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Figure 1: Safe injection locations for neurotoxins. Injections ("x") 2.5 cm above the bony orbit (horizontal line), 1 cm lateral to and above the orbital rim (small dots) should avoid unwanted diffusion and paralysis

Dr Ben Chan

Dr Ben Chan 

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Medical Director, Cosmetic Institute of Australia, Principal, Skintech Group of Cl

What Does the Recent Texas Botox Arrest Mean to You? - American Med Spa Association

What Does the Recent Texas Botox Arrest Mean to You? - American Med Spa Association

By Alex R. Thiersch, CEO  of the American Med Spa Association (AmSpa)

As many have seen in the news recently, a Texas LVN named Michelle Bogle from Savvy Chic Medical Spa was arrested under the claim that she was practicing medicine without a license.; specifically, she was offering Botox injections. Although all of the facts about the case are not known, AmSpa wanted to take this time to review the rules in relation to delegating cosmetic medical procedures in Texas. The state of Texas is fairly liberal in who it allows to physically perform Botox and other injectable procedures. Anyone with proper training may inject Botox and other cosmetic injectable as long as it is under the protocols, supervision, and delegation of a physician. The Texas Medical Board has adopted Rule §193.17 (available here) to provide guidance to physicians who delegate these nonsurgical cosmetic procedures. The rule applies to nonsurgical cosmetic procedures, including injecting or using a prescription medical device performed by someone who is not otherwise licensed to perform the procedure and not a physician, PA, or NP.  The rule includes 13 points that physicians must adhere to in properly supervising and delegating such a procedure to anyone other than a physician assistant or a nurse practitioner. These include the following.

1. A physician is responsible for being properly and appropriately trained in the specific procedure, and keep records documenting their training.  
2. Before the procedure is performed, the physician or a PA or NP acting under their delegation must perform an initial examination. This examination must include: taking a history, performing a physical exam, making a diagnosis, recommending treatment, developing a treatment plan, obtaining a patient’s informed consent, and providing emergency and follow-up care instructions. They must also maintain medical records, and have signed and dated written protocols and standing orders for the procedure
3. Following the above examination and diagnosis, the procedure can be delegated to another person as long as a PA, NP, or physician is on-site, or the delegating physician is available for emergency consultation and able to conduct an emergency appointment if necessary.
4. The physician, regardless of who they delegate to, maintains ultimate responsibility for patient safety. 
5. The physician is also responsible for documenting and maintaining the patient records. 
6. The facility must have a quality assurance program in place, including mechanisms to identify complications, adhere to protocols, monitor the quality of treatments, a review and improvement mechanism for protocols, and ongoing training.
7. Physicians can delegate procedures only at a facility where they have either approved of that facility’s written protocols for the procedure or they have developed their own protocols.
8. The physician must also make sure that the delegated person has appropriate training in several areas related to performing procedures (see the rule for details).
9. The physician must have in place a written office protocol for the delegated person to follow in performing the procedure.  his protocol must identify the delegating physician, criteria for the physician, PA, or NP to screen the patients, and description of appropriate follow-up care including for complications, injury, and emergencies.
10. The physician must make sure that the delegated person follows that written office protocol.
11. Patients must sign consent forms before receiving any treatment. The form must identify potential side effects, complications, and identity of who will perform the procedure.
12. The delegated person who performs the procedure must have a name tag which discloses their name and their credentials. 
13. The facility must have at least one person on-site who is trained in basic life support whenever a procedure is performed.

Each of these above points are necessary to be in compliance with the rule. However, this article is not meant to be an exhaustive compliance check rather to give more of an overview. So, if you are a physician planning on delegating such procedures to anyone other than a PA or NP, please carefully review the rule in total or consult with an attorney to ensure that you develop policies and procedures that are compliant with its requirements.   

The implications of this story are far-reaching. This is the second instance of an LVN being charged with the unauthorized practice of medicine in recent months as a result of an undercover sting operation (the other occurred in California). AmSpa encourages all of its members—particularly those in Texas—to ensure that they strictly comply with every step of the Texas delegation and supervision rules governing cosmetic procedures. Following each step specifically is critical, and practitioners must take care to pay very close attention to the specifics of the rule and follow it exactly. As now has been seen, failure to do so may result in criminal prosecution, not to mention action by the medical and/or nursing boards.

Tags:  Med Spa Law 

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The Difference Between Muscle-Relaxing Injections and Dermal Fillers

Enquiring minds want to know, “what is the difference between muscle-relaxing injections and dermal fillers?” Stop wrinkling your brow and wonder no more, you don’t want those lines to become permanent, do you, so you end up looking like Gordon Ramsay?

Dermal fillers are types of injectable cosmetics, intended to provide temporary solutions to minor facial skin problems and skin irregularities. Injected just under the skin by a qualified medical practitioner, dermal fillers can smooth out lines, creases and wrinkles by, well, filling them in or plumping them up. The most common dermal filler in use is a brand called Restylane. This has been around much longer than most of the other brands, and has a very good safety profile.
Muscle-relaxing injections (which are derived from Botulinum Toxin A, but don’t be worried as it’s perfectly safe in this form) are very effective as an anti wrinkle treatment, and is also introduced to the face via injection. Muscle-relaxing injections effectively relax your facial muscles (including, perhaps, the ones that are creating those creases in your forehead from wondering too much) and smoothes out your skin, eliminating deeper lines, creases and wrinkles.

Dermal fillers are more suitable for individuals wanting to get rid of lines and creases that are not too deep, or reduce the appearance of other facial skin imperfections, such as scars from acne spots. Dermal fillers are also very popular for non-surgically filling in dips and depressions on the nose bridge. Fillers also can be used for plumping up lips that are asymmetrical, or simply to give one more of a pout. There are many different types of dermal fillers on the market, each with its own particular benefits and/or shortcomings.
Muscle-relaxing injections are generally the choice of discerning men and women who are trying to eliminate facial lines and wrinkles that are more apparent than mere creases in the skin. Your cosmetic doctor will assess whether muscle-relaxing injections or dermal fillers are more suitable for you. The choice of which one to use is dependent on the positioning, severity and depth of your wrinkles.
As a general rule of thumb, the wrinkles around and between your eyes and on your forehead are usually treated with muscle-relaxing injections. Folds around your mouth and chin are usually treated by dermal fillers.'

Muscle-relaxing injections and dermal fillers are used to treat different areas and issues. However, in terms of their longevity, both muscle-relaxing injections and dermal fillers are temporary resolutions to the problems of ageing, offering a three to six month respite from wrinkles, before needing to be repeated.
For a more in-depth look at the different types of anti-wrinkle treatments available in Dublin, Ireland today, including Radiesse, Restylane and Sculptra, –download your FREE report called ‘The Facts About Anti-Wrinkle Injections and What You Need to Know’  from http://nonsurgicalfacelift.ie/

Normal ageing = Loss of Hyaluronic Acid

Hyaluronic acid is an essential skin component. It acts like a sponge that retains water and keeps the skin moisturized, plumped and healthy. We lose 50 % of our hyaluronic acid between the age of 40 and 50(1). The skin becomes dry, thin and fragile. (1) L’observatoire des cosmétiques, Octobre 2010 In addition to normal ageing and loss of hyaluronic acid, our skin is exposed daily to various external factors that change its surface which results in the loss of brightness: - Sun exposure - Pollution - Junk food - Lack of sleep - Smoking

	•YOUNG, HEALTHY SKIN  - Smooth and hydrated skin surface - Perfect light reflection - No shaded areas • AGEING, DAMAGED SKIN - Shriveled and dehydrated skin - Altered light reflection - Numerous shaded areas

Premature ageing = Excess of oxidative stress (free radicals)

Your body has a stock of antioxidants capable of neutralizing the oxidants. This balance can be disturbed by an unhealthy lifestyle and several external factors. The excess of oxidative stress (free radicals) attacks the skin, decreasing its elasticity and tonicity. An injectable revitalizing treatment with the adequate ingredients is a must to restore SKIN’S HEALTHY balance and fight against all aspects of SKIN AGEING.

 http://www.teoxane.com/en/skin-glow-loss