WHAT ARE THE MEDICOLEGAL TRENDS IN INJECTABLE FACIAL AESTHETICS AND EYELID SURGERY?

GLOBALLY-LEADING DOCTORS EXPLAIN

By Rachna Murthy BSc MB BS FRCOphth and Jonathan C P Roos MB BChir MA PhD FEBO FRCOphth

[ NUMBERS DON’T LIE: both by volume and money the aesthetics sector is booming and is the fastest growing area of private medicine. The face is the main target – after all, it is how we present ourselves and interact with the world. Facial neurotoxin injections, facial fillers and facial surgery together now surpass any other area of the body for enhancement or rejuvenation. But the aesthetics industry differs from other areas of medicine in terms of whom it attracts as both clinicians and patients, as well as the treatments offered.

What is different about the aesthetic industry practitioners?

In fact, not every aesthetic practitioner is a medically trained person. Self-proclaimed experts abound. In the UK – unlike in most other countries – fillers can be administered not just by doctors, nurses or dentists, but by anyone, including hairdressers, beauticians and those without any training at all.

Even the doctors may be unusual, many having had no clinical training beyond the mandatory foundation years or having dropped out of specialist registrar training early. Some will seek to upskill and sign up for a panoply of for-profit aesthetic training businesses which vary greatly in quality.

The clinics in which the work is performed also vary, of course, with some national chains offering high-volume low-cost treatments with little variation, despite differing patient needs. At the other end of the spectrum those treating celebrities may charge an order of magnitude more for the same treatments and without marked advantages.

Unlike those working in the NHS, whose salaries are unrelated to their clinical decision-making, the aesthetic industry is almost exclusively private, resulting in an incentive to over rather than under-treat.

What is different about the aesthetic industry patients?

The patient population is also different. The aesthetic industry has always attracted those wishing to reverse the signs of ageing or to redress a disparity in their external appearance and sense of self. However, there are also now social media-driven facial trends, with younger people seeking ‘hunter eyes’ or ‘fox eyes’ and risking permanent facial disfigurement.

There has been an industry-wide push to identify those suffering from body dysmorphic disorder (BDD), where the actual appearance is not recognised, leading to excessive treatments and disfigurement often with an alien-like appearance with exaggerated lip size. The BDD can affect the practitioner doing the treatment too.

The location of the chosen treatment is also different. While disease tends to warrant treatment near ones loved ones and carers, the aesthetics field is notable for medical tourism – most often driven by price. Until there is an untoward event many may not identify as patients, but as customers or clients.

What is different about the aesthetic industry products?

When a pharmaceutical product is brough to market, regulations are tight and clinical trials showing safety and efficacy are required. Except for botulinum toxins – which are only available on prescription – aesthetic injectable products are classed as devices or cosmetics and have a much lower standard for approval. That can lead to a delay in the identification of complications.

For example, around 20 years ago a novel French injectable was found to create granulomas, and the ensuing abscesses would erupt through the skin, expelling the product. The lack of safety studies also means that complications monitoring is performed by international groups of leading clinicians working as a team through IMCAS Alert, for example, or the companies producing the product themselves.

A more recent example involved the model Linda Evangelista, who claimed to have suffered a rare complication of fat over-production in her chin after a treatment intended to reduce that fat. Much in the industry is marketing rather than science led and exaggerated claims abound.

What is different about the medicolegal scene in aesthetics?

We run a London-based practice which frequently receives tertiary referrals for managing complications. Over the past few years we have noted a number of distinct trends. These most commonly include:

• Not listening to what patients want and giving treatments which the

• patient had not envisaged having: “I went for toxin for my wrinkles

• and they gave me fillers to my jowls”.

• Practising outside ones area of expertise: “I went for a breast lift but

• he offered to do my eyelids instead”.

• Doing a one-size-fits-all approach, which fails to recognise patients’

• unique wishes and facial appearances.

• Forcing patients to sign nondisclosure agreements.

• Punishing patients by refusing to see them again if they seek a

• second opinion from another doctor.

• Inflating credentials or awards, for example suggesting one is

• ‘Harvard trained’ after spending a medical school elective there

• observing, or suggesting one is a ‘consultant’ surgeon or

• anaesthetist when one has dropped out of registrar training prior

• to completion.

• Failing to recognise medical conditions such as thyroid eye disease,

• dry eyes or scarring disorders, which preclude certain procedures.

• Failing to recognise warning signs suggesting the patient may be

• unsuitable for treatments, such as having a psychological condition.

• Compounding of injuries by further treatments such as dissolving

• filler or doing further surgery with skin grafting which worsens the •

• appearance.

• Using inappropriate devices and in the wrong locations – there are

• different types of filler products and laser devices which can burn

• certain skin types or create granulomas and product migration if

• placed incorrectly.

• Failing to seek informed consent.

• Chain clinics altering surgical staff without notice and leading to less

• competent surgeons operating and removing excessive skin.

• Seeking to bribe patients when GMC referrals have been made. Vexatious complaints can be made by patients who regret spending money or who suffer with psychological dependencies, but the crux is that they are high-value procedures combined with sometimes relatively unskilled practitioners who are not adept at dealing with medical aspects of care, such as identifying psychological conditions or dealing with adverse events or reactions – including by listening. That compounds injury and leads to complaints and lawsuits.

We have found repeatedly that clinical photography pre and postprocedure is key to supporting either a claim or defence. Beauty is very subjective and memories of a prior appearance can be distorted or forgotten. q

• Rachna Murthy and Jonathan Roos are consultant ophthalmologists and eyelid surgeon specialists with decades of experience. They are globally recognised for their aesthetic and clinical work and have won many industry and academic prizes. Rachna was Consultant Surgeon of the Year 2022 and sits on Allergan’s UK complications board.

They contribute to the IMCAS Global Alert and teach for Allergan –a leading producer of injectable aesthetic treatments.

Both Dr Roos and Dr Murthy are invited lecturers at leading aesthetic events in the UK and internationally, and teach anatomy and safe injection techniques. They have published textbook chapters on the management of aesthetic complications and contributed to guidelines to minimise the risk of blindness and other filler and surgical-related complications.

They have Bond Solon accreditation and are now producing many medicolegal reports per year. They are increasingly the go-to experts when periocular surgery or facial filler has gone wrong and needs remedial treatment or a robust medico-legal opinion.