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When Not To Treat

“Good surgeons know how to operate, better ones when to operate, and the best when not to operate.” (Anon)

lips surgeon hat girl shutterstock_388208080

This is a rough guide for those involved in the treatment of patients with Botulinum Toxin type A & Hyaluronic Acid.

Here we’ll use the medical history form from the Flourish Cosmetic App as a reference – this can be viewed here. You may find it useful to open this now in a new window. This medical history form incorporates the questions taken from the medical history and consent forms disseminated by all of the leading Botulinum Toxin and Hyaluronic Acid manufacturers. It seeks to be comprehensive. The Flourish Cosmetic App is currently co-owned by Visage Aesthetics UK (the same company that owns this website).


Introduction

Basically, there aren’t many conditions that we need to absolutely avoid when using Botox and Fillers, which is why, if you took a punt and treated everyone without question, you’d probably get away with it. But i’ll go through the Flourish medical history form so that you can see the kinds of things I pick up on when I review this with a patient, either before I treat them myself or whenever I consult with them and decide to go ahead and issue prescriptions for them to their own practitioner.

Are you attending or receiving treatment from a doctor or specialist?

This one should catch most things and many of the later questions are just double-checking the answers. For example, many people who have chronic illness can forget to mention it when you ask them about medical problems. That’s why Doctors often ask this same question in other ways, such as “do you see your own Doctor regularly for anything?”. Believe it or not, some people forget to mention that they have diabetes or even that they have had cancer but have since been given the all clear. Also, some people tend to think that if they can’t see a connection between botox or fillers and their condition, they might think it’s irrelevant – and it probably is (see above) – but still worth being thorough and documenting it. One group of rare conditions that should arguably have their own section on medical history forms, are those conditions that cause facial or throat weakness. If these exist, botox could make their condition worse. These conditions include (but aren’t limited to) ectropion and myaesthenia gravis. Note that if a patient has Bell’s Palsy or cerebral palsy affecting facial movement, it may be aesthetically beneficial to treat the side of the face with movement in order to restore some degree of symmetry. 


Are you taking any medications?

Another catch-all question. Basically, we’re interested in Warfarin, aspirin and the newer, NOACs. If a patient is on one of these I usually say “we can still go ahead with your treatment, but it just means that if you do get a bruise, it is likely to be larger and last longer than it would in someone who wasn’t on this medication. Don’t suggest they stop the medication – even stopping aspirin for a few days can have catastrophic results if someone is on it for stroke or heart attack prevention, so don’t feel that it’s ok to tell them to stop it just because aspirin is available over the counter.

Note that some dermal filler manufacturers state in the small print within their information leaflet that their product should not be used in patients on anticoagulants or anti platelet medication. This means that you can’t use the filler if someone is on warfarin or aspirin without risking your insurance cover. Our own brand of filler, Dermal Revolution doesn’t have this disclaimer, simply as I challenged the manufacturing pharmacist supervisor about it and he agreed that there was no good reason to include that disclaimer in there.

tablets pills medicine capsules shutterstock_364107608Are you allergic to local anaesthetic injections, lignocaine, adrenaline or EMLA/ANESTOP/LMX4 cream?

This question is the most important question potentially on the form, although it might not seem like it is! The most potentially dangerous drug we use as aesthetic practitioners is lignocaine. Because it comes in the form of cream and gel as well as being inside many fillers, we sometimes assume that it isn’t really a drug. AND, in a busy clinic, this cream or gel will often be applied by an assistant. It is vitally important that the assistant checks with the patient that they are not allergic to lignocaine before applying the cream or gel. Lignocaine can cause an anaphylactic reaction which can lead to death, but fortunately the chances of developing anaphylaxis to lignocaine appear to be approximately 0.005% (1 in 20,000) (Southworth). 

 

Do you have any known allergies or a history of anaphylaxis (a life-threatening allergic reaction)?

Again, we’re putting this in a slightly different way to reduce the chances of missing out on this important issue. Also, we’re opening it up in case there is a rarer allergy, such as to rubber bungs in Botox vials, latex in gloves, lactose in their cup of tea etc!

Heart problems including an irregular heartbeat or angin£

More detail now. Generally, surgeons will ask this question to help them decide on the risk of general anaesthetic vs local anaesthetic. If there’s a high risk of someone having a heart attack during a procedure (there is a high risk if they have had a heart attack previously) the surgeon will prefer to do the surgery under local anaesthetic where possible, as the other benefits of general anaesthesia will be outweighed by the risks. Applying similar logic i’d like to know if there is any chance that this procedure i’m about to perform, which is by nature of it being cosmetic, unnecessary, has any chance of exacerbating a heart problem. If there is no heart problem, there is nothing to consider. If someone has had bypass surgery 2 years ago and only attends for a yearly review and exercises regularly and gets Botox all the time and has a high pain threshold etc, then i’m not worried, if they’re due bypass surgery next week because of two heart attacks in the past month and they are a smoker and are afraid of needles and appear anxious and sweaty i’d be quick to reschedule their appointment until after the surgery has been a success.

heart attack shutterstock_253445560High or Low Blood Pressure or circulation problems including Raynaud’s Syndrome?

High blood pressure- a major risk factor for heart attacks – so worth knowing about, but needs to be fitted into the bigger picture, as above.

Low blood-pressure. These people are fainters, beware!

Epilepsy/Blackouts?

Under control with medications or haven’t had for a long time? No problem.

Get them regularly, often proceeded by pain or anxiety? Again, beware. Think about what you’d do if a seizure occurred in your clinic room.

 

Blood disorders/leukaemia/lymphoma/anaemia/cancer?

Autoimmune disease, arthritis or recurrent sore throat?

Diabetes?

I’ll lump these three together. Basically i’m assessing whether or not the patient might have a lowered immunity and therefore be at an increased risk of infection. Also, if someone is already on antibiotics or antifungals or antivirals, there is a fair chance that their immune system is already pre-occupied and that maybe we’ll be putting unnecessary stress on them in delivering an unnecessary treatment. Is it possible to wait a few weeks to treat them? If they are actively undergoing cancer treatment, I personally would advise them to return whenever they have completed the treatment as they have bigger fish to fry.

chemotherapy shutterstock_218458957Contact Dermatitis/Eczem£

If someone has an open wound or raw skin from dermatitis / eczema, it’s best to avoid injecting through those areas as there is an increased infection risk due to microbes preferentially clinging to roughened, damaged skin – better to wait for it to settle down. Eczema on their arms and legs is irrelevant when you’re going to inject their face.

Keloids (hypertrophic scarring) or recent scar tissue (6 months)?

This is more common in dark-skinned individuals. See here for a pictureIf they normally get keloid scarring you need to be careful that they don’t get it at your injection sites. Because of where I work, i’m mostly injecting fair-skinned patients so unfortunately I can’t give any further advice on how likely this is to happen with tiny botox needles in darker-skinned patients.

 

Easy bruising?

This phrase annoys me but it is on the ‘official’ consent forms, hence us including it in ours. I like to tell patients “if the needle punctures a blood vessel, you’ll get a bruise and if it doesn’t, then you won’t’. But sometimes, patients still reply with ‘I don’t usually get bruises when I get Botox’ to which I then reply, ‘well, it’s good that you didn’t get bruising before, and the risk of you getting it this time is small but there is still a risk’. If they then say ‘well I never get bruises’ at this point, it’s your choice, but do try to remain calm.

Cold Sores?

Cold sores are caused by a virus called herpes simplex. They live in the nerve that supplies the skin where they erupt. They erupt and heal but never fully go away. They erupt again on the surface of the skin whenever the carrier experiences physical or psychological stress. They are contagious; when they have erupted, they can be spread between different people and can also cross contaminate a sufferer- e.g. spread from one lip to the other. Furthermore, if herpes simplex affects the eye, it can cause permanent blindness. So, as practitioners, we should avoid treating patients who have an active cold sore. We should also advise patients who normally suffer from cold sores that there is a small chance that the treatment could trigger an existing cold sore.

cold sore shutterstock_188903120Psychiatric Illness/Depression?

Sadly, there is still (as I write this on 6th September, 2016) stigma surrounding mental health. This is just a quick mention-all i’m interested in with this question is to ensure that i’m not treating a patient who is currently psychotic. This means, that I don’t want to treat someone who has lost insight or who is experiencing hallucinations & delusions. A quick way of checking this is to ask – ‘have you ever been admitted to hospital with this condition’ and if yes, ‘how often do you see your CPN (community psychiatric nurse)?’ There is one condition in particular, where a patient would be predisposed to overspending and taking overt risks that they ordinarily wouldn’t take- this is the ‘happy’ side of manic depression or bipolar disorder known as mania. It would be unusual for you to come into contact with a patient in this condition and it would be extremely difficult not to notice that something was very unusual about the patient’s behaviour so it is almost a moot point here. But, imagine the news headlines if you did treat them- they would be unlikely to reflect well upon your practice.

Do you use sun-beds or sunbathe?

This is an opportunity for you to give some free advice and possibly improve someone’s life. If someone admits to sunbathing and / or using a sun-bed, I gently advise that they consider using sunblock on their face, neck and décolletage and instead getting their tan from a bottle. Sun, smoking and stress are the big causes of premature ageing of the skin.

Do you play a woodwind or brass instrument?

Ok, this one always gets a laugh for some reason.

If someone plays a brass or woodwind instrument, they will have stronger mouth muscles than the rest of us, but it won’t be obvious to look at them. The consequences of treating a musician like this with botox around their mouth (lipstick lines or depressor oris angularis) is that they might lose the ability to play their instrument for up to 6 months. Maybe ok if it’s a hobby but, catastrophic to a professional.

Are you pregnant/planning pregnancy/engaged in IVF treatment or are you breast-feeding?

More than once, i’ve had pregnant patients ask for botox. The bottom line is that although botox and filler are probably both safe in pregnancy, there is no evidence to back this up. Miscarriages are unfortunately common in pregnancy (20-25% of all pregnancies), so it follows that the chances of miscarriage following treatment with botox or fillers is also 20-25%. Best to avoid until after breastfeeding. If someone gets treatment then finds out the next week that they were actually pregnant when they received treatment, you can reassure them that there is no known risk to their foetus.

Have you had a consultation or been treated with a dermal filler or Botulinum Toxin, laser, chemical peels or microderm abrasion before?

Worth checking so that you can learn from others’ mistakes. E.g. did their frown not shift- do they need a larger than standard dose? Did their left eyebrow droop the last time? Are they prone to the ‘frightened rabbit’ or ‘spocking’? Do they have a misconception surrounding their previous treatment, that you should expose and discuss now before you proceed to treating them?

Have you had an allergic reaction to any dermal filler or Botulinum Toxin product?

Nobody has yet, but worth checking this.

Have you had a consultation or had plastic surgery of the face or neck or are you planning to have surgery?

plastic surgery shutterstock_97552763Think of the timelines for the treatments you are offering – botox lasts roughly 3-6 months and filler, 6-12 months (depending on where you treat and which product you use). If someone is going for a consultation about facial or neck surgery or getting surgery in these areas, it’s best to ensure that botox and fillers aren’t having an effect. Unless the patient tells you that they have been told by the surgeon that it’s ok to go ahead with treatment. I’ve heard of plastic surgeons asking patients to wait for their filler to wear-off before they can have surgery. 

So, that’s it. That’s everything I can think of for now. If you think that i’ve missed something out, please let me know at [email protected]

If you have enjoyed reading and would like to learn more, please check out our online Foundation and Advanced modules in the use of Botox and Fillers. Also, if you’d like to read more about or purchase our Dermal Filler, click here and finally, if you’d like to start a free 10-patient trial of the Flourish Cosmetic App for your cosmetic patient records (including consent forms and photo-management), email [email protected] and let us know your name and clinic name*.

*Note that Flourish could change your life.

Written by Dr Michael D Aicken.

References

Southworth JL, Dabbs CH. Xylocaine: a superior agent for conduction anesthesia. Curr. Res. Anaesth, 1953; 32(3): 159-70.

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