Aesthetics asks practitioners for their views on the results of two recent reports that indicate a high number of lip filler complications
Last month, not one, but two reports were released on complications and patient complaints across the specialty. The first was from independent accreditation body Save Face1 and the second from the Aesthetic Complications Expert (ACE) Group.2 Interestingly, lip fillers trumped any other complication or complaint across both reports. The Save Face report was an annual summary of patient complaints and concerns regarding 934 practitioners who were unregistered with the body and five who were registered with Save Face. It was indicated that out of all concerns, there were 616 complaints regarding dermal fillers, 72% of which were in relation to lip treatments. The most common treatment outcome relating to the lip complaints, with 163, was swelling and bruising. Whilst 144 people had lumps and nodules, 56 felt they looked worse, 52 thought they had an uneven result, 24 had an infection and four reported vascular occlusion or impending necrosis.1
The ACE Group runs a Facebook forum where many of those registered with the group (of which you must be a medical professional) turn to for guidance, particularly in relation to complications. Nurse prescriber and co-founder of the group Sharon King audited its then 1,700 forum members across an 18-month period. She reported 389 filler-related complications, with 207 (53%) relating solely to the lips. It stated that 22 of those were obvious vascular occlusions, 43 practitioners reported bruising and the rest included complications such as herpes, asymmetry and delayed onset nodules.2 It was also noted that 76 of those who posted in the forum displayed signs that they couldn’t distinguish between a vascular occlusion and bruising.
So, what do practitioners think of these statistics and why are we seeing such high numbers in relation to lip procedure complications?
Consultant plastic and reconstructive surgeon Mr Adrian Richards, who is also the clinical director of training provider Cosmetic Courses, says he is not surprised by these figures. “These figures are not a shock to me. The combination of the popularity of the treatment, the advanced anatomy in this area and the lack of regulation in the specialty comes as no surprise to me that there are problems,” he explains. Both King and aesthetic practitioner and founder of the International Association for Prevention of Complications in Aesthetic Medicine (IAPCAM), Dr Beatriz Molina were also not alarmed by the figures, for reasons much like the above, but emphasise that the figures are far too high. They are also very concerned with the number of practitioners unable to confidently differentiate between the type of complication and adverse event. Changes in supply and demand King believes that a lot of the complications are due to the ‘supply and demand’ for the popular procedure. She explains, “Lips are an advanced treatment area of the face and a lot can go very wrong, very quickly. People are asking for these procedures all of the time but the quality of injections shouldn’t be compromised just because of the demand.” Dr Molina states that she too is concerned that due to the popularity of the treatment, lips are being taken less seriously. She notes, “A few years ago, lip treatments would be more commonly performed for corrective measures – we would create a more defined upper lip for an ageing patient who had lost volume or fill in any wrinkles. Now, there is so much focus on enhancement and volume that we see practitioners pump in more and more product when, in actual fact, many of the patients’ faces can’t tolerate that.”
Both King and Dr Molina recognise that a complication can happen at any stage in an aesthetic career, however, believe that those who have had more experience tend to be able to recognise the signs quicker and can intervene to prevent it. Dr Molina says, “Of course a complication can arise with 15 years’ experience behind you, but the difference that I find is, you can anticipate it much quicker and sometimes prevent it from happening. An inexperienced practitioner may not notice the complication occurring straight away.”
King notes that there was a significant correlation between new injectors and complications from the ACE Group data, and although she recognises that new injectors are more likely to use the forum than their more experienced colleagues, she was concerned with how ‘new’ the practitioners really were. “The majority of the complications reported from the ACE Group forum were from practitioners who are new to the industry, particularly those with less than 12 months’ experience. Don’t get me wrong, we all had to start somewhere, but what I am finding now is that the pathways into aesthetics are very different. When I first started out, the majority of those going into aesthetics would have had several years’ experience. Nowadays, many people are working in aesthetics part time and although they may be experienced in their field they may not be in aesthetics,” she explains.
All of the practitioners interviewed also believe the lack of regulation surrounding products, premises and practitioners are affecting lip complication rates. It was stated in the Save Face report that 83% of the treatments reported were carried out by beauticians, hairdressers and lay people (someone who is not qualified in a given profession).1
Mr Adrian Richards says, “One of the ongoing concerns in this specialty is that it isn’t regulated. Although the ACE Group stats are in relation to medical professionals, we also see a lot of non-medics giving fillers. In the UK, dermal fillers are classed as a medical device, not a prescription only medicine.3 This can enable those who are not medically trained or have little experience to have access to it. This is absolutely reflected in the high number of complaints in the Save Face report.”
When it comes to lip procedures, one may ask, ‘Is there a lack of training in the area?’ All three interviewees agree that lip augmentation training should not be offered to beginners and novice injectors. Both Mr Richards and King, who is also a trainer, agree that practitioners should have had previous injecting experience, in a lower risk area, undertaken basic training and consolidated their learning by treating patients before moving on to areas of greater risk areas, like the lips. King says, “If I train someone on a beginner’s level, I will not be teaching them anything about the lips at all – they need to have a considerable amount of injection experience, obviously it’s dependent on the individual but I’d say around 30-40 procedures. The lips warrant a course in its own right and I won’t teach any other indications during that period.”
Mr Richards also believes that the trainers have a responsibility to prevent beginners from going out and injecting when they are clearly not ready. He adds, “All trainees should be assessed as part of their course, someone shouldn’t start injecting just because they have attended. If an assessor doesn’t feel like the practitioner would be safe to inject alone they should advise more training.”
He adds that although other forms of training, such as a Master’s degree, for example, may be very beneficial, its essential to get hands-on experience. “The theory is great and they may learn lots about the anatomy, but it is absolutely vital that practitioners have hands-on experience during training; it’s a practical specialty after all. In the Cosmetic Courses Level 7 course, delegates need to observe 10 dermal filler and 10 toxin treatments and perform the same amount supervised by a trainer. We tend to judge each delegate individually and then tailor their training plan to their specific needs. I believe factors such as these will directly reduce lip complication rates,” he says.
All the practitioners interviewed were not surprised by the rate of lip complications in the specialty at present. The fact that the procedure is highly popular and is also in a potential danger zone ‘make it prone to problems’, according to Mr Richards. Dr Molina notes that it is a step in the right direction that statistics are being published to highlight the issues so that patients and practitioners alike are aware of the dangers of the treatment. She says, “Reporting a complication is nothing to be ashamed of, no one is pointing the finger, it actually shows that you are taking your job incredibly seriously.”
King concludes, “The popularity of lip treatments speaks for itself, but with that being said, so do the complications. It appears to me that those who are seeing the most amount of complications with lip augmentations are those who are new to the specialty. We should tighten up on the training of this particular area to potentially prevent the figures getting any higher than they already are.”
1. Save Face, Consumer Complaints Audit Report 2017-2018 <https://www.saveface.co.uk/wp-content/uploads/2018/11/Save-Face-Consumer-Complaints-Report-2017-18-FINAL-1118.pdf>
2. Data on file obtained from ACE Group
3. Kilgariff S, Aesthetics journal, ‘Should dermal filler be a POM?’, September 2017 <https://aestheticsjournal.com/feature/should-dermal-filler-be-a-pom>