The Last Word: Marking Up

By Dr Arti Singh / 26 Jul 2022

Dr Arti Singh debates the pros and cons of marking up injection points before injectable treatment

Since I embarked on my aesthetics journey, I have always followed a strict process in the lead up to injecting a patient. This process includes understanding my patients’ wishes, taking a full medical, aesthetic, and social history, taking photos, discussing treatment options, including the risks, benefits, and complications, compiling a treatment plan, and gaining informed consent. 

For each procedure, I cleanse and disinfect the skin and there is one more important step – marking up. Although this is something that I learnt in my initial training, I have continued this throughout my career. However, I have noticed that not all practitioners implement it as part of their procedure. 

This article will go through what I believe to be the pros and cons of marking up, so that you can consider the best approach for both you and your patients. 

The pros 

When carrying out treatment, you need to respect your patients’ individual anatomy to ensure each face is treated with a bespoke approach. Marking up, typically using a white pencil with the patient sat upright, benefits safety by highlighting patients’ anatomical topography, asymmetries, safe and no-go zones. For example, when marking up for neurotoxin injections, it is important to know the function, position, origin, insertion, innervation and blood supply of the facial muscles, and therefore where to place the injection. The markings can therefore act as an aide mémoire for precisely planned injections. The markings can be varied, using different colours to denote depth of injection, for example. This strategic planning prior to injecting can help prevent an undesirable result for your patient, such as a brow drop/eyelid ptosis, and ensures the treatment is tailor made. 

In my experience, I’ve also found that marking up can make my patients feel more comfortable. If I am treating someone who is particularly anxious, or hasn’t had treatment before, it can be reassuring that the first time I am touching their face after disinfection isn’t to place an injection, but to mark them up. This seems to calm patients as they can see I am taking the time to consider them individually and prescriptively plan their treatment. Often, I will show them areas of asymmetry in the mirror and highlight this by marking it on their face. My patients appreciate that I do not use a ‘cookie cutter’ approach, and this is a great way for them to see it in action. So, while it is beneficial for you as a practitioner in planning treatment, it can also help in reducing your patient’s anxiety. 

I often take photos of the areas that I have marked up too. These photos can be used as a comparison tool following treatment. It allows me to review injection points, consider if amendments are necessary for future treatments and therefore create better aesthetic outcomes for my patients long-term. It focuses me to be more precise. 

When I first started out, I considered marking up a way to show my working out methodology. When asking for advice from my mentors, being able to show my plan on a marked-up photo allowed me to communicate my understanding of the principles I had been taught, and for them to advise if I needed to amend my planned injection points. For clinicians early in their career, the benefit of marking up the patient allows for clear communication between mentee and mentor. 

Causes of concern 

Clinicians may be concerned about increasing the risk of infection through marking up. By introducing the pencil onto the skin prior to injection, there is a risk of contamination of bacterial/fungal/viral origin. Indeed, the Aseptic Non-Touch Technique states that the disinfected area should not be touched again, except with the needle (or cannula).1 The process of marking up may also be deemed slightly more time-consuming, so experienced clinicians may see it as a step they can miss out. 

The solution 

I believe marking up is integral to injecting methodically, precisely and safely, as well as allowing me to review and refine my treatment outcomes. To avoid any risk of infection, clinicians should always ensure that they follow an aseptic technique by cleansing and disinfecting the skin prior to marking up. Always sharpen the pencil using a clean sharpener between use. You can clean the pencil by spraying it with disinfectant too or use a fresh pencil. Practitioners should avoid injecting directly into the white marks, to prevent tattooing the skin and therefore inject into the aseptic area. Following treatment, disinfect the skin and remove the white marks. Or as an alternative method, prior to injecting, remove the markings by disinfecting the points as you move from one injection point to the next, allowing you to visualise where the marking was and inject into the aseptic area. 

Ultimately, marking up is practitioner preference, however, I personally find it to be extremely useful to enhance precision in injecting. I acknowledge that marking up is only one of a multitude of factors in the process of perfecting treatment outcomes for patients. I believe if you adhere to excellent infection control measures, you can mark up the patient without causing an adverse outcome. And finally, if you are new to injecting, it is a great way to plan your treatments and perfect your precision in injecting. 

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