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Spotlight on Aesthetic Surgery

What is aesthetic treatment?

Aesthetic treatments, otherwise known as cosmetic treatments, are non-surgical procedures used for lip and facial enhancement and volumisation as well as to help alleviate the signs of wrinkles, scars, acne, skin tags, and moles. They can also be effective in improving the appearance of veins, helping remove pigmentation, and reducing excessive sweating.

Treatments can be applied to almost any part of the body, but the most common areas are the face, neck and decolletage and they are intended to rejuvenate the skin and combat the signs of ageing, sun damage, and other stresses that compromise skin appearance.

Some of the more common aesthetic treatments include:

  • Wrinkle-relaxing injections – various brands of botulinum toxin are available as prescription-only medication in the UK. When injected, the toxin uses its constituent neurotoxic proteins to temporarily block signals between nerves and muscles to prevent contractions that cause lines and wrinkles. Botulinum toxin can be used on the lower and upper areas of the face or underarm for excessive sweating
  • Dermal fillers – Hyaluronic acid (HA) is a natural component found in the skin and retains water like a sponge to help keep skin soft and firm. When used in aesthetic medicine, hyaluronic acid comes in the form of a gel. The practitioner uses specific Hyaluronic Acid fillers to obtain a global lifting effect such as restoring lost volume in the mid-face, projecting the chin, correcting expression lines and under-eye circles, plumping and redefining the lips, and enhancing skin texture
  • Chemical peel – A chemical peel solution is applied to the face to remove dead skin cells and stimulate the growth of new cells. The aim is to improve the appearance of the skin including fine lines, hyperpigmentation, and acne. There are 3 types of peels, called superficial, medium, and deep.
  • Plasma treatment – a non-invasive treatment that can be effective in treating unwanted wrinkles, stretch marks or skin sagging. Plasma is a state of matter created when energy and gas collide that react to our body’s electrical charge. This form of treatment targets fibroblasts, which are collagen and protein-producing cells in the dermis layer of the skin and discharges a high-frequency electric current to specific areas to break down proteins in the skin and encourage tissue regeneration and tightening.

Common injuries and complications

The effects of these treatments cannot be guaranteed and can differ from person to person, with some achieving the desired outcome and others left with a range of short or long-term impacts that can include:

  • Bruising / haematoma – A common complication of aesthetic treatment due to the use of needles puncturing the skin as blood escapes the vascular system into surrounding tissue. Misplacement of dermal filler can cause lumps which can be visible and include Tyndall effect, which is when the patient's skin takes on a bluish tone due to superficial placement of dermal filler
  • Skin necrosis – necrosis relates to tissue death and occurs when a specific area of the body is starved of blood and oxygen. Although it can occur during or following many aesthetic treatments, it is most associated with the injection of dermal fillers and is one of the most severe early-occurring complications in aesthetic treatments.
  • Infection / Sepsis - Infection and sepsis are always a risk factor from any treatment that penetrates the skin, at any one time 1-10 will require follow-up medical treatment and 1-5 are at risk from sepsis, to minimise these risks all treatments should be undertaken using strict aseptic techniques.
  • Nerve damage – nerve damage secondary to dermal filler treatment may be transient, reversible or permanent. Neuropraxia can occur if the nerve is lacerated or pierced by the needle and can result in sensory and or motor deficits.
  • Delayed onset nodules – a descriptive term rather than a diagnosis used to describe nodules or areas of induration which typically occur at least 2 weeks after filler treatment. They can be diagnosed as Delayed Hypersensitivity Reactions, Biofilm, Granulomas and Redistributed Filler. They can potentially be chronic and impact one’s quality of life.
  • Hypersensitivity – cosmetic injections can sometimes cause immediate or delayed hypersensitivity, which occurs when the body has an allergic reaction to an antigen which can result in anaphylaxis or angioedema.
  • Vascular occlusions – a blocked blood vessel or vessels that occurs when blood is no longer able to pass through a blood vessel. It may be a complete or partial occlusion and can occur if dermal filler either obstructs or compromises a blood vessel. If left untreated, a vascular occlusion of a blood vessel supplying the skin can lead to skin necrosis and tissue death and even blindness.

Psychological impacts

There are many psychological benefits associated with aesthetic treatments, including improved confidence, a better quality of life, a renewed feeling of youthfulness and increased self-esteem. It is extremely important that before any treatment the patient should have a psychological and mental health assessment as part of the consultation process for the practitioner to identify any mental health issues which may be exacerbated should the patient be treated, this would include screening for Body Dysmorphia, Obsessive-compulsive disorder and mental illness. Without a full consultation including medical, psychological screening and a cooling-off period then treatment should not be carried out.

Non-surgical treatments continue to grow in popularity, but the emotionally debilitating impacts of some of the physical complications associated with these procedures often lack proper consideration. Although growing in popularity, many wish to maintain discretion regarding treatments they have – some family members or friends may be supportive, but others less so and demean someone for what they perceive as vanity.

The extent of any side effects from aesthetic treatments can be significantly different to expectations and can also differ between individuals. The thought of explaining the origin of bruising caused by filler injections, for example, can cause social anxiety and embarrassment. By their definition, unsuccessful treatments can also have a detrimental effect on a person’s appearance and leave them looking in a condition they might consider worse than before they had the treatment.

Financial influences may also have negative impacts on a person’s mental health. Treatments may be expensive and beyond the means readily available, causing some to over-extend themselves to meet the costs and become anxious at being in debt. Poor treatment outcomes can exacerbate these feelings, as some may feel they perhaps have to borrow more to correct the issues.

Negative feelings about appearance can manifest themselves in low self-esteem, OCD, depression, and anxiety, which in turn breed a further lack of confidence and low levels of mental well-being. Choosing an aesthetic treatment should always be an individual choice and not driven by peer pressure or influenced by the media. Perhaps the psychological impacts of such decisions and their implications are not explored as thoroughly as they should be.

Current challenges

Some of the risks to patients undergoing popular treatments such as botulinum toxin and filler treatments are currently far greater due to the unregulated nature of the non-surgical aesthetic sector. The Joint Council for Cosmetic Practitioners (JCCP) and the Cosmetic Practice Standards Authority (CPSA) are recognised self-regulators of the non-surgical aesthetic industry in the UK and seek to promote patient safety, but there is no obligation to register as a practitioner.

Karen Garcia is a registered aesthetic nurse consultant and director at her own successful private aesthetics clinic where she has practiced for the last 10 years. She is also  aesthetic medico-legal expert witness at Bush & Co and highlights the challenges:

Whilst medical professionals such as doctors, nurses, and other health care practitioners have a legal duty of care to ensure their actions do not cause harm, the lack of regulation within the non-surgical aesthetic industry allows literally anyone to set up and market treatments. There is currently no requirement for the product, practitioner, or premises to be approved as safe. The variation in the type of practitioner, added to the breadth of products available, leaves patients vulnerable and at increasing risk of harm. It is a crisis waiting to happen.”

The main issues leading to litigation include a failure to proper consent from the patient, lax standards of care, and practitioner competence. An expert witness is experienced in assisting litigation by providing detailed liability reports that explore these areas and other areas to determine the levels to which they were addressed.

Expert witness services from Bush & Co

Liability reports from Bush & Co are prepared by our experts and assess the standard of care provided to the Claimant as part of a clinical negligence case and address relevant issues by applying NICE guidelines and evidence-based research in support of expert opinion.

Areas scrutinised within a liability report where the practice of aesthetics is concerned may include:

  • Montgomery-compliant consent: Informed consent is a fundamental principle of medical ethics and law highlighting that following a full explanation of the treatment the patient has sufficient knowledge and understanding before making a final decision
  • Standard of assessment: A full assessment of the patient can ensure the treatment is appropriate or necessary, identifying motivations and where body dysmorphia is present, any obsessions or compulsions that may be driving a patient’s decision-making
  • Products used: The use of FDA or EEC-approved products regulates the use of appropriate treatments and can advocate the use of botulinum toxin injections, which are only available with a prescription, as opposed to non-prescription dermal fillers
  • Practitioner competence: The practitioner can be assessed for their level of competence and their premises evaluated to determine the level of cleanliness, both of which could impact the prevalence of injuries or complications
  • Causation: Considers the relationship between the action of a practitioner and the outcome of the treatment, essentially determining whether their practice directly resulted in injury and establishing the legal responsibility for harm

Bush & Co are also able to assist with expert witness reports to address aesthetic dentistry complications and negligence. Looking at assessment, products, competence and causation, like with aesthetic surgery. Alex Michael, dentist and expert witness is experienced in all aspects of restorative dentistry including restoration of dental implants. He has experience of cosmetic and clinical dentistry, periodontal disease treatment and oral surgery and is able to comment on standards, assess liability and causation, condition and prognosis.