Botox? Bollocks!

I had a little chuckle when I saw the Cosmetic Physicians getting upset at what they perceive to be the underhanded tactics of some Cosmetic Nurses.

For the benefit of those who have been living under a rock, there is a movement called Cosmetic Medicine. It is championed by the Cosmetic Physicians Society of Australasia the Australasian Society of Cosmetic Medicine and the so-called Australasian College of Cosmetic Surgery.

In a sense, many doctors practice cosmetic medicine in some way. Some skin lesions aren't likely to be cancers but are removed anyway at the patient's insistence. Some varicose veins are more a nuisance than a risk to life or limb and still get removed. Some footballers have surgery to speed their recovery and short term function when they would have healed on their own anyway. The line between what is truly deserving medicine and what is discretionary (or "cosmetic") is a very fuzzy one.

Nevertheless, cosmetic medicine is a booming industry. They like calling it Cosmetic "Medicine" because it is much more acceptable to pop a pill or have an injection than to have "Surgery" these days.

I have occasionally been caught at the dinner table between a plastic surgeon and a "cosmetic surgeon" having a good go at each other. The plastic surgeon (who, like me, undertakes a minimum of 5 or more years of basic surgical principles and practice after at least 2-3 years of general medical experience, followed by specialist surgical training in plastic surgical and reconstructive surgical techniques, and often further subspecialty fellowships locally or overseas) argues that cosmetic surgeons are not trained in the basics of surgery and surgical techniques, the care of the complex patient, the management of severe complications after surgery, and the wide range of techniques required in modern surgery.

The cosmetic surgeon (who could be from a wide range of backgrounds such as a doctor who has not undertaken any form of specialist training and just decides to set up shop, or a specialist in another field like a dermatologist or a GP who decides to extend their practice into cosmetic fields, or any of these people who choose to undertake a 1-3 year informal apprenticeship with another "cosmetic surgeon") argues that you don't need to learn how to do a microvascular anastomosis in order to inject collagen, do tummy tucks, perform liposuction, or do a boob job. Instead, they say that you need an "eye for aesthetics" which they say plastic surgeons lack, and you need experience in a dedicated cosmetic clinic where finer and more subtle work is done rather than a public hospital where plastic and reconstructive surgeons deal with major deformities and mangled patients.

Obviously I am a little biased, but cosmetic physicians are really in a much bigger mess because firstly they have failed to set common standards for themselves. This is inevitably because they come from very disparate backgrounds, and therefore any attempt to standardise a training program akin to surgical training runs the risk of rendering a whole generation of self-taught cosmetic physicians unable to meet their own standards, without very prolonged and generous "grandfathering" provisions.

Secondly, cosmetic physicians perform a wide variety of procedures, from Botox injections, Collagen or dermal filler injections, liposuction, abdominoplasties, breast enhancements, facelifts, dermabrasion, laser skin therapy, varicose veins surgery, and all sorts of procedures related only in the fact that their goal is to make you look better. There is no common set of skills. There is no fundamental "principle". There is, in short, nothing to base a training program upon other than learning a few tips and tricks here from as many other disciplines as possible. It's like taking a random factory production-line worker off the Boeing production line and saying "Why don't you ask everyone else in the factory a few questions, then we'll give you a building and you can build the new 787 Dreamliner for us?" From all the trouble that Boeing is having, perhaps that is really what is happening!

Thirdly, once you leave the moral high ground and start sniping at your own colleagues and lowering the standards of training necessary to perform these procedures, there is really no limit as to how low it can go. Cosmetic physicians standing up and saying that you don't need to be a surgeon to do cosmetic procedures is only step one. Step two (as described below) is cosmetic doctors supervising procedures done by cosmetic nurses in order to make more money. Step three (also described below) is for Cosmetic nurses standing up and saying that you don't need to be a doctor to do these procedures. Step four is beauticians standing up and saying that you don't need to be a nurse to do these procedures. Step five is some bloke in Mexico who does breast implants with a second hand diathermy machine and a spoon in his garage.

Just like Melissa Blandfort who is a travelling cosmetic nurse performing invasive procedures in patients for cosmetic purposes in various beauty salons, and without the review or approval of a doctor. Her website does not mention Botox by name, but clearly says that she performs:

Injectable wrinkle treatments
Injectable wrinkle treatments have now been in use as a cosmetic treatment for over 20 years. They relax a wrinkle causing muscles, to help improve the appearance of the wrinkle. It is extremely effective in treating crows feet, frown lines and other wrinkles caused by a muscle contraction. It is generally most effective in people aged form 25 to 55 years of age. It takes up to ten (10) days to have full effect and can last up to four (4) months.

Now, last I checked Botox and similar paralytic or neuromuscular blockade agents were prescription-only in Australia, so unless she takes a doctor around with her to write out scripts for these patients, I can't see how she can be legally injecting anybody with Botox. Her website says nothing about her being accompanied by a doctor, and I would hate to be the 20th patient receiving Botox out of her multi-dose vial that mysteriously appeared out of nowhere.


Links:

• Botox trend creating worry lines - Brisbane Times
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  Botox trend creating worry lines
  Jill Stark
  August 23, 2009
  
  DOCTORS groups claim nurses are putting patients at risk by illegally performing cosmetic procedures such as Botox, wrinkle fillers and fat-dissolving injections without supervision.
  
  The Cosmetic Physicians Society and The Australasian Society of Cosmetic Medicine say nurses are increasingly injecting the restricted drugs in beauty salons and at Botox ''parties''.
  
  They claim nurses should administer anti-ageing medication only after patients are assessed by a doctor. But they say people are often injected without medical checks and prescriptions are provided for patients doctors have not met.
  
  Complaints have been made to nursing boards in three states, including Victoria, amid fears that nurses lack the medical expertise to deal with infections, allergic reactions or nerve damage from injections.
  
  One nurse in Victoria is being investigated amid claims she administered Botox and fat-dissolving injections over a 12-month period at regional beauty salons without having patients checked by a doctor. The doctor she claimed to work for is only registered to practice in a neighbouring state.
  
  But nurses deny breaking the law and have accused doctors of a scare campaign to protect their own profits.
  
  The Sunday Age believes two nurses reported to the Nurses Board of Victoria have had cases against them dismissed.
  
  Botox is a schedule four, prescription-only drug. It cannot be advertised directly to the public and must be used under medical supervision.
  
  Nurses board chief executive Nigel Fidgeon said he could not disclose information on hearings but added: ''There is no legislative restriction preventing a nurse from administering Botox as long as they have a doctor's order. There is also no requirement for a nurse to be supervised by a doctor when administering such medicines.''
  
  Gabrielle Caswell, who heads the Cosmetic Physicians Society, said she had no problem with nurses administering the drug if a doctor had examined the patient. But she said: ''We are getting situations where nurses are now holding Botox parties. So you get together with friends and usually there's alcohol around, you have a bit of a drink, no medical history is taken, you just wait your turn, get your Botox and it's all just a bit of a laugh,'' Dr Caswell said.
  
  ''But the moment you've taken a drink, then you're not giving informed consent. There's no doctor there to check if you're psychologically or physically suited to Botox or fillers.''
  
  Melissa Blandfort, a nurse who has been visiting beauty salons across Victoria to inject clients with Botox for nine years, said the claims were nothing more than a ''turf war''.
  
  ''They [doctors] don't like nurses injecting Botox because it means less business for them. This isn't about patient health concern. You can actually have more of a problem taking too many Panadol than you can taking Botox,'' she said.
  
  Ms Blandfort conceded the law on cosmetic treatment was a ''grey area'' and said she would welcome regulation that provided more clarity.
  
  But Alicia Teska, board member of The Australasian Society of Cosmetic Medicine, said nurses were trivialising the specialty. ''These are medical procedures and they shouldn't be trivialised as being of no more importance than having a manicure or having your hair done,'' Dr Teska said. ''It's the standards that are not being met and people should be quite concerned about that.''
  
  Dr Caswell said patients might not have legal recourse if such a procedure went wrong.
  
  ''The nurse is not technically responsible for the treatment, it is the prescribing doctor. If you have never met the prescribing doctor and haven't undergone a medical examination and history-taking, it may be difficult to discover who the doctor is.''
  
  Ms Blandfort said she had full insurance with a reputable provider. ''All the nurses that I know who do this have indemnity as well … I've had people abuse me for not treating them because I thought they might be a high-risk person and I sent them away.''
  
  Victorian Health Services Commissioner Beth Wilson said Botox was a relatively safe drug if used responsibly. ''If a nurse is adequately trained and they understand infection control and they know how to get informed consent, then I can't see a problem with it. However, I don't think alcohol and medicine should ever be mixed and to have people come to a Botox party and get injected is asking for trouble.''

  
  
• Four Corners 2006 Episode "Buyer of Beauty, Beware" - MUST SEE! The reporter for this episode is Jonathon Holmes who currently fronts Media Watch. Watch out of the liposuction procedure gone wrong at about 40 minutes in.
  
  
• A death after liposuction exposes busy illegal clinic - The Boston Globe, 2006
  
  
• Ex-footballer Colin Hendry's wife dies after operation to repair botched cosmetic surgery - Daily Mail UK 10th July 2009
  
  
• Choice Magazine review of Cosmetic Surgery
  
  
• Patients at risk in ugly cosmetic surgery wars - SMH, 2006