For the most part, the use of botulinum toxin injectables for the treatment and reduction of wrinkles and lines has proven to be a highly effective procedure. Yet, there are certain instances when they do not produce the desired results.
Dr Riekie Smit discusses patient dissatisfaction with botulinum toxin for aesthetic reasons.
“The master has failed more times than the beginner has even tried” ~ Stephen McCranie
As a doctor, the above quote has always resonated with me – as the reality is that the more a physician performs a specific treatment, the higher the chance of having a patient with a side effect, a treatment failure or a dissatisfied patient.
I suppose the best way to explain this is by comparing it to cycling. If you’re not keen to get on a bike, or maybe it happens once in a blue moon when on holiday, then your chances of falling are really low. But for those of you watching the recent Tour de France race, we see how even these highly trained and skilled professional cyclists can still tumble to the ground, scraping and scratching their elbows and legs to ribbons (which only adds to their many scars from previous accidents).
Now, by using this same analogy with doctors, what we see is that when they become an expert in a procedure (because they have performed and perfected a fair amount of this specific procedure), they will obviously have a higher chance of a problem arising from this treatment.
And unfortunately, when that one problem comes along, the patient often thinks the doctor is inadequate – who then often shares this with friends, families – or even worse – on social media.
Fear of failure
Many doctors have a tremendous fear of having just one dissatisfied patient. Numerous reasonings behind this include fear of failing, fear of loss of reputation, fear of being inadequate and fear of harming (Hippocratic oath). They have also put so much effort into studying, staying up-to-date on all the latest innovations and following all the rules, that one disappointment feels like a disaster for a doctor.
In fact, this anxiety may sometimes be so extreme, that a doctor may avoid performing certain procedures altogether. Lance Armstrong once said, “ If you worried about falling off the bike, you’d never get on.”
Now, when looking at botulinum toxin treatments for aesthetic procedures, there is quite a bit of pressure on ensuring that all patients are pleased.
And since this treatment is well-known to be very effective and safe, the first one to be blamed when a patient is not happy is often the doctor.
Reasons for dissatisfaction with botulinum toxin treatment
Why would someone be dissatisfied with botulinum toxin treatment for aesthetic reasons (frown lines, eye wrinkles, forehead wrinkles or other)?
1. The treatment procedure itself
a. The doctor
b. The consultation
c. The staff
2. The treatment results
a. Insufficient result
b. No result
c. The duration of the result
d. The expectation
Treatment procedure dissatisfaction
Patients may be disappointed immediately following the treatment procedure itself, which could be attributed to the doctor not being kind, compassionate, maybe too much in a rush, inadequate injection skills that cause pain and multiple bruises, overcharging, or insufficient discussions during the consultation.
This is a tricky one as patient expectations vary, with some patients being more demanding than others. Patients could also be unhappy due to the way the reception or other staff treated them, or it could be related to unhappiness regarding financial reasons. Aesthetic treatments come at a high price due to the cost of medications and medical devices needed to perform a quality procedure. Most often, people expect miracles from one syringe just because it is expensive.
Doctors, therefore, need to explain to each individual patient what to really expect, how often it will be needed and what else will be required to achieve really good results. Furthermore, the older a patient is when starting their aesthetic journey, the more they need to combine treatments, repeat treatments and ‘boost’ treatments. In this scenario, the financial aspect is a cause for patient dissatisfaction.
Lastly, patients often compare their results with their friends, where they expect the same outcome from a specific treatment – not realising how different each person’s face, muscles, bones and muscle structures are.
Treatment results dissatisfaction
Insufficient or no results with botulinum toxin is a major concern, not only for the patient paying but certainly for the doctor as well. There are numerous factors that could contribute to the treatment not working:
- Medication handling errors
The product was not stored in a fridge, the cold chain was broken somewhere along the line, incorrect reconstitution of the product or miscalculation of units.
- Inadequate dosing
The results of botulinum toxin depend on the amount of units delivered to the muscle. A larger, stronger muscle requires more units to have the same effect, and therefore insufficient dosing could result in insufficient results. This could be because the doctor did not predict the muscle to be so strong, or because the patient did not want to, or did not have, sufficient funds for more units. This will result in a less visible outcome, along with a shorter duration of result.
- Incorrect injection
If the right amount of units are injected outside the muscle, then less units will reach the muscle with reduced efficacy. This is due to either muscle variations amongst patients, or to inadequate evaluation of the patient’s unique muscles.
- Anatomical factors
There are beautiful anatomic educational courses, books, apps and online learning where doctors can update their knowledge and skills. However, there are numerous patients with unique muscles and unique locations of muscles that do not follow the textbooks. This could lead to incorrect placement of units.
- Patient evaluation factors
Certain patient factors may also affect the result of the treatment, which is why doctors insist that you complete full medical history forms. With that said, however, most patients feel it is not necessary that your doctor needs to know everything. Medical factors that may affect results include certain chronic diseases, medicines, surgical procedures, other aesthetic treatments, age and gender features of muscles. As for patient evaluation factors, these may include the increase of patient expectations of treatment results over time, the nature/cause of wrinkles, the overlying skin quality, and volume changes in the face.
- Antibody formation against botulinum toxin
Antibody formation against botulinum toxin is a very rare occurrence in aesthetic treatments. This happens rarely, but mostly in the use of the product in large doses, such as seen with neurological/therapeutic indications. Patients who receive botulinum toxin for aesthetic treatment actually receive small doses of toxin, with a relatively long interval between injection cycles compared with therapeutic or neurological indications. This results in a low risk of the development of neutralising antibodies.
Also, research has shown that the development of neutralising antibodies is not always related to a lack of efficacy. Nonetheless, it is always recommended to keep at least three-month intervals between treatments with botulinum toxin.
- Duration of results
Patients are very unhappy if their frown lines are back within a month or two. The expected duration of results on frown and eye wrinkles is at least four to six months. Factors that could result in a shorter duration of effect includes underdoing, very strong muscles, very active patients (like athletes) and certain medications.
The duration of the result is also directly related to the amount of product used. Yet in certain areas of the face, very low doses of botulinum toxin is used to prevent side effects such as in the forehead lines and around the mouth. If higher doses are used to increase the duration, then the brows will drop or the patient will not be able to speak properly. The result will therefore be shorter in those areas due to the use of lower doses. Patients do not always understand this, especially if the doctor did not discuss this with them.
- Patient expectations
Now this is the fiddly part, as some patients really expect miracles from one syringe of product (especially if starting too late). It must then be noted that while botulinum toxin relaxes a muscle over an area where wrinkles form, it does not plump up a wrinkle, remove sun damage or volumise the face (so it’s certainly not a magic potion against ageing exclusively).
Moreover, since ageing and wrinkles is a multi-dimensional process that involves skin, fat, muscles, bone, gravity, genetics, environmental exposure and lifestyle, it’s really important for doctors to discuss all aspects of the treatment, such as what it entails and how many treatments are needed to look younger, fresher and more beautiful. A good consultation will ensure that patients have realistic expectations.
The images below are an example of a patient that did not respond to a botulinum toxin treatment due to a problem with a specific saline used to reconstitute the product. The top images shows the patient frowning and lifting her brows before treatment. The middle images shows the result (no result) after two weeks using botulinum toxin that had a faulty bacteriostatic saline batch. The bottom images depict the result of the patient after using normal injectable saline for reconstitution.
This was a series of cases in one week, and only after a full investigation into all the possible factors, incident reports and other clinical tests, it was confirmed not to be antibodies or faulty product, but rather faulty reconstitution product.
Take home message
The secret of managing patient non-response or dissatisfaction lies in not shifting blame, but to investigate intensively into each case in order to maximise learning from your (and others’) mistakes. Managing each patient with a specific protocol will help physicians to take control (and feel in control) in difficult patient cases.
Patients and doctors should have a good relationship where realistic expectations are often discussed, and holistic treatment plans are formulated and revised regularly to ensure both doctor and patient remains satisfied.
Written by Dr Riekie Smit – MBChB, MSc Sports Med, Adv Dip Aesth Med
- Dr Smit has a private practice in Pretoria, South Africa. Her focus of her practice is aesthetic medical procedures for face, body and skin treatments www.drriekie.co.za
- Honorary secretary of AAMSSA (Aesthetic & Anti-Ageing Medicine Society of South Africa).
- Faculty member of the American Academy of Aesthetic Medicine.
- Chairperson of the Aesthetic Medicine Congress South Africa (AMCSA).
- President member of the International Union of Aesthetic Union.
A2 Disclaimer: This article is published for information purposes only, nor should it be regarded as a replacement for sound medical advice.
This article was written by Dr Riekie Smit and edited by the A2 team EXCLUSIVELY for the A2 Aesthetic & Anti-Ageing Magazine Sep 2019 Edition (Issue 31).
A2 Magazine prints only four magazines each year – reporting seasonally on everything you need and want to know about aesthetics, anti-ageing, integrative medicine, quality and medical skin care, cosmetic dentistry and cosmetic surgery in South Africa – where to go, who to see, what to expect, something new and so much more! Never miss an edition – click here for more info about where you can buy the print and/or digital copy of A2 Magazine (including back copies).
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