistance is more likely in patients who have more regular follow-up appointments, with top-ups, and those who come back for further treatment as soon as they can; eventually it seems to stop working for them.

Do not forget to download Dr Tim Pearce’s free guide to 26 essential patterns for Botox® for more specific information on product placement when treating with botulinum toxin.

Should you routinely book patient in for a follow-up appointment after Botox treatment?

Dr Tim reassured Nurse Charlotte that in the beginning, as she starts her career in aesthetic medicine, it is a good idea for her to see every patient back for a follow-up appointment after every treatment. The rationale for this is that it will provide a considerable amount of learning for her. Patients will get into the habit of seeing her and she will see what her individual injections have achieved, especially if she takes photographs before treatment with the injection points marked. Overall, this will have the effect of speeding up her learning and is entirely worthwhile.

However, he explained that in the long run, it can be counterproductive as you end up training your patients to come back to your clinic multiple times, and they tend to expect adjustments and top-ups that are unnecessary. When the dosing and injection positioning is well established, patients do not usually need to be seen again after the initial treatment, hence you can move away from routinely booking a follow-up appointment and leave it to them to decide if they need a review. Dr Tim explained that the typical follow-up rate in his clinic is 15%.

Read more on BOTOX® reviews, follow-ups, or top-ups and 6 reasons why patients return for a BOTOX® follow-up.

Are high strength topical anaesthetic creams dangerous?

Nurse Charlotte described how she uses the LMX4 brand of numbing cream or topical anaesthesia on her patients but has noted a rise in the use of high strength lidocaine creams in the aesthetic sector, something she feels is unsafe. She asked Dr Tim for his opinion.

He threw light on the issue of lidocaine toxicity. There are safe levels when it comes to the use of topical numbing creams, but with the high strength products, it is easy for quantities to be used that become harmful, or toxic for a patient. The temptation with using such products is the theory that you can stop all the pain for your patients, and most aesthetic clinicians want to reduce discomfort as much as possible. However, if you use higher concentrations of lidocaine in a stronger product, it will not take much application before you risk undesirable symptoms and the potential for cardiac problems. He advises using 4% strength creams, like LMX4, and allowing enough time for adequate action, whilst you do other things. This should avoid most significant discomfort for patients.

Remember, topical anaesthesia will make a difference to pain at the entry point of the needle, which is where most of the sensation is present in the skin, but will not be of much benefit below that, into the deeper layers. Hence, why many dermal filler products often contain lidocaine within the syringe to help with numbing as you inject below the skin.

Certainly, the use of numbing cream can have a psychosomatic effect on the patient, making them feel better. Dr Tim offered a cheeky tip to help a very anxious patient who is having multiple areas treated, but not their lips. When applying the topical anaesthesia to the face, he will often skim the corner of their lip because they will feel the numbing more acutely in this area and be more confident in the numbing effects of the cream. This can have an immediate calming effect on a nervous patient or someone who is needle phobic.

You can find Dr Tim Pearce on Instagram if you have any ideas for things you would like to see him discuss and you can also follow aesthetic nurse Charlotte on Instagram at Refined Aesthetics.

Botox® is a registered trademark of Allergan Aesthetics plc.

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Aesthetics Mastery Show

Making Clinical & Ethical Decisions as an Injector. What You Need To Know As A New Injector

Tim helps a newly trained injector to explore clinical decisions and ethical questions in aesthetics, including BOTOX age limits and follow-up appointments.

Dr Tim Pearce eLearning

Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.

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