Frequently Asked Questions Regarding Wrinkle Reducing Injections Using Toxin
How does toxin work?
Toxin is a prescription only medication and is a drug called Botulinumtoxin Type A. There are three brands available in Britain that are licensed for cosmetic use. They are all variations of the drug but are all Type A in nature. They are called a neuromodulator drug. The medication is a protein made up of heavy chain and light chain parts. The heavy chain drops the light chain off at the nerve endings in the muscle. The light chain snips a protein in half in the nerve endings called SNAP 25. This stops our movement chemicals passing through the nerve endings as efficiently as they would normally. Some of the movement chemical gets through but not all. The movement is reduced. A reduction in muscle movement improves the appearance of our wrinkles. It is not an anti wrinkle medication, it is a wrinkle reduction medication.
How long does it last?
Each patient is different. There are many variables to consider. Age, medical history, surgical history, medications, lifestyle, sun damage, grade of wrinkles, environmental, occupation, smoking status. Generally speaking, a cycle of toxin is every 12 weeks but the gradual decline starts to begin about week 7. Please see the graph below.
Will it hurt?
There is a slight discomfort but it is a relatively quick procedure. Most patients find it very bearable. The gauge of the needle is very small so shouldn't hurt too much!
Why do you reassess two weeks later?
The medication needs a full two weeks to carry out its mechanism of action. All prescription medications should be reassessed as per prescribing guidelines.
Does it have to be two weeks for reassessment or can it be longer?
The drug manufacturer recommends two weeks for best results. A maximum of four weeks in exceptional circumstances. New nerve sprouting begins from week 4 so it is not recommended to tweak the dose after this time frame as it is not beneficial to the final result.
What happens if I missed my reassessment appointment and it is now week 6?
A reassessment will still be offered to allow to make notes for future treatments but no tweak will be performed of the dose given. The reassessment does not mean you will be automatically offered a top up. Top ups do not exist for medications. Insisting you are entitled to a top up is factually incorrect. You wouldn't ask your doctor for extra tablets other than the recommended course of the treatment being prescribed. Each muscle has a recommended dose and will cover a certain area. This is the dose you pay for. The tweak is complimentary and at the prescribers discretion once they have reassessed you at two weeks. Any tweak given will be to catch any superficial muscle fibres that the medication has not spread to, to ultimately give a better finish. The muscles are not all topped up. This is a misconception.
Will I be frozen?
This clinic does not promote or encourage the frozen look. Its an extremely difficult expectation to achieve for various reasons. You might appear frozen the first few times you receive the treatment but its not guaranteed long term. Everyone's reaction is very different. Our muscles are part of our waste disposal system so some movement is actually healthy and more natural looking!
Why am I not frozen when I was previously?
There are various reasons for this:
See the graph below on expectations.
Why can I still move my eyebrows?
Your forehead muscle is an elevator muscle. When we use it, it raises up. If we add too much toxin to the outer parts of this muscle above the brow, it will lose its lifting capacity and the brows will drop. This is not a good look and causes stress to the patient and the injector. If we add too much toxin to a muscle that is already dropping due to aging, we will cause a droop!!
Why did my friends work better than mine?
There are too many variables to consider as mentioned earlier. You cannot compare yourself to others. Everyone's strength of reaction to medications is different. Never compare yourself to someone much younger than yourself either. Your grade of wrinkles and skin quality is different to theirs. Grade 4 wrinkles can't disappear after one treatment but grade 1 wrinkles might! See the wrinkle grading score below.
How often should I get the treatment?
No sooner than 12 weekly as per prescribing guidelines and to avoid making even more antibodies!
Are there other treatments that could be used in adjunct to better the results?
Consider treatments that improve overall skin quality.
The law and toxin treatment
Healthcare Improvement Scotland (HIS).
Regulation is a topic that has took over my life since I became a nurse but more so when I started in cosmetics 6 years ago. It is a controversial topic and causes many issues in Britain. I have put together a list of information to help patients and practitioners understand it a bit more as it is very difficult as a patient in this country to know what's safe and legal and what's not.
HIS are the regulators of independent medical clinics and private hospitals in Scotland. Their job is to implement laws and standards of practice to independent clinics,
assess their fitness to practice and premises, issue them with a certificate stating they are fit to practice, inspect their property on a regular basis, and investigate any clinics that have been highlighted as unfit to practice.
Anyone in Scotland can own an independent clinic, you don't need to be a health professional. The owner will have health professionals offering services from their registered premises.
This is no different to an entrepreneur owning a range of nursing homes but hiring medical staff and clinical leaders to make sure it is running efficiently, safely and
according to Scottish laws.
Therefore, rather than a person being regulated, it is actually the service which includes the premises. If someone has a chain of clinics, every single one must be registered separately and fees paid for each individual premises. It is not enough for the owner to hold one certificate for one premises and run a chain of clinics, each individual one is treated as a service in its own right.
Advice for patients and professionals wishing to register their premises
If you are looking for a regulated cosmetic clinic to receive your treatments from, please go to the Healthcare Improvement Scotland webiste and use their search bar to search for the premises you wish to go to, not the persons name, but the premises address.
If this address has been passed, it will have a listing on the HIS website and should say 'REGISTERED'. This means it is safe to use.
A premises that is registered can allow health professionals to work from the premises under a contract called practice privileges. This is why it is best to search for the location rather than a person as there can be many health professionals working from a regulated clinic.
If a health professional is working as a mobile practitioner, they must hold a licence to practice with HIS and their home address will usually be the registered service address. This means they have submitted risk assessments and standards of practice that allow them to work as mobile but they absolutely need to be regulated by HIS in order to do this legally.
If a beautician or other non health professional is working safely and ethically alongside a prescriber to offer cosmetic treatments, the salon or clinic they are working from will be registered with HIS and so you should search for this address on the website to make sue it has been regulated. Please note any beauticians working alongside a prescriber and they are not registered with HIS, the prescriber is breaking the law. Any beautician/prescriber who truly respects law, code of conduct, regulatory bodies and patient safety will be registered with HIS. Any prescriber offering cosmetic treatments and not registered with HIS or working in an HIS clinic are breaking the law.
Therefore, there are only three scenarios that are safe for patients in Scotland regarding obtaining cosmetic treatments. For each scenario you must always meet the prescriber face to face before any treatments are carried out. It is illegal to remote prescribe by any health professional. Every single health professionals prescribing guidelines state they should not remote prescribe for any patients at all for cosmetic purposes. If you are not offered a consultation with the prescriber, then laws are being broken. The medication used to dissolve lip fillers is prescription only medication and carries a slightly higher allergen risk than other meds used in cosmetics and you must always meet the prescriber to make sure you are safe to have them dissolved.
The three safe and legal scenarios are:
1. They visit a health professional regulated by HIS in their licensed premises that is listed on the HIS website or use a mobile practitioner with a mobile HIS licence.
2. They visit an HIS regulated clinic and are seen by a health professional using a practice privilege contract issued to them by the lead clinician in the regulated premises.
3.They visit a beautician or other non health professional that has been fully trained in cosmetics including anaphylaxis, CPR, emergency first aid, and patch testing. The premises has an HIS licence with a health professional attached to it who oversees the non health professional in the building.
For scenario 3, I must stress all other countries, including Southern Ireland, have made this scenario illegal, it is only Britain who have yet to change their law. This process has been started but is running behind due to Covid-19. I strongly recommend that anyone who truly cares about their work and safety spend time gaining a medical degree before the law changes, its not a case of 'if' the law changes, it is 'when'. Also there are no health professionals legally allowed to prescribe for non health professionals for cosmetic use anymore, all prescribers guidelines state this so technically even though HIS will regulate the premises and prescriber, the prescriber is still breaking their code by prescribing to a non health professional. Again, please bear this in mind and do your training before the law catches up!! Training providers will teach you based on all the grey areas but please believe me when I say its not completely legal, help yourself by looking up each type of health professionals prescribing guidelines and you will see that not one type (nurse, doctor, pharmacist, paramedic etc) is permitted to prescribe to non health professionals. They do it at their own risk of losing their career as they are going against their code. If you are not in a position to study for a medical degree then create a business model that is legal where you have your own registered clinic with medical professionals and a prescriber but you are the owner. It does not mean your career is over when the law eventually stops non health professionals from injecting. This is not a personal attack on non health professionals, a quick fact check will assure you I am telling the truth and most insurance companies have a very strict stance on this now.
You then have other scenarios which are dangerous and should be reported as soon as you see them including:
1. health professionals remote prescribing (report to HIS)
2. health professionals doing pop up clinics in non HIS registered salons or home visits without having a mobile licence (report to HIS)
3. non health professionals with no prescriber and no HIS licence buying black market stock from non EU countries. These products are not licensed, not insured, not safe and not legal. (report to environmental health)
Dermal Fillers Migration
Migration of fillers means the product has managed to move to a place away from where it was injected.
This is a lot more common in aesthetics than the public might be aware of.
There are various reasons why migration might happen.
1. The injector
2. The patient
3. The product being used
4. The technique used
5. Facial Activity
1. The injector
Lets start by saying no one is perfect!! Has the injector had sufficient training to do the treatment? We see posts all the time of a person completing a one day course then looking for people to practice on. Would you trust someone who did a one day course in hairdressing or the full two year course?
This matters for health professionals too. How do we expect this industry to become safer, if we can't get our own house in order?
This is not a debate of medic v non medic. There are pro's and cons to everything. That's a discussion for another day :-)
I try my best every day to be a good health professional. I under sell every single day. I order products for patients then they appear on the day of treatment and I don't feel they should go through with it so we cancel their treatment. This costs me time and money but I have literally done it hundreds of times since the beginning of my time in aesthetics and I will continue to work this way for the rest of my career. Its not always about money. Sure we all need a wage at the end of the day that cant be debated but at what cost??
2. The patient
The patients medical and surgical history must be looked at in depth before any treatment is given. A thorough face to face assessment must be carried out too to check for any
concerns that may result in a poor result. E.G, scarring or surgical deformities etc. The patients general well being should be checked on the day of treatment too. Patients who are feeling unwell are more at risk of complications and should be rescheduled. Patients can have an immune response to the fillers so should always be feeling well before undergoing any treatments. There is evidence via ultra sound of product migration purely because the patient had significant volume loss and the product could bleed into another area due to gravity and space to move.
3. The Product
Products is a big topic. There are so many products available. Some are legal and some are not. Some have strong clinical data to back them up. Some are very cheap and never passed a trial. The product is picked based on various things. Age of the patient, area being treated, grade of volume loss, grade of skin quality etc etc. The products have different aspects to them including rheology, G prime, viscosity, dose per ml etc. Effectively how thick or thin, elastic or fluid the product is and how it integrates into the tissue.
4. The Technique
Techniques constantly change over the years based on new trends, new data available, reporting of adverse events, cultural trends etc. Two years ago I attended a conference with some of the most knowledgeable health professionals working in our four nations. They had 20 years experience and had seen it all. Two of these professionals started their lectures by showing us problems they'd encountered over the years. Poor techniques they had used, poor products, complications that had arisen etc. They were open and honest and human. They are, however, health professionals. They must by law continue to train and learn and always be offering the most up to date evidence based research. They must revalidate regularly to prove they are doing this. We see this in medicine all the time. Treatments your GP would have given you 20 years ago they might not do now as they've learned a lot along the way and better treatments are available. As long as the patients safety is always a priority and they are honest that's all that can be asked.
I trained 6 years ago with a very reputable training provider. The technique I was first taught for lips I would NEVER use now but six years ago that's where the evidence led. I've attended over 40 training sessions since then. Completed thousands of hours of learning, and i'm currently half way through my first year of my masters degree in aesthetic medicine. I will always put the patient first. My friend attended the same training school two years later and was taught a completely different lip technique that caused lumpy lips and is not used now either. Lessons are learned, medicine evolves. Complications are managed in the clinic with a wider network of health professionals always available as we are a member of a safety group. High pressure, high volume techniques tend to cause migration. It doesn't need to be something the injector has done wrong. They could have assumed a certain amount of product should have been used but once the area has healed, it appears to be too much. Less is definitely more especially with products that attract water to the area.
5. Facial Activity
And finally, lets not forget that the face is an extremely muscular, hyper active part of the body, Especially around the mouth and eyes. The muscles of the mouth and eyes work constantly, all day, every day. Months later this constant movement can result in displacement of the filler. Its no ones fault. Patients are encouraged to always keep in touch even if its months later.
This is why sticking with one injector can be important, if you get a complication months later, who's responsibility is it to help you?
Welcome to our new monthly blog!
We will use this platform to discuss anything relevant and as an education platform.
Our first topic is the relevance of Covid Vaccines in relation to aesthetic treatments. This topic needs to be addressed prior to us hopefully re-opening on the 26th of April 2021 (fingers crossed!)
Dermal fillers carry a risk of an immune response (thats a topic for another day). We screen patients on arrival to ensure they are feeling fit and well before a dermal fillers procedure. If the patient is 'under the weather', they may not react to the dermal filler treatment as we would want them to due to their immune system being on high alert(again i'll bore you all with this in more depth another day).
The covid vaccine is not a live vaccine, therefore it CANNOT make you unwell with Covid. It does, however, induce an immune response from the patient that can cause them to feel poorly for a couple of days after their vaccine. How many times do we hear parents say 'they are under the weather cos they just got their jags this week'. Its no different for the covid vaccine. We have asked the immune system to do a job and this in turn makes us feel 'under the weather' for a couple of days.
The latest advice, therefore, from the British Association of Cosmetic Nurses (BACN), is to delay dermal filler treatments two weeks before and two weeks after a covid vaccine. There is no evidence to suggest they are contra indicated with each other. However, if the immune system already has some work to do, there is a greater risk to the patient by adding in a dermal filler procedure to an immune system that's already working hard.
Additionally, the latest advice is to not treat any patients with aesthetic products who have tested postive for covid in the last 28 days. Whilst I appreciate the isolation period is only 10-14 days, it takes longer than that for the immune system to build itself back up again
I hope this makes sense and feel free to email us for more information if required