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Study Investigates Who Treats Patients with Injectables

Dermatology TimesDermatology Times, October 2021 (Vol. 42. No. 10)
Volume 42
Issue 10
Pages: 38

The Dermatologic Surgery journal published a study on who performs cosmetic injections at dermatology and plastic surgery practices.

A recent study1 of procedures at 492 dermatology and plastic surgery practices in United States metropolitan areas found that physicians perform the vast majority of cosmetic injections to relax wrinkles and add volume.2

Data from the research revealed that 18.35% of dermatology and 25.4% of plastic surgery practices allowed nurse practitioners and physician assistants to give injectable treatments. This percentage includes procedures done both with and without oversight of a supervising physician.

According to the authors, demand for minimally invasive cosmetic procedures continues to rise. In response, there is an increasing number of non-physicians who can legally perform these procedures, enabling practices to offer more cost-effective care. However, physicians have a more rigorous and longer training, according to the American Society for Dermatologic Surgery (ASDS).

“I think patients always need to be treated by the person who is most qualified to perform the procedure,” said Patricia Farris, MD, founder of Old Metairie Dermatology, Metairie, Louisiana, and Dermatology Times®editorial advisory board member. “This ensures not only best results but also patient safety. In the case of injectables, core physicians trained in aesthetics are undisputedly the most qualified.”

Farris added that while non-physicians may be qualified, the patients cannot verify their credentials. And, in the world of social media, she said it is easy to pose as an expert.

Farris, Harold J Brody, MD, dermatologist, Atlanta Dermatology in Georgia, and Roy Geronemus, MD, director of the Laser & Skin Surgery Center of New York, New York, and Dermatology Times®editorial advisory board member, initially published the results of their investigation in 2003.3 They surveyed 2400 members of the ASDS in July 2001 and conducted 8 phone interviews with patients who experienced complications that arose when the procedure was performed by a non-physician.

Data showed that patient complications arose primarily in treatments performed by non-physicians such as cosmetic technicians, aestheticians, and employees of medical and/or dental professionals who performed various invasive medical procedures outside their scope of training or with inadequate or no physician supervision.

“In our practice, we have a physician-only model. We do not use extenders for any cosmetic procedure, especially injectables,” Geronemus told Dermatology Times®. “There are many reasons for that. Specifically, I think it does require a skill set that may not be taught to those who are not trained the way we are as physicians and dermatologists.”

Injectable treatments can have serious adverse events (SAEs) if not done properly, including scarring, blindness, and other medical trauma that a non-physician may not be prepared to address if they occur during treatment, he explained.

The ASDS’s stance is that providers need dermatologic expertise to perform injectable treatments because only physicians have extensive medical education, training, and aesthetic expertise to deal with complicated facial anatomy and possible complications.

“The role of non-physician practitioners in dermatology and plastic surgery practices is controversial and highly debated,” said Naomi Lawrence, MD, coauthor of the study from the Dermatologic and Cosmetic Surgery and Skin Cancer Center at Cooper University Health Care in Marlton, New Jersey. “However, studies have shown that non-physician providers are being used increasingly in the delivery of dermatological care. We were surprised to see that a significant number of practices that use non-physician injectors could not verify on-site supervision at all times.”

Geronemus noted additional challenges. “The issue one has with extenders is that they’re less invested in your practice and may be there 1 month and perhaps not the next,” he said. “They’re not going to be familiar with your preferences or your technique, and many times there’s no oversight. The doctors [may be] in the operating room, and someone’s in their office [performing the] injection and maybe that’s not in the patient’s best interest.”

Geronemus pointed out that this does not mean that non-physicians are not well trained or that they are not good at performing the procedures. However, Geronemus said, in his practice, which offers many different technologies and services in addition to injectables, complications are more likely to result from procedures performed by non-physicians.

Ashley Decker, MD, another of the study’s coauthors, said patients should be aware that cosmetic procedures carry risks of temporary and permanent AEs from improper techniques. Patients also need to understand that different injectables could have a broad range of properties and AEs, noted Decker, who is a dermatologic surgeon at the Dermatologic and Cosmetic Surgery and Skin Cancer Center at Cooper University Health Care in Marlton, New Jersey, and associate professor of medicine at the Cooper Medical School of Rowan University in Camden, New Jersey.

In her view, injectors have to be sufficiently experienced with the products being used. They also must maintain detailed knowledge of facial anatomy and be prepared to provide appropriate treatment should AEs occur. However, she said, the ultimate responsibility for each patient’s outcome rests solely with the supervising physician.

In some cases, the practice owner can decide who administers injectables and, in others, it’s the state’s choice.

State laws differ on whether certain procedures can be done by a non-physician. The laws can define what can be delegated, who can perform the practice of medicine, and the impact on malpractice insurance coverage, according to Geronemus.

Some organizations believe there is not enough regulation protecting patients. This is why the advocacy group American Society for Dermatologic Surgery Association (ASDSA) was created. The ASDSA is an advocacy group separate from the ASDS that promotes patient safety. It includes more than 6400 board-certified dermatologists as members. They support requiring on-site physicians to supervise all non-physician providers to ensure patient safety. ASDSA also opposes decision-making based on financial gain to ensure the best quality of care and patient outcomes, as stated in its position on Physician Oversight in Medical Spas.4

The ASDSA has drafted new model legislation, called the Medical Spa Safety Act5, to keep medical procedures under the supervision of physicians in medical spas. The model would require on-site supervision of any non-physician treatment providers, along with requiring medical directors to have training on all procedures being performed. The bill also mandates additional education requirements, such as training by a vendor or manufacturer; notification if a physician is not on site; and options for mandatory AE reporting.


  1. Nesi L, Belcher M, Decker A. Midlevel injectable practice patterns in dermatology and plastic surgery offices. Dermatol Surg. 2021;47(5):645-648. doi:10.1097/DSS.0000000000002927
  2. New study confirms physicians perform the majority of cosmetic injections. News release. American Society for Dermatologic Surgery. July 8, 2021. Accessed July 13, 2021. https://www.prweb.com/releases/new_study_confirms_physicians_perform_the_majority_of_cosmetic_injections/prweb18059670.htm
  3. Brody HJ, Geronemus RG, Farris PK. Beauty versus medicine: the nonphysician practice of dermatologic surgery. Dermatol Surg. 2003;29(4):319-324. doi:10.1046/j.1524-4725.2003.29088.x
  4. Position statements. American Society for Dermatologic Surgery Association. Accessed September 9, 2021. https://www.asds.net/asdsa-advocacy/positions-model-legislation/position-statements
  5. Model legislation. American Society for Dermatologic Surgery Association. Accessed September 9, 2021. https://www.asds.net/asdsa-advocacy/positions-model-legislation/model-legislation
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