Medical Aesthetics: The Rise of Injectables

Written by Erin Lucie, D.N.P., FNP-C

Injectables are a fast-growing sector of the aesthetics industry. Whether interested in adding these services to the spa or simply seeking a better understanding in order to aid clients who are considering services and are seeking advice, here are some essential facts about injectables to help professionals with the basics.

The most common cosmetic injectables are neurotoxins. Neurotoxins create a paralysis of the muscles under the skin to stop the dynamic movement that creates facial expression lines (smile and frown lines). These injections only take a few minutes and activate in about three to10 days. They give the skin a break from the constant movement allowing it time to naturally heal the lines. The healthier the skin is, the better the results will be. Combining this treatment with topical peptides, growth factors, vitamin C, and retinol increases the skin’s collagen production to repair those wrinkles. Neurotoxins need to be readministered every three to four months, which can give a spa a boost in the frequency a client is in office. The return on investment for neurotoxins and injectables in general depends on how much is charged. Some practices charge an injection fee and, then, add the cost of the products used to the bill and some double the price of their cost similar to typical retail product sales.
Injectable dermal fillers are also a popular treatment to instantly improve the visible shadowing and flatness created by a loss of volume in the face. Aging, illness, and weight-loss can be contributing factors to volume loss. When the structure and foundation of collagen breaks down and the fat pads under the eyes and cheeks start to deflate and shift downward, this creates a triangle-shaped heaviness. A more youthful look has an upside down triangle shape, with the focus on the eyes and the width or volume throughout the mid-face. To put this triangle back in its place, injectable dermal fillers are the fastest tools to accomplish this. What they cannot fix is skin elasticity. Treatments like chemical peels, microneedling, radio frequency, and other lasers that tighten and tone the skin achieve a more natural appearance. Think of the face like a table and a tablecloth. The ideal look is to keep the tablecloth tight, not hanging, and the table size or volume appropriate. If one or the other is too big or too small it will be out of balance and will not look right.

Types
Just as a professional would select a makeup brush for a specific application technique, there are many different types of fillers to choose from to achieve the look clients want. Each product has its niche. Some of the most widely used fillers are made from a hyaluronic acid gel. Hyaluronic acid is often used topically for its humectant properties, as it can hold 1,000 times its own weight in water, but when hyaluronic acid gel is injected deep beneath the skin, it is like injecting thousands of tiny beads to correct the wrinkles and folds within minutes. With some hyaluronic acid fillers, the injector will fill to 80 percent wrinkle correction and the other 20 percent will appear in a few days after the hyaluronic particles have attracted the water molecules to complete the final look. There are different sizes or weights to the hyaluronic particles. Standard fillers are made with a single high weight but newer technology blends low weight in with the high weight to give a more smooth, natural look and feel. Hyaluronic acid fillers can be firm and give significant volume or soft with sublet volume and can last anywhere from three to 24 months depending on their formulation. One of the safety benefits of hyaluronic acid injectables is that hyaluronic acid is a naturally occurring substance that can be dissolved if needed.
Fillers that cannot be dissolved are considered semi-permanent. An example is the ingredient polymethyl-methacrylate (PMMA). PMMA microspheres are typically injected in a series over a three-month period that builds on top of one another to avoid overfilling, since a reversal procedure cannot be performed. Both the hyaluronic acid and PMMA give volume and hydration to reduce wrinkles but do not technically repair any damage that has been done. But, there are some injectables that repair or stimulate the collagen.
An example is calcium hydroxylapatite. It is naturally found in human bones and is a mineral-like compound. This deeply injected filler not only provides immediate volume, but, also, minimally stimulates the growth of new collagen. Even with this additional benefit, hydroxylapatite is considered a long-term, but temporary, filler.
For maximal stimulation of collagen tissue, polylactic acid can be injected deep, right on the cheek bone. It does not provide immediate results, but as a stimulator of the client’s own natural collagen, results appear gradually over a period of a few months. This ingredient has been used in surgery as biodegradable suture for over 40 years, so it has a proven safety profile.
There are always newer injectables on the market. Fortunately – and unfortunately – due to regulations, the United States is several years behind Europe in aesthetic injectables. By the time a new filler reaches the United States, there is usually no need to be afraid of its minimal safety track record, as the product has most likely been successful in Europe for the past 10 years or more. Some of the most recent launches in the United States have been for hyaluronic acid fillers, but the differences comes down to the technology used to connect the molecules together. Imagine the beads of hyaluronic acid in a lattice type of frame work. Trending terms like thixofix cross-linking technology or vycross technology are used to describe how this framework is made. One filler boasts that their hyaluronic acid particles are rounder, tend to stay close together, and are consistent in size, leading to a more durable and easily molded product. One of the theoretical benefits of having a more rounded molecule is that it would create less trauma to the tissue, therefore less swelling and downtime. Think of it like a fruit seed-based scrub creating microtears in the skin verses a synthetically produced dissolvable microsphere for exfoliation. This concept is especially important when injecting sensitive areas like the lips that can have significant swelling post-injection.

Side Effects
Other side effects of fillers can be bruising and allergic reactions. It is important for the injecting provider and the clients to know the signs and symptoms of different reactions. Expected side effects are swelling and minimal bruising due to the simple fact that when a sharp needle creates trauma to the skin, an inflammatory response will ensue. Allergic reactions can happen, but for the most part are very minimal. Remember an allergic reaction is when the body is having a histamine response with symptoms of itching, swelling, or rash. An infection is when bacteria has entered the injection site and there is redness, swelling, warmth, and, sometimes, hardening of the area, known as induration. With an infection, itching is usually not a symptom, but could be. Bruising is a fact life with needles, but specific techniques used by the injector – such as having a gentle hand, minimal pressure, a visual avoidance of veins, and using a blunt needle or cannula that would push the veins out of the way instead of piercing them – all help to minimize bruising. Even though many of these ingredients can be found in nature or in the body already, it does not mean they are naturally sourced from plants or animals for the injectables. They are biosynthetically produced, which means they are made in a sterile laboratory to match exactly what the body produces. For example, if one were to look under one microscope at natural calcium hydroxylapatite found in a human bone and under another microscope at calcium hydroxylapatite made in a laboratory, they would be identical. This decreases the risks of rejection and allergic reactions because the body does not see the injected molecules as foreign substances.
Negative side effects related to injection technique occur from selecting the wrong product for the area to be injected. For instance, using a firm product in the lips, or a very soft, fine product to create volume in the cheeks, would not produce a natural or ideal result. Another injection technique faux pas is when filler is injected too superficially into the skin’s surface where it can still be seen. When this happens, it is called a Tyndall effect. Named after the 19th-century physicist John Tyndall, the effect is that when light catches a specific wavelength of white, for example across milk or the stone opal, it can display a blushish hue in the light. While beautiful in jewelry, it is a very unnatural look on the human face.
Now, the worst case scenario for a filler is when it is injected directly into the blood supply of an artery or vein. When this happens, it can lead to tissue necrosis of the skin or, if injected into the blood supply to the eye, can create blindness. It is recommended to keep at least 10 vials of the enzyme hyaluronidase on hand to degrade or dissolve the hyaluronic acid filler if a loss of vision or blanching of the skin occurs at the time of treatment. The injector would be able to immediately flush and flood the area with hyaluronidase repeatedly until all traces of product have been removed allowing blood supply to return, resulting in minimal and, hopefully, no long-term damage. Having hyaluronidase readily on hand is imperative for anyone injecting hyaluronic acid fillers. One of the most common negative side effects for neurotoxins is a temporary eyelid droop or ptosis.

Training
Knowing the facial anatomy is one of the most beneficial means of avoiding an adverse event with injectables. This is where the professional licenses, certification, and ongoing special training for facial anatomy and injection technique is imperative when selecting an injector. Cosmetic injectables are not a standard topic in medical and nursing school curriculums, therefore, the individual will need to invest a significant amount of their own time and money into training and certification. Professional courses can range from $1,000 to $5,000 a day. When selecting a certification course, look for a smaller class size with several hands-on opportunities. Learning online or in a didactic lecture setting is not enough to give professionals the skills needed to perform the treatments; hands-on training is imperative. Some state laws allow non-physicians to administer injectables, as long as they are working under a licensed doctor’s supervision. This would include aestheticians or even unlicensed individuals. But, most states are changing or adapting their laws to ensure only those with higher degrees of anatomy education – such as registered nurses (RN), physician assistants (PA), advanced practice registered nurses (APRN) (also known as nurse practitioners (NP), and physicians – are the only ones capable of performing the injections. That said, just because a medical license allows a provider to use a needle to penetrate the skin does not mean they will be good at facial aesthetics. There is still a certain finesse and technique the injector needs to possess, along with the artistic skills to create a beautiful, eye-pleasing symmetry and balance to the face. While considered experts in the skin, there are many dermatologists that have not had training in fillers and do not offer it as a service to their patients. They may not have an interest in expanding into aesthetic dermatology and will hire a trained RN, NP, or PA to perform these services for them. This is absolutely legal and appropriate to meet the needs of the client.

Insurance
Insurance is necessary to help businesses and professionals be prepared for the worst. There are many types of insurances to carry when doing injectables including malpractice, business owner insurance, and business interruption insurance. Malpractice insurance, sometimes called professional liability insurance, protects physicians and other licensed health care professionals from liability associated with wrongful practices resulting in bodily injury, medical expenses, and property damage. Depending on the license, malpractice insurance can cost $2,000 to $10,000 a year. Business insurance protects the business from injuries caused in the office, like slip and fall injuries. Renters insurance could be added to this policy if renting an office and need to cover damage to the building itself. Interruption insurance covers instances when products are destroyed in a disaster or when the power goes out and all the cold injectables are ruined and insurance is needed to replace lost items, as well as the money lost by not seeing clients. If a professional does injectables while working for an employer, request a copy of their insurance policy to ensure it covers employees or even get personal coverage as backup. These types of insurances are around $300 to $1000 a year.

Non-surgical cosmetic injectables are some of the fastest growing services in aesthetics. These services are a fun and sought-after trade because of the immediate results and happy clients. But, it can be hard to get a foot in the door due to the financial strain of certifications and the experience needed. Consider all of the above when making the decision to add injectables to a practice and when referring clients out.

Erin Lucie 2019Erin Lucie, D.N.P., FNP-C is a Stillwater, Oklahoma native, where she obtained a bachelor of arts from Oklahoma State University and an aesthetics license. She also obtained a bachelor of science in nursing from The University of Oklahoma Health Sciences Center in Tulsa. Her doctoral residency was obtained at The University of South Alabama, where she focused on the prevention and treatment of obesity, diabetes, and metabolic syndrome and used bio-identical hormone replacement therapy in the prevention of heart disease. Prior to her career in family practice, Lucie had 14 years of experience in the aesthetic industry.

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