The Last Word: Treatment Duration

The Last Word

Dr MJ Rowland-Warmann explains why she believes practitioners should stop advertising the length of treatment times for dermal filler procedures

Advertising how quickly a procedure can be carried out is the latest fad. A 10-minute lip filler here, a five-minute non-surgical rhinoplasty there, facial volume replacement promising recontouring in five minutes… Is this good practice or is promoting accelerated aesthetic treatments potentially harmful? Is ‘fast’ really what our patients want? In this article, I explore whether promoting and promising speedy treatments is actually beneficial for both the patient and the practitioner, while discussing what I believe to be best practice.

Patient perception Some practitioners want to minimise their patients’ time in the chair, one of their reasons being that faster treatments equate to a better patient experience. But is this really true? Patients are surprisingly unconcerned about many aspects of their treatments if they feel they are being adequately cared for.5 In a recent straw-poll of around two dozen of my patients, not one mentioned treatment time when asked what their priorities were during a procedure. It’s not news that what patients really worry about is the standard of care given to them and the effectiveness and quality of that treatment. The latter has been shown to influence patients’ intent to revisit a service.5 Supporting this concept is research into patient satisfaction.5,6 As a key quality indicator in healthcare, satisfaction is directly linked to not only retention and outcomes, but also malpractice claims.5,6 Whilst time waited before receiving treatment is often cited as a contributing factor to satisfaction (especially in public healthcare systems such as the NHS), the speed of the treatment is not.6 Conversely, there is a strong link between increased time spent with the patient and increased satisfaction.6 This indicates that, in fact, your patients want to spend longer with you, not be ‘over and done with’ in just 10 minutes. As providers of luxury medical procedures, I believe we should strive to provide a compelling patient experience. In my opinion, perceived indifference, the act of making a patient feel unvalued and unimportant, can occur when the patient is not awarded with enough time. According to John Gattorna of Macquarie Graduate School of Management, perceived indifference is the reason 68% of all customers switch to competitors.2,8 I must presume that these five-minute nonsurgical rhinoplasties being offered by some clinics don’t include greeting the patient, photography, consent, and preparation of the patient or the room, as well as making sure the patient is comfortable and happy. At the very least this mismanages the patient’s expectations for treatment, as the actual time spent surrounding the procedure is not made clear. If it is the case, I have serious misgivings about significant aspects of the treatment procedure being omitted. Expectation setting is a key ingredient in the practitioner-patient relationship and should start at the advertising stage with clear and transparent statements.

Practitioner perception There is an obvious difference between working efficiently and rushing procedures. Yet in my opinion, many practitioners seem to get the two confused. They fall into the trap of believing that if they can do it faster, they must be better. A tried and tested USP is usually the basic faster is better model. This is certainly what some customers want in some industries, however I would argue that patients simply aren’t interested in express aesthetic treatments. What I see is practitioners advertising internal KPIs in place of a competitive selling proposition in a ‘race to the bottom’ that is not good for patients, the aesthetic market as a whole and the perilous incidence of serious complications. Just because you see someone else promoting their services in this way, it doesn’t mean that you have to.

Clinical considerations It cannot be disputed that there is a correlation between injection speed and the incidence of complications.1 Rapid injection and flow rate increase the amount of filler volume placed, increasing discomfort, swelling and bruising at best and possibly resulting in disastrous adverse events such as obstruction of vessels or even blindness at worst.1,3 On the contrary, slow injection of micro-volumes are less likely to result in complete blockage of vessels, or retrograde flow capable of blocking the ocular circulation.1,3 Injecting slowly and with caution allows practitioners to monitor the patient and change technique

It cannot be disputed that there is a correlation between injection speed and the incidence of complications

intra-procedurally should the need arise.7 I would argue that boasting about taking five minutes to complete a potentially risky aesthetic procedure undermines the seriousness of its medical nature. It has also been suggested that it would likely be indefensible in a negligence action, should it come to light that a complication had arisen when the practitioner spent such little time on the procedure.7 I would strongly encourage practitioners to consider your position if a patient raises a grievance or negligence action for a complication. Imagine arguing at the tribunal that you took care of the patient and were doing a splendid job, yet opposing counsel produce your advert promoting your five-minute procedure. So, with that information in mind, practitioners who continue to inject quickly and carry out treatment as quickly as possible, with a disregard for these obvious elements of safety, will soon be graduating from ‘negligence’, when your patient suffers harm as a result of a breach of a duty of care, to ‘recklessness’, where you are deliberately and unreasonably disregarding risks that could potentially result in injury to the patient, vitiating consent and constituting a criminal assault.9

Moving forward I believe the way to grow a patient base and have the practice and patients you want is to spend more time with patients. You must be caring, build relationships, do a good job and get repeat business. In my experience, patients respond well to values of basic decency in any service or retail business. Advertise your excellence in care, not speed. As complications are becoming more widely reported, in part due to the growth of the industry and its unregulated nature, we should consider it our responsibility to not to contribute to them, but to conduct safe and careful procedures.

Dr MJ Rowland-Warmann is the founder and lead clinician at Smileworks in Liverpool. She is highly committed to continuing professional development, in 2016 completing her MSc in Aesthetic Medicine (with distinction) from Queen Mary University of London. She has a special interest in the management of complications, writing extensively on the subject.

REFERENCES

1. Ablon, G, Understanding How to Prevent and Treat Adverse

Events of Fillers and Neuromodulators. Plast Reconstr Surg

Glob Open, 2016 2. Aesthetic Business Transformations, How to maximise your medical aesthetic business profits, 2019 <https://www. aesthetic-bt.com/grow-your-practice-in-todays-economy/> 3. DeLorenzi, C, Complications of injectable fillers, part 2: vascular complications. Aesthet Surg J, 2014 4. Glogau, R G., Kane, M. A, Effect of injection techniques on the rate of local adverse events in patients implanted with nonanimal hyaluronic acid gel dermal fillers, Dermatol Surg, 2008 5. Kim, C E et al., Quality of medical service, patient satisfaction and loyalty with a focus on interpersonal-based medical service encounters and treatment effectiveness: a crosssectional multicenter study of complementary and alternative medicine (CAM) hospitals. BMC Complement Altern Med, 2017 6. Prakash B, Patient Satisfaction. J Cutan Aesthet Surg, 2010 7. Urdiales-Galvez, F et al., Preventing the Complications

Associated with the Use of Dermal Fillers in Facial Aesthetic

Procedures: An Expert Group Consensus Report. Aesthetic

Plast Surg, 2017 8. CustomerThermometer.com, CSAT Stat of the Month: 68% <https://www.customerthermometer.com/customersatisfaction/csat-stat-68-percent/> 9. Loveless J, Intention, recklessness, negligence and gross negligence, Complete Criminal Law: text, cases and Materials, 2016

BOOK YOUR TICKETS NOW!

A PARTNERSHIP YOU CAN COUNT ON

CELEBRATING OUR 10TH ANNIVERSARY IN AESTHETIC TREATMENTS As your trusted partner in aesthetics, Azzalure is a truly global toxin approved in 72 countries with 40 million glabellar line treatments in Europe and the United States alone.1,2 Here’s to another decade of natural-looking results and high patient satisfaction.3

Azzalure Prescribing Information (UK & IRE) Presentation: Botulinum toxin type A (Clostridium botulinum toxin A haemagglutinin complex) 125 Speywood units of reconstituted solution (powder for solution for injection) Indications: Temporary improvement in appearance of moderate to severe: • Glabellar lines seen at maximum frown, and/or • lateral canthal lines (crow’s feet lines) seen at maximum smile in adult patients under 65 years, when severity of these lines has an important psychological impact on the patient. Dosage & Administration: Azzalure should only be administered by physicians with appropriate qualifications and expertise in this treatment and having the required equipment. Botulinum toxin units are different depending on the medicinal products. Speywood units are specific to this preparation and are not interchangeable with other botulinum toxins. Reconstitute prior to injection. Intramuscular injections should be performed using a sterile suitable gauge needle. Glabellar lines: recommended dose is 50 Speywood units divided equally into 5 injection sites, 10 Speywood units to be administered intramuscularly, at right angles to the skin; 2 injections into each corrugator muscle and one into the procerus muscle near the nasofrontal angle. Lateral canthal lines: recommended dose per side is 30 Speywood units divided into 3 injection sites; 10 Speywood units to be administered intramuscularly into each injection point, injected lateral (20 - 30° angle) to the skin and very superficial. All injection points should be at the external part of the orbicularis oculi muscle and sufficiently far from the orbital rim (approximately 1 - 2 cm); (See summary of product characteristics for full technique). Treatment interval should not be more frequent than every three months. The efficacy and safety of repeat injections of Azzalure has been evaluated in Glabellar lines up to 24 months and up to 8 repeat treatment cycles and for Lateral Canthal lines up to 12 months and up to 5 repeat treatment cycles. Not recommended for use in individuals under 18 years of age. Contraindications: In individuals with hypersensitivity to botulinum toxin A or to any of the excipients. In the presence of infection at the proposed injection sites, myasthenia gravis, Eaton Lambert Syndrome or amyotrophic lateral sclerosis. Special warnings and precautions for use: Care should be taken to ensure that Azzalure is not injected into a blood vessel. Use with caution in patients with a risk of, or clinical evidence of, marked defective neuro-muscular transmission, in the presence of inflammation at the proposed injection site(s) or when the targeted muscle shows excessive weakness or atrophy. Patients treated with therapeutic doses may experience exaggerated muscle weakness. Not recommended in patients with history of dysphagia, aspiration or with prolonged bleeding time. Seek immediate medical care if swallowing, speech or respiratory difficulties arise. Facial asymmetry, ptosis, excessive dermatochalasis, scarring and any alterations to facial anatomy, as a result of previous surgical interventions should be taken into consideration prior to injection. Injections at more frequent intervals/higher doses can increase the risk of antibody formation. Avoid administering different botulinum neurotoxins during the course of treatment with Azzalure. To be used for one single patient treatment only during a single session. There is a potential risk of localised muscle weakness or visual disturbances linked with the use of this medicinal product which may temporarily impair the ability to drive or operate machinery. Interactions: Concomitant treatment with aminoglycosides or other agents interfering with neuromuscular transmission (e.g. curare-like agents) may potentiate effect of botulinum toxin. Pregnancy, Lactation & Fertility: Not to be used during pregnancy or lactation. There are no clinical data from the use of Azzalure on fertility. There is no evidence of direct effect of Azzalure on fertility in animal studies. Side Effects: Most frequently occurring related reactions are headache and injection site reactions for glabellar lines and; headache, injection site reactions and eyelid oedema for lateral canthal lines. Generally treatment/injection technique related reactions occur within first week following injection and are transient. Undesirable effects may be related to the active substance, the injection procedure, or a combination of both. For glabellar lines: Very Common (≥ 1/10): Headache, Injection site reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, pain, discomfort, stinging and haematoma). Common (≥ 1/100 to < 1/10): Temporary facial paresis (due to temporary paresis of facial muscles proximal to injection sites, predominantly describes brow paresis), Asthenopia, Eyelid ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching (twitching of muscles around the eyes). Uncommon (≥ 1/1,000 to <1/100): Dizziness, Visual impairment, Vision blurred, Diplopia, Pruritus, Rash, Hypersensitivity, Eye movement disorder. Rare (≥ 1/10,000 to < 1/1,000): Urticaria. For lateral canthal lines: Common (≥ 1/100 to < 1/10): Headache, Temporary facial paresis (due to temporary paresis of facial muscles proximal to injection sites), Eyelid ptosis, Eyelid oedema and Injection site disorders (e.g. haematoma, pruritus and oedema). Uncommon (≥ 1/1,000 to <1/100): Dry eye. Adverse reactions resulting from distribution of the effects of the toxin to sites remote from the site of injection have been very rarely reported with botulinum toxin (excessive muscle weakness, dysphagia, aspiration pneumonia with fatal outcome in some cases). Prescribers should consult the summary of product characteristics in relation to other side effects. Packaging Quantities & Cost: UK 1 Vial Pack (1 x 125u) £64.00 (RRP), 2 Vial Pack (2 x 125u) £128.00 (RRP), IRE 1 Vial Pack (1 x 125u) €93.50, 2 Vial Pack (2 x 125u) €187.05 (RRP) Marketing Authorisation Number: PL 06958/0031 (UK), PA 1613/001/001 (IRE) Legal Category: POM Further Information is Available From: Galderma (UK) Limited, Meridien House, 69-71 Clarendon Road, Watford, Herts. WD17 1DS, UK. Tel: +44 (0) 1923 208950 Fax: +44 (0) 1923 208998 Date of Revision: September 2018

Adverse events should be reported. For the UK, Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. For Ireland, Suspected adverse events can be reported via HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517. Website: www.hpra.ie; E-mail: medsafety@hpra.ie. Adverse events should also be reported to Galderma (UK) Ltd.