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Clinical Practice Guidelines
Wrinkle Relaxing Injections
These injections are made using very small quantities of a medicine called Botulinum Toxin Type
A (BOTOX, Dysport, Xeomin). Botulinum Toxin is a protein and neurotoxin produced by the
bacterium Clostridium Botulinum and in the body it blocks nerve signals. It is now used regularly
to help the symptoms of nerve conditions such as cerebral palsy, stroke and multiple
sclerosis. However, it is also the most internationally popular aesthetic treatment for women, and
increasingly men, and is deemed to be a safe therapeutic product to help prevent or relax deep
and fine-line facial wrinkles. It can be used to treat the frown lines between the eyebrows,
forehead lines, crow’s feet, bunny lines, gummy smiles, jawline, chin and many other areas
including for treatment of hyperhidrosis (excessive sweating) and migraine headaches. The
benefits of botulinum toxin in these instance extend beyond a mere cosmetic appeal, giving
medical benefits to the patients.
Botulinum Toxin A is listed as a schedule 4 medication. As a result, a full medical and cosmetic
consultation, together with before and after photographs, is carried out before administration. As
the effects can take up to 30 days to develop we ask that patients return for a follow up
assessment to ensure the best results. Should more be required it would be added at this
time. The effects can last approximately 3-4 months however most clients find that after about 2
years of regular use, these effects may last longer.
The use of botulinum toxin type A in all of the above areas must fall within the scope of the Nurse
Practitioner endorsed in cosmetic therapy.
Dermal Fillers
Whilst cosmetic treatments such as botulinum toxin can reduce wrinkles by paralysing underlying
muscles, dermal filler injections can offer so much more.
Dermal fillers can add volume to skin thinned by aging or trauma or just to give a fuller, more
youthful effect. They are made from a clear gel (Hyaluronic Acid) composed of a substance that
is naturally found in the connective soft tissues and skin dermis therefore the risk of problems,
such as allergies, are greatly minimised.
Products such as Juvederm, Restylane, Emervel, Esthelis, Modelis and Princess Filler are used
to non-surgically enhance the shape of the face, or to lift the face. The main differences between
these fillers are their thickness, viscosity, and longevity. The finer and smoother HA products
tend to be used on finer lines, whilst the thicker viscous fillers are beneficial in filling facial
contours for structural augmentation and revolumisation of the face.
Common areas for treatment with dermal fillers include; lips, chin, nose, brows, frown, nasolabial
folds, temples, cheeks, peri-oral, and static wrinkles. Most treatments last between 6-18 months.
Hyaluronic Acid Dermal fillers are an unscheduled product and are not registered on the
Pharmaceutical Benefit Scheme. However, they must be prescribed and administered by a
health professional within their scope of practice. A full consultation will be performed, including
consent and before and after photos, before any HA treatments are performed.
Hyaluronidase is an enzyme are that degrades hyaluronic acid dermal fillers. The product is
used when patients are dissatisfied with their results either because of overfilled areas or
because of small localized bumps which can occur with dermal filler injections. It can also be
used in the rare occurrence of adverse effects. Hyaluronidase is injected directly into and
surrounding the treated area and can work within a few days to dissolve the filler.
Platelet Rich Plasma
Platelet-rich plasma (PRP) is a revolutionary Dermal Rejuvenation Technique that uses several
different growth factors and other cytokines to stimulate healing of bone, soft tissue and repair
ageing skin at the cellular level.
The most frequent areas to be treated are: peri-ocular (for the thin, crepe like skin and fine lines),
acne scarring, cheeks and mid face, neck, hands, Décolletage and other body areas such as
abdominal striae.
The treatment involves obtaining a blood sample therefore the practitioner must be competent in
venepuncture. The blood is collected in special sterile tubes and centrifuged in the clinic to
separate the plasma. The plasma is drawn up into a syringe and injected for facial rejuvenation.
Each patient will have undergone an individualised medical and cosmetic assessment, including
consent and photographs obtained. Topical anesthesia will be offered and will require
prescription before treatment. The PRP is injected, by multiple punctures under the skin
(including the dermis) using a needle or a fine bore cannula.
This is a low risk procedure but infection control measures must be strictly adhered.
Eyelash Clinic
Lumigan (Bimatoprost 0.03%) is a prescription only solution that can stimulate the lash follicles to
enhance naturally long lashes or repair those damaged by false applications. It is apply once
each night to the base of the top eyelid. As the treatment progresses, patients will begin to see
changes in length and darkening of the lashes. Results are seen after just 6-8 weeks with full
results at 16 weeks.
This is a licenced medicine for glaucoma. It is not available on the PBS scheme for the purposes
of lash enhancement. Side effects are uncommon but may include: darkening of the peri-orbital
area and colour changes to the iris. A full consultation including written consent will be required
before any prescription can be issued. Before and after photos will be obtained.
Dermaroller/DermaPen
Dermaroller and Dermastamp are medical devices used to provide skin-needling, a procedure
that stimulates the skin to regenerate and repair itself naturally and safely, creating smoother,
brighter, healthier, younger-looking skin. During treatment, the small needles (1mm-2.5mm) are
rolled over the skin. This causes gentle and controlled trauma to the skin and encourages
fibroblast cells to produce new collagen and elastin to repair the skin damage. The skin
regenerates itself every 6 weeks and this is the approximate time that patients would notice the
best improvement after treatment. The amount of sessions needed would depend on severity of
the skin damage.
Stretching caused by weight gain/loss or skin trauma can result in loss of collagen and elastin
leaving red/purple marks and indentations in the skin (striae). For striae, usually a course of three
sessions is recommended for the optimum outcome. Prescription topical retinol or vitamin A
products can be added to enhance the cellular turnover and improve the outcome.
In addition, Dermaroller (micro-needling) or Dermastamp can be a very effective treatment for
acne scarring and décolletage.
Patients will be prescribed a topical anaesthetic (EMLA5%, Trilocaine or LMX4) prior to treatment
for the purposes of reducing painful stimuli during the procedure. Before and after photos will be
obtained.
Facial, hand & Décolletage Rejuvenation
The aging process affects everyone and people often develop unwanted signs such as dark
circles under the eyes, nasolabial folds or jowls. Much of this can be attributed to facial volume
loss. The facial bones and natural fat pads that give the face its structure and support tend to
shrink and the skin becomes loose, enhancing the hollowness under the eyes, over the
cheekbones and around the temples.
Years ago, a surgical face lift was your only treatment option available. However surgical facelifts
alone can only address some of these changes. It is important to always to identify the
underlying reasons for the aged appearance. The use of advanced techniques using temporary
injectable products (Radiesse) can be injected into specific fat compartments in the face or
further diluted and injected superficially in the hands and décolletage. This can achieve naturally
attractive results which can often last in excess of eighteen months.
Skin Care & Chemical Peels
Solar Damage
The skin is the largest organ in the body and is therefore extremely important. It protects you
from the environment, helps control body temperature, hydration and contains nerves that allow
you to feel pain, and pressure. Age related skin changes are caused by environmental factors,
genetic makeup, nutrition, facial expression, sleeping positions and smoking. In Australia,
patients must be made aware of the powerful UVA rays. These are a product, not just of direct
sun, but of all natural light, capable of reaching the skin through glass, clouds and smog. It is
therefore recommended that we all use sun protection in our daily skin care regime, such as an
SPF 30 in the winter and SPF 50 in the summer. Although most cosmetic foundations and tinted
moisturisers now contain, at least SPF15, this is not enough. The clinics will stock a wide variety
of sun protection and skin care products approved by the Cancer Council Australia, including
tinted sun creams, gels and compacts.
However, without sun protection just a few minutes of exposure each day over years, can cause
noticeable changes to the skin, such as, freckles, age spots, spider veins on the face, rough and
leathery skin, fine wrinkles, loose skin, blotchy complexion and skin cancer.
Pigmentation
Hyperpigmentation is not only a prevalent condition; it’s one that can also be particularly
stubborn to treat. Although it is most common in middle age and beyond, hyperpigmentation can
also be seen in much younger clients. Directly caused by either overactive melanocytes, the cells
responsible for producing melanin or a proliferation of the melanocytes themselves (melanocytotic hyperpigmentation). Although, it is often viewed as a cosmetic problem, it can sometimes
be a symptom of disease or illness therefore a diligent approach to full medical assessment is
essential. For example, there is a wide array of medical conditions that may contribute to
hyperpigmentation, including Addison’s disease, Cushing’s disease and hypothyroidism. Current
or recent pregnancy, or current or recent use of birth control pills or hormone replacement
therapies. The main types of hyperpigmentation are Post-inflammatory hyperpigmentation (PIH),
Lentigines (liver spots or age spots) and Melasma. When a health professional is involved in the
treatment of the client’s condition, it is important that the client regularly communicate updates
regarding prescriptions and diagnosis so the skin care professional can ensure the most
appropriate treatment is being implemented.
There are two categories of treatment: topical agents and nonsurgical skin procedures. Although
good results can be achieved using either approach, the best results are accomplished via a
combination of the two. OBAGI Medical Products combine active ingredients in topical
formulations, such as tyrosinase inhibitors, alpha hydroxy acids (AHAs) or retinol to exfoliate and
rejuvenate the skin. Hydroquinone (4%) is among other topical agents available to skin care
professionals for the treatment of hyperpigmentation. Hydroquinone is frequently referred to as
the gold standard for hyperpigmentation. It has been used for more than 50 years and can be
combined with antioxidants, retinoids and hydroxy acids to improve results.
By combining topicals with superficial chemical peels (OBAGI Blue Radiance), as well as derma
needling, better results can be garnered more quickly.
Acne
Acne is very common and associated with comedones (blackheads and whiteheads) and pusfilled spots (pustules). Acne is caused by a build-up of oily fluid in the glands of the skin. This is
the perfect environment for the normal skin bacteria to multiply and cause pustules. Acne
usually starts in puberty and varies in severity from a few spots on the face, neck and back to a
severe problem that may cause scarring and severely affect self-confidence. Unfortunately for
some, acne can continue, or even begin, in late 20’s and 30’s.
There are many treatments for acne, ranging from fairly mild creams that can be purchased over
the counter to potent tablets that require specialist hospital dermatology input. Patients will be
assessed and initially treated with topical prescription products using OBAGI Medical products
(Tretinoin 0.05%, Benzyl Peroxide, Salicylic Acid, Metronidazole ointment). Photographs and
consent will be obtained and patients reviewed within 4-6 weeks. If patients are not responding
to topical therapy, they will be assessed for oral antibiotics such as tetracycline
(Minocycline/Doxycycline) or macrolides (Erythromycin/Clindamycin). In severe cases, patients
will be referred to a GP or Dermatologist.
Chemical Peels
Chemical peels are one of the most popular non-invasive cosmetic procedures performed to
rejuvenate the appearance of the skin. Often performed on the face, neck, and hands, various
types of chemical peels can reduce the appearance of facial wrinkles, scars, and uneven
pigmentation. Superficial peels (OBAGI Blue Radiance) are the mildest form of chemical peel
treatment and are usually performed using alpha-hydroxy acids (AHA), and in some instances
beta-hydroxy acids (BHA).
Alpha-hydroxy acids are naturally occurring acids which include glycolic acid, lactic acid, and
salicylic acid. Although the concentration of acid may vary depending on the extent of treatment,
the acids used to perform superficial peels are not as harsh as other chemical peels. With
minimal downtime, superficial peels are a safe, effective method of treating fine lines,
pigmentation abnormalities, acne scars, and persistent dry skin.
During a superficial peel, a chemical solution is applied to the face. The solution causes mild
trauma, or injury, to the epidermis, which is composed of five distinct layers. Similar to exfoliating
the skin, the injury causes the damaged outer layers of the epidermis to peel away. As part of the
healing process, increased cell growth produces new, healthier skin layers beneath, which give
the face a more youthful, rejuvenated appearance.
Administration Guidelines
BOTULINUM TOXIN A – ADMINISTRATION GUIDELINES.
TREATMENT AREA ANATOMICAL
RECOMMENDED
LAND MARKS
DOSE
POTENTIAL SIDE
EFFECTS.
Frontalis (forehead)
Upper half of
forehead
10 – 50 units
Brow Ptosis
Glabella
Corrugators and
procerus muscles
16 – 70 units
Brow ptosis, eye lid
ptosis, peri-orbital
oedema
Orbicularis Oculi
(Crows Feet)
1 cm outside orbital
rim and above
zygomatic arch
10–50 units bilaterally
Eye lid ptosis,
diplopia,
asymmetric smile
Chemical Brow Lift
Lateral orbicularis
oculi.
5 -20 units bilaterally
Eye lid ptosis,
diplopia, localized
eye oedema
6-10 units bilaterally
Upper lip ptosis,
periorbital oedema
Nasalis (Bunny
Lines)
1cm outside of the
orbital rim
Lateral wall of nasal
bridge
inferior
to
nasal radix
LLANSI (Gingival –
Gummy smile)
Inject levator labii
alaequae nasi.
Superomedially to the
nasolabial fold into
the muscle belly and
not the line.
2.5-6 units bilaterally
Lengthening of
uppers lip. Upper
lip ptosis.
Orbicularis Oris
(Upper lip lines and
lip fullness)
At vermillion border
or up to 3 mm above.
2.5-5 units per site
(up to 4 sites)
Asymmetric smile,
drooling, dribbling,
inability to pucker
Orbicularis Oris
(Lower lip lines)
At vermillion border
2.5-5 units per site
Inability to pucker,
drooling,
asymmetric smile
DAO (Jowls)
Injections must be
posterior to the lateral
border of the
depressor anguli oris
and anterior to the
belly of the
30-40 units bilaterally
Weakness of the
neck flexors.
sternocleidomastoid.
DAO (Marionette
lines)
Depressor anguli oris
outward from the
depressor labii
inferioris
5-10 units bilaterally
Asymmetric smile,
drooling, flattening
of lower lip,
inability to pucker.
Masseter
Below angle of jaw
and ear tragus
20-100 units
bilaterally
Weakness in
clenching,
asymmetrical smile
Mentalis (Dimpled
Chin)
Inject below transvers
mental fold in 2
injections
5-20 units
Drooling,
asymmetry
Platysmal Bands –
neck
Anterior aspect
muscle band
20 units per band
Weakness of neck
flexors.
Axilla Hyperhidrosis
Over central axilla
50-100 units
bilaterally
Nerve palsy, skin
infection
of
Contraindications
Botulinum toxin A is contraindicated in any person suffering from a peripheral motor neuropathic
or neuromuscular disease such as Eaton Lambert syndrome or myasthenia gravis.
Administration with aminoglycoside antibiotics may potentiate the effect of botulinum toxin and is
therefore avoided.
There is insufficient evidence in the use of botulinum toxin type A during pregnancy and breast
feeding to deem it safe in these circumstances. The use of botulin toxin A is therefore
contraindicated in pregnancy and breast feeding. It is categorized as pregnancy category C.
Skin infection in area to be treated is contraindicated.
Although not absolutely contraindicated in treatment, the risk of bruising can be reduced by
advising patients to avoid medications that inhibit clotting such as non-steroidal antiinflammatory, medication, warfarin, aspirin products, vitamin E and fish oil. Perform a risk-benefit
assessment when considering the patients’ medical history before temporarily ceasing such
medications and inform the patient that bruising may become an issue.
Bruising is a contraindication in the use of Dermal Fillers.
Any skin conditions (eczema, psoriasis, Lupus) or obvious skin cancers must be addressed
before injecting dermal filler products.
Any patient with an allergy to any products used must not receive treatment.
Side Effects
PRODUCT
Botulinum Toxin Type A
(Xeomin, Dysport & Botox)
Dermal Fillers (Emervel,
Esthelis, Juvederm, Voluma,
Restylane, Princess, Modelis
& Radiesse)
Dermaroller/DermaPen
Chemical Peel (Blue
Radiance)
Skin care (Tretinoin,
retinoids, NuDerm,
Clenziderm, CRX)
Oral medications
(antibiotics, antivirals, mild
analgesia)
POTENTIAL SIDE EFFECTS
Asymmetry
Local Muscle Weakness
Brow & Lid Ptosis
Peri-orbital oedema
Drooping
Drooling
Bruising
Swelling
Lumps
Granuloma
Asymmetry
Vessel occlusion
Bruising
Pain
Swelling
Peeling
Stinging
Peeling
Oedema
Burning
Peeling
Increased Sensitivity
Nausea & Vomiting
Diarrhoea
Headache
hypersensitivity
DURATION
4-12 weeks
2-18 months
1-6 weeks
LOCATION
Forehead
Frown
Crows Feet
Chin
Jaw
Mouth
Lips
Cheeks
Nasolabial folds
Jawline
Temples
Frown
Face
Décolletage
Abdomen
1-6 weeks
Face
Neck
1-6 weeks
Face
1-2 weeks
N/A
Consultation for all Treatments
Initial Assessment
Care of the patient or client is the primary concern for health professionals in clinical practice.
Providing good care includes:
•
•
•
•
Assessing the patient or client, taking into account his or her history, views and an
appropriate physical examination where relevant; the history includes relevant
psychological, social and cultural aspects including patient expectations.
Formulating and implementing a suitable management plan that (including providing
treatment and advice and, where relevant, arranging investigations and liaising with other
treating practitioners)
Recognising the limits to a practitioner’s own skills and competence and referring a
patient or client to another practitioner when this is in the best interests of the patients or
clients
Recognising and respecting the rights of patients or clients to make their own decisions.
Consent
Informed consent is a person’s voluntary decision about medical cosmetic care that is made with
knowledge and understanding of the benefits and risks involved. The patient is guided through
the consent process and is informed of all potential side effects. The Nurse Practitioner should
provide information to the patient in a way that they can understand (verbal and auditory) before
asking for consent. The informed consent should be obtained before proceeding with any
examination, investigation or treatment, unless it is an emergency situation. The patient should
be fully aware of the fees and charges and possibility of any additional costs.
Due to the fact that medical and health professionals are obviously better informed than the
patient and as a duty of care, they should adhere to a certain method in obtaining written
informed consent forms. The consent forms will therefore be supplied by the pharmaceutical
companies supplying the prescribed medications.
Physical Examination
Every patient will have a physical examination of facial anatomy. This involves assessing the
patients’ facial muscles at rest and on movement, facial asymmetry, degree of volume loss, fat
pad prolapse, bony prominence and skin integrity. Any identified areas are discussed and a
treatment plan formulated.
The client will have consented to the examination and will be involved in the formulation of the
proposed treatment plan, including prescribed dose. Botulinum toxin will weaken muscles and
this has to be considered when there is muscle reliance to maintain eyelid opening if there is a
natural brow ptosis. Patients should therefore be fully aware of potential side effects. In
addition, if the muscle mass is large, they may require a larger dose and several review
appointments to achieve the expected result.
With regards to dermal fillers and facial rejuvenation methods, the level of volume loss and depth
and extent of deep lines and wrinkles with determine the product required in relation to molecular
density.
Post Treatment Advice
All patients will receive post-treatment advice verbally and in written form. They will also be
provided with a review date, if necessary, before leaving the clinic and an emergency number to
contact in the case of adverse effects.
Avoid excessive alcohol, and strenuous exercise after the procedure.
If bruised, apply ice and arnica cream. Depending on severity of bruising, take arnica
tablets for 1 to 5 days afterwards.
Do not massage or rub the area. Take care to avoid excessive touching due to
infection risk.
First 24 hours
Do not apply any cosmetics to the treated area.
If you are prone to cold sores and you have been treated in that area, you should
have been prescribed zovirax tablets to be taken just before the treatment, and for a
few days after.
24-48 hours
Avoid moisturisers or products that contain AHA (Alpha Hydroxy Acids/Glycolics), BHA
(Beta Hydroxy Acids) or Retinoids.
Avoid taking Aspirin/Disprin, anti-inflammatory and pharmaceutical blood thinners.
Avoid sunbeds and saunas, and excessive sweating and sun exposure.
Gently massage the treated areas with clean fingers smoothing away any remaining
lumps from the procedure.
First 14 days
Avoid having facials, waxing, Gycolic or AHA peels, liquid Nitrogen or Laser treatments
on the treatment area for the next 14 days. Laser resurfacing should only be done
after the dermal filler has disappeared from the skin.
After 14 days
Continue to apply SPF 50 + sunscreen every day to avoid further sun damage and
aging of your skin from the Australian sun.
We recommend you to return to the Clinic within 2-4 weeks after treatment, so we
can assess your satisfaction with the outcome.
Documentation
Each patient will receive their own patient file. This includes assessment details (Demographics,
Presenting complaint, Past Medical history, Drug History and Allergies), consent and a record of
treatment performed (including product, prescriber, batch number and expiry date, dosage, area
injected and any additional information). Each patient visit is documented in their patient file. All
patient files contain confidential information and are stored securely.