What should you ask before a treatment?

Asking Questions Is Part of the Treatment

Informed consent – the permission you give once you understand the procedure, its risks and its possible outcomes – is not just a signature; it is a conversation. A review of medico-legal cases and court rulings on filler treatments spanning 15 years found that, when a known complication occurred, patients claimed that the practitioner had not obtained their informed consent. The researchers highlight communication and the recording of what was discussed as the factors that make sure patients are aware of the consequences of their treatment.

In practical terms, this means that the questions you ask before a treatment are not a sign of mistrust; they are the consent itself. A patient who asks no questions is not considered to have accepted the risk; they have simply not heard about it.

A publication on the ethics of aesthetic treatments makes the same point: safety cannot be judged by the name of the procedure alone. The practitioner’s competence in that particular procedure, the setting in which the treatment is carried out and that setting’s capacity to manage a complication must also be taken into account.

The questions to ask also fall under these three headings: who, where, and what is in place if something goes wrong. You do not have to ask them all. Whichever ones you ask, the way the answer is given will also tell you something.

Who Will Treat You, and Their Professional Title

The first question is the simplest: who will be holding the needle? You have the right to ask for the name and professional title of the person who will carry out the treatment, and about the training they have had for this procedure. Ask this before you go into the treatment room.

This question matters more than it may seem. A review of the regulations in all 50 states of the United States and in the District of Columbia shows that neuromodulator (muscle-relaxing) and filler injections are classed as medical procedures everywhere. Yet the rules on delegating these high-risk procedures to others and on supervising them have often remained similar to those for low-risk procedures. In other words, a procedure being classed as medical does not mean there is tighter control over who carries it out.

The consequences are on record too. In a study in Iran comparing three years of forensic case files, the cases involving unlicensed practitioners most often concerned minimally invasive procedures such as fillers and botulinum toxin (often called Botox®). In more than half of these cases, the treatment had been carried out in an informal setting such as a home, and infection and tissue death (necrosis) stood out markedly in this group. The cases involving licensed doctors showed different problems: technical complications, structural deformities and dissatisfaction with the result.

These two pictures are not the same. In the cases involving licensed doctors, the dispute is about the shape of the result and whether the patient liked it; in the cases involving unlicensed practitioners, tissue loss is involved.

The publication on the ethics of aesthetic treatments expects the same of practitioners: competence is specific to each procedure, it cannot be covered by a general title, and what a given training authorises someone to do must be clearly defined. For you, this comes down to a single question: how many times have you done this procedure before, and if a complication occurs, do you manage it yourself, here?

Which Product Type Will Be Used, and Why

Not every injected substance is the same. Research shows that the product types used in facial aesthetics, such as hyaluronic acid (HA), calcium hydroxylapatite (CaHA), poly-L-lactic acid (PLLA), polycaprolactone (PCL), the person’s own fat (autologous fat) and polymethyl methacrylate (PMMA), differ from one another in how they work, their consistency and behaviour in the tissue, how long they last and their safety characteristics.

For you, the most concrete consequence of this difference is whether the result can be reversed. Hyaluronic acid fillers add volume as soon as they are injected, and they are reversible. Calcium hydroxylapatite, poly-L-lactic acid and polycaprolactone both add volume and stimulate collagen production. Polymethyl methacrylate, on the other hand, provides permanent correction in selected cases.

So the question to ask is not ‘Am I going to have filler?’ The real questions are these: which type of substance will be used, can it be reversed, and if it cannot, what will happen if you do not like the result?

Reversibility is specific to hyaluronic acid fillers and is achieved with an enzyme called hyaluronidase; this procedure is explained in detail on the Filler Dissolving page. For the other types, there is no equivalent way of reversing the result. When you are making your decision, these two situations do not carry the same weight.

Seeing the Product Being Unpacked

You may want to see the product’s box and syringe as they are opened. This is not an unusual request. A record of what was injected into you is the only document you will have if a problem arises later.

There are examples that show why this matters. According to a publication on delayed hypersensitivity reactions to substances of unknown content injected by unlicensed individuals, when the substance is unknown, the immune reaction can be more severe than with approved products and can appear much later.

If a problem arises, the doctor’s first question will be ‘What was injected?’, and often only you can answer it. Keeping your own record of the product’s name, its type of substance and, if possible, its batch number will also help you if you later see another doctor.

Where the treatment was carried out is also part of this record. A study following up complications of permanent fillers reports that complications were significantly more common in people who had their injections in a non-medical setting.

What Informed Consent Covers

A consent form is not a piece of paper to sign without reading. According to researchers who have examined the consent process for filler treatments, consent should include not only the name of the procedure but also the consequences of known complications, explained in a way you can understand. They also report that a lack of communication and of records has become the basis for legal claims.

Look for these points on the form:

• Which procedure will be carried out, on which area and with which type of substance?
• What is the expected effect?
• What are the common, temporary side effects?
• What are the rare but serious complications?
• If one of these happens, what will be done, and who will do it?

Rare complications should also be named in the consent. In the UK, a multidisciplinary consensus group explicitly recommends, in its guidelines on filler-related vision loss, improving consent processes and raising awareness of complications affecting vision. Vision loss is rare, but that is no reason to leave it out of the consent conversation.

You have the right to read the form on the day of treatment, before you lie down on the treatment couch, without being rushed. If there is a line you do not understand, ask before you sign.

Consent also has a record-keeping side: documenting what you agreed to is regarded as an integral part of the process. If the type of substance used, the area and the date are written in your file, you also have the right to ask for a copy; if you later see another doctor, that is the first place they will look.

Expected and Unexpected Effects

There are two separate questions here, and you should ask both: what is expected from this treatment, and what is not?

Discussing the limits of what to expect from the start prevents much of the disappointment that could come later. The same standard applies to consent: what counts is not that you have heard the name of the procedure, but that you are aware of its consequences.

Unexpected events should also be named. Research on facial injections shows that most adverse effects are mild and temporary; by contrast, rare cases of vascular occlusion (a blocked blood vessel) need to be recognised and treated quickly. These two facts should be read together: what is common is mild; what is serious is rare, but it cannot wait.

There is one more point, about timing. A review of delayed-onset inflammatory nodules (small firm lumps) after hyaluronic acid fillers reports that, as well as the structure of the product, this condition has been linked to the person’s immune status, events that trigger the immune system and bacterial contamination. In other words, there is no moment when you can say ‘the treatment is over, and that’s the end of it’; you should have somewhere to turn even after time has passed.

Who to Contact, and How, If There Is a Problem

When you leave after the treatment, you should have a name and a phone number. Who will you call, at what times, and what happens outside opening hours? Ask about this before the treatment, not after.

There is a medical reason for this. Research on vascular occlusion caused by hyaluronic acid filler shows that recognising the blockage early is decisive in limiting later tissue damage; this research also looks at preventive measures together with a first-aid protocol.

Early recognition is not only the doctor’s job. In vascular occlusion, the skin first turns pale and then takes on a net-like purple colour; the pain is more severe than expected and keeps getting worse. For signs affecting vision, the UK consensus guidelines provide guidance. Call if you notice any of these signs:

• Pain in the treated area that is more severe than expected and getting worse.
• Skin turning pale or purple.
• A spreading, net-like pattern on the skin.
• Blurred vision or vision loss.
• Pain around the eyes.

If you have any of these, booking an appointment, waiting until the next day or hoping it will pass is not an option.

These guidelines recommend that, for vision loss, the urgent first measures and the route to specialist care are both decided in advance. The clinic is expected to know before your treatment where it would refer you if needed.

What the Clinic Has on Hand in an Emergency

This question may sound strange, but it is worth asking: ‘If a vascular occlusion happens here, what do you have available?’

A publication on the contents of an emergency kit for filler treatments proposes classifying the necessary medicines into three levels: mandatory, recommended and suggested. These medicines are grouped by the situation in which they are used:

• Vascular occlusion without eye involvement.
• Vascular occlusion with eye involvement.
• Anaphylaxis (a severe, life-threatening allergic reaction).
• Cardiopulmonary resuscitation and circulatory disorders.
• Delayed reactions.

Keeping track of stock coming in and going out, and of expiry dates, is also considered part of being prepared.

With hyaluronic acid fillers, the enzyme hyaluronidase is at the heart of first aid. The review on vascular occlusion lists the following as part of the first-aid protocol: using the enzyme without hesitation, applying heat, and massage. It also states that the check made by pulling back the plunger before injecting (aspiration) does not reliably show that the needle is not in a blood vessel.

Your question is a short one: is hyaluronidase available here, what is there for anaphylaxis, and is the person who would use these in the building during the treatment? More than the details of the answer, what tells you something is whether the question catches the other person unprepared.

Tell Your Doctor About Medicines and Blood Thinners

Questions go both ways; there are also things your doctor needs to hear from you.

The first topic is medicines. If you take blood thinners, always tell your doctor. A review of how these medicines (antithrombotics) are managed in dermatological surgery states that stopping them increases the risk of events such as stroke, heart attack, pulmonary embolism (a blood clot in a blood vessel in the lungs) and deep vein thrombosis (a blood clot in a deep vein), while continuing them carries a risk of bleeding. There is no agreed guideline for skin procedures; approaches vary from doctor to doctor.

The person who should strike this balance is the relevant doctor. Do not stop your blood thinner on your own because of an aesthetic treatment. Tell your doctor that you take it; the decision on whether to stop it should be made together with the prescribing doctor.

Supplements such as garlic, ginger and ginkgo are also among the things assessed for bleeding risk. So the right question is not ‘Do you take any medicines?’ but ‘What do you take?’; this includes anything taken without a prescription and herbal supplements.

Pregnancy, Breastfeeding and Autoimmune Disease

Always tell your doctor if you are pregnant or breastfeeding. In a survey study on the use of botulinum toxin during pregnancy and breastfeeding, most of the participating doctors said they had treated breastfeeding patients or had been treated themselves while breastfeeding, and no adverse effects were reported. However, the researchers’ conclusion is clear: these findings are not evidence of safety but observations that need to be confirmed, and they show a gap between everyday clinical use and the safety data available.

In other words, research cannot give you a definite answer on this. When there is no definite answer, the decision is made at the consultation, by discussing your situation, together with you.

Autoimmune diseases – conditions in which the immune system attacks the body’s own tissues – are also among the things you should mention. A review of hyaluronic acid fillers in people with an autoimmune disease of the hormone glands (autoimmune endocrinopathy) states that, because of the disorder in their immune system, this group has a higher risk of immune-related adverse effects. The most common are recurrent swelling (oedema) and small inflammatory lumps (granulomas).

This is not a list of prohibitions; whether you can have the treatment is decided at the consultation, after your situation has been assessed. If you do not mention these things, your doctor makes the decision based on an incomplete picture.

Previous Treatments and Any History of Permanent Filler

Tell your doctor about every treatment you have had before, even if it was years ago.

The most serious part of this is permanent fillers. In a study that screened new patients and followed them over time, a filler-related problem was found in more than half of the patients who had had permanent filler. All of those with a problem had a lump that could be felt, and the problem most often appeared 1–5 years after injection. The researchers recommend avoiding these substances completely, and taking great care, as the way to prevent complications from permanent fillers.

This is what your doctor needs to hear from you: what was done, when, on which area and by whom. If you do not remember, say so too. ‘I don’t know’ is also information, and it changes your doctor’s assessment.

As the publication on delayed-onset inflammatory reactions points out, a filler-related problem can also appear late, after an event that triggers the immune system. So the fact that a past treatment went without problems does not make it irrelevant; it only shows that no problems have occurred so far.

How These Questions Are Received Here

When you come to this clinic, you can ask all of these questions; none of them will be treated as unusual. Who will carry out the treatment, which type of substance will be used, the product being taken out of its packaging, what the consent covers, how you can get in touch after the treatment and emergency preparedness are discussed at the consultation; they are explained even if you do not ask.

The treatments carried out at the clinic are hyaluronic acid fillers, collagen-stimulating fillers, thread lifting with dissolvable threads, botulinum toxin, mesotherapy and filler dissolving. Which of these may be considered for you is assessed at the consultation.

The only aim of this article is to give you these questions in advance. You decide which of them to ask, what to do with the answers you get and whether to go ahead with the treatment.