As a commitment to participatory learning, discussion and development, PIAPA holds bi-annual reflection meetings. These regional meetings encourage development, confidence and good practice. Here is a summary of our February and March meetings.
Northwest
On 7th February 2019, our Northwest members gathered for a clinical reflection session with a particular focus on lower face toxin. We began by discussing the Association of British Pharmaceutical Industry (ABPI) licencing rules for toxin, or indeed the lack thereof, in the case of the lower face, as this is an off-licence treatment. Having a mixture of nurses, doctors and, in particular, dentists in the room gave an interesting perspective of treatment motivations, such as bruxism or gummy smile.
We discussed key treatment elements including dosage, depth and placement, and the impact these have on results and potential complications. My greatest rule in lower face toxin is to always start with the lowest dosage and increase at review if necessary, especially when treating a new patient. The only exception to this rule is the masseter, though this remains an area that many prefer not to treat altogether.
What was clear in the room was the disparity of our initial training on lower face toxin and the knowledge we have developed since. We deduced that a significant reason for this was because of the restrictions placed by the ABPI around off-licence treatments on manufacturers such as Galderma, Allergan and Merz, who often sponsor ongoing research and workshops. The session was rounded off with pastries, coffee and a catch-up on general matters.
Yvonne Senior
Northeast
The Northeast members held a meeting on 20th March. It had been decided that toxin is rarely discussed now, in comparison to dermal fillers, and that it would therefore would be helpful and informative to return to this topic.
We quickly established that, out of the group of 12 members, only one was a non-prescriber. As such, it was determined that the knowledge in the room around toxin as a prescription only medicine (POM) should be strong. We discussed efficacy, dose and dilution within the commercially available toxins, as well as considering pricing structures. Adverse events were also considered, and members felt that there were far fewer adverse events when using toxin than with fillers. Also discussed was the issue of using toxins in the lower face: who does it, who doesn't and the incidence of adverse events in this area, which, according to the members of this meeting, appear to be rare.
The role of nurses prescribing for others was discussed at length. Members discussed where they felt the responsibility lay and what could be done to protect themselves. It was established that some of those who prescribe for others have a checklist that they adhere to when prescribing for a new practitioner.
One of the longest discussions focused on the advertising and incentivising of POMs on social media. I posed the question ‘Does anyone report when the see this happening?’. The response was a unanimous ‘No’, the main reason being that it could place someone's livelihood and reputation at risk. After an extensive discussion on the advantages and disadvantages of reporting, opinion remained divided on this issue.
There was lively debate and all member had the opportunity to learn something new, regardless of their level of experience. We then enjoyed some sandwiches and cakes, bring a very enjoyable session to a nice close.
Linda Mather
Tamworth
On 7th March, a mixture of nurses and doctors attended our Clinical Reflection Session in Tamworth to discuss the topic of using dermal fillers to support and define the jawline.
It was established that the jawline should demonstrate a relatively sharp and angular transition to the neck, as this frames the lower third of the face.
During the meeting, the anatomy of the jawline was explored, as well as how the ageing process can alter the profile of this area of the face. Genetic influences on the lower face shape were also covered.
This is a treatment rarely covered in basic or initial training and, as with all dermal filler treatments, it must be approached Meeting with peers allows for development, networking and confidence buildingwith caution and should only be carried out by a practitioner with extensive awareness of the facial anatomy; in particular, the submental nerves, mandibula and sub mandibular lymph nodes, parotid gland and associated arteries and veins.
The group then observed a model and identified the borders of the jowls, being mindful not to volumise this area, as this would further accentuate the jowl, creating a more masculine appearance.
We palpated and marked the pogonion of the chin and the angle of mandible using the agreed guidelines. A demonstration was given using both needle onto periosteum at the angle of the jaw below the ramus and mental protuberance or pogonion of the chin, then a cannula using slow retrograde threads tightly approximated of dermal filler product of 0.1 ml per thread, to a total of 0.5 ml per side of the face.
One member of the group questioned why a calcium hydroxylapatite (CaHA) wasn't being used for this procedure. Although entirely suitable for use in this area with similar technique, CaHA fillers are not recommended for less experienced practitioners, as their effects are irreversible.
In conclusion, it was decided that safe and effective treatment of the jawline using dermal fillers requires a highly experienced practitioner, especially when using CaHA fillers.
Sarah Barker
Conclusion
Taking the time to meet with peers to discuss developments, technique and topical issues is an essential part of aesthetic practice. Doing so allows the opportunity for continuing professional development, networking and encouraging confidence and good practice in a sector where many professionals practice in isolation. PIAPA is committed to ensuring opportunities for development for its members in the future.