In 2018, a botched lip procedure at a ‘Botox party’ led to Rachael Knappier's upper lip swelling to five times its normal size. Filler had been accidentally injected into her artery and she was forced to seek urgent medical treatment. Six months later, her MP, Alberto Costa, tabled a Westminster Hall debate to discuss her case and raise concerns about the lack of regulation in aesthetics.
Training was one of the core issues debated, with MPs calling for practitioners to have the right level of anatomical knowledge to enable them to advise people on potential complications. Renewed demands for more formal training and a regulatory body to hold practitioners accountable were also raised.
We all know, of course, that adequate training is key to patient safety. The problem is the lack of industry consensus about what adequate training looks like and what makes an adequate trainer.
In reality, there is no barrier to entry in aesthetics training other than a PowerPoint slide. Many insurance companies only need to see a simple presentation before they will indemnify someone, and, as the recent parliamentary debate highlighted, there is little formal regulation around the training they can then provide.
However, two recent developments indicate a shift in the landscape. Last year, the Joint Council for Cosmetic Practitioners (JCCP) signed memorandums of understanding (MOU) with medical regulatory bodies, including the Nursing and Midwifery Council (NMC), the General Dental Council (GDC) and the General Pharmaceutical Council (GPhC). These agreements aim to improve patient safety by sharing education, training and practice standards, and they build on an existing MOU with the General Medical Council (GMC).
The JCCP also launched a new competency framework for aesthetic practice, in line with fresh practice standards developed by the Cosmetic Practice Standards Authority (CPSA). This framework evolved from the 2013 report by Health Education England (HEE) about training standards for aesthetic practice, and it can be used to voluntarily register practitioners. Education providers can also draw on the framework to develop training that corresponds with JCCP and CPSA practice standards.
But there is a problem here. This regulation is all voluntary. There is little mandatory control of aesthetics practice. Many healthcare professionals working in this sector argue that regulation already exists from their own professional bodies, and say that a dedicated aesthetics watchdog is not required. Indeed, the JCCP's MOUs with professional statutory regulators are a significant development, but I would maintain that relying on existing regulation is not enough to boost training standards. The only way patients can be truly protected is through legislation that requires practitioners to reach a certain standard before they can practice.
Unfortunately, the industry is very far from reaching this consistent standard when it comes to training. Providers vary widely, with a handful of systemised businesses regularly training large volumes of delegates in group courses led by medical professionals. A few beauty therapist schools do similar things—although they have been impacted by the JCCP's ruling to remove non-healthcare practitioners from the injectable register. The rest of the sector is made up of small providers, with varying degrees of experience. Shockingly, I'm even aware of some delegates offering their own teaching courses when they themselves have only just completed a foundation qualification.
This smorgasbord of providers is mirrored by the course content on offer. I have seen some trainers offering to teach thread lifts to non-medics—a practice that should be a CQC-regulated. I've seen others saying they can train delegates in breast and buttock augmentation, done via dermal fillers. Since the PIP (poly implant prostheses) breast implant scandal, more people are aware of the risks inherent in this type of practice, particularly if performed by non-medical professionals.
One inconsistency is post-course support. Only a few providers offer e-learning resources, shadowing groups and support frameworks where delegates can get advice after their course has ended. In fact, the opposite is often common, with some courses consisting solely of a trainer demonstrating how a procedure should be done. Delegates watch but never actually practise themselves. Once the course is over, the delegate receives the slides and the relationship ends there.
Probably the biggest discrepancy in aesthetics training is the lack of agreement about what safe practice looks like, where you inject, how you inject and what safety procedures you take. For example, one of the worst complications possible is skin necrosis. However, the possibility of skin necrosis occurring can be significantly reduced by using safe injection techniques. Such techniques require a strong understanding of the facial anatomy, as well as an approach to safety that is entirely intolerant of risk.
It is the small, incremental steps, repeated every day that are the key to a consistent safety ‘system’. Yet lots of practitioners do not always complete these tasks. Their justification is that they've never had any issues—many practitioners go for years before they witness a complication—but if their behaviour is multiplied over thousands of treatments, or their advice, as a trainer, is multiplied over millions of procedures, then that risk is magnified.
If a practitioner needs to reverse dermal filler, the substance used can lead to an allergic reaction, which occasionally triggers anaphylaxis. In the case of impending skin necrosis, many practitioners will say that time is short and there is no point doing an allergy test before administering hyaluronidase.
However, a blocked blood vessel takes hours to damage the skin and it is important to remember the context of the situation. If a practitioner is working from their back bedroom and they are by themselves and an hour away from hospital, then anaphylaxis could be perilous. A blocked blood vessel is not life threatening, and trainers must teach practitioners to maintain small safety measures—like allergen tests—to manage risk effectively.
This links to another training issue, born out of the industry's fixation with injection technique. Yes, injecting effectively is key to safe practice; however, there is so much more to the skill of an aesthetic professional. For instance, as well as assessing physical risk, training courses should teach delegates how to evaluate psychosocial risk.
I believe the only way an aesthetics practitioner can justify the risks they take with a treatment is by knowing it will improve the mental wellbeing of their patient. Teaching consultation skills is vital here, so delegates can identify the psychological impact a procedure might have on a person's life. These skills will help practitioners to identify those patients with a deeper insecurity which can't be solved via treatment. In these cases, it is important for practitioners to see that the psychological benefits don't warrant the medical risk and to discuss this fully with their patient.
Another key part of training is that of the diagnosis and management of complications. Many practitioners operate on their own and can feel isolated. As a result, they reach out to others when they have complications, often via images shared on social media with very little context. As a result, problems often arise when other practitioners suggest diagnoses.
Many issues, such as blocked blood vessels, have a very low risk rate, so the chance of someone having dealt with them directly is small. If incorrect diagnosis and management tips are shared online, practitioners have no way of knowing whether guidance is accurate or reliable. Due to the lack of regulation around aesthetics training, it is hard to know how well trained the practitioner offering the advice actually is. That's why it's important that courses cover complications in enough detail (videos are an important tool for this), but also that they offer longer term support to delegates. For example, I regularly see my trainees' patients if they have complications. As part of this, providers must teach practitioners about how to ask for help more consistently, at the same time developing a communication network so they can reach out quickly to validated experts.
Anyone going into aesthetics will quickly become aware that they are re-designing people's faces. Artistry is fundamental to doing this well, but the ability to create proportion and shape, being conscious of lighting and shadows, is seen as a ‘soft’ skill, and this means that many providers don't give it much focus, concentrating instead on perceived ‘harder’ skills, such as injection techniques.
It is important that all training courses support trainees on the wide range of issues discussed above. It is my personal aim to develop practitioners who understand the importance of small safety checks in everything they do. I want professionals to be guided by the psychological impact a treatment will have, and to ensure that they translate anatomical knowledge into aesthetic goals. The role of the trainer is to systematically cover and connect these different domains of practice.