Tatjana Pavicic, M.D., a dermatologist based in Munich, Germany, is an internationally recognized expert in aesthetic dermatology, and injectables in particular. She launched her highly successful private practice on Maximilian Street in the heart of Munich in 2014, but started working with injectables near the end of her specialist residency for dermatology and venereology around 2007, when they were still fairly new in the world of aesthetics. Since then, Dr. Pavicic has watched the changes in injectable filler formulations and injection techniques evolve over that time. However, the lack of focus on patient safety when it comes to HA filler injections inspired her to become a staunch advocate for its improvement, leading to her speak at conferences around the world on this subject and stand out as a voice for change and improved regulation and patient education, particularly in relation to injectable fillers, in the aesthetic industry.
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Tatjana Pavicic, M.D., a dermatologist based in Munich, Germany, is an internationally recognized expert in aesthetic dermatology, and injectables in particular. She launched her highly successful private practice on Maximilian Street in the heart of Munich in 2014, but started working with injectables near the end of her specialist residency for dermatology and venereology around 2007, when they were still fairly new in the world of aesthetics. Since then, Dr. Pavicic has watched the changes in injectable filler formulations and injection techniques evolve over that time. However, the lack of focus on patient safety when it comes to HA filler injections inspired her to become a staunch advocate for its improvement, leading to her speak at conferences around the world on this subject and stand out as a voice for change and improved regulation and patient education, particularly in relation to injectable fillers, in the aesthetic industry.
Dr. Pavicic points out the advancement of knowledge around the anatomy of facial aging in aesthetics and the unintended consequences when the industry first started realizing that we lose facial volume as we age. She states that after this realization, practitioners, “would try to fix everything with volume, resulting in these pillow faces and overfilled lips.” While on the one hand, knowledge is power, industry professionals in recent years have now had to course correct for this more simplified view of lip enhancement, redefining the proper safety measures and aesthetic technique for the utilization of HA fillers. The results of bad lip filler can vary depending on the severity of the issue and the specific circumstances. Experiencing overfilled or uneven results from lip fillers can be disappointing and, at times, uncomfortable.
Ensuring proper patient safety, technique and an artistic eye when using HA fillers to enhance volume, correct unevenness and overall appearance of a patient’s lips or other area of the face is vital to providing optimal results and a positive patient experience. This is a treatment that all aesthetic practitioners need to make sure they are handling with care, as mistakes can have serious consequences and even cause tissue necrosis if the product is accidentally injected into a blood vessel. On top of that, the face, and the lips in particular, is an area that is difficult to hide if something does go wrong, meaning practitioners that want happy patients need to take the utmost care to treat the face safely and with an artistic eye.
Understanding HA Filler: Injector Training & Certification
To elevate lip enhancement techniques and optimize treatment results with HA fillers requires the proper understanding of differences in HA fillers and excellent injection technique. Not all HA fillers are created equal, and each is only as safe as its user. Depending on the modification to the HA filler caused by differences in the manufacturing process, different HA filler gels have different structures with different characteristics. Understanding the differences in HA fillers and their individual characteristics is vital to knowing which formulation of HA filler is most suitable depending on the individual patient being treated (patient age, individual facial characteristics, skin quality, etc.) and what purpose the filler is intended for, whether that be the enhancement of the lips, jaw, midface or other area.
Part of this comes down to a need for better education and training in injectables and improving regulations for what type and duration of training is required to be certified as a professional injector. Dr. Pavicic states, “What I think is still missing is there are not many training opportunities that teach the aesthetic aspects of injecting. Somehow the topic of what is aesthetically desirable for the appearance of lips is left instead to social media, people that aren’t qualified or prepared to thoroughly research this aspect of aesthetics and beauty standards.”
Dr. Pavicic explains the impact of inadequate injector training, the lengths practitioners have to go to if they wish to be properly trained in filler injections and the complications resulting from individuals taking advantage of this lack of injector regulation. She states, “It’s not just being a doctor; it’s also being an artist. Since now it’s available everywhere and to any doctor, and in many countries not even doctors, someone can take a mere 4-hour course and call themselves injectors. This is really dangerous, and that’s why we’ve started to see so many complications. We need to create better regulations for who can be an injector. It’s a must. It should be a subspecialization. Even if I’m a board-certified dermatologist or you’re a plastic surgeon, you might learn how to reconstruct a face after trauma, but filler injections are not a part of the basic education provided. You have to take time out and/or travel to get it. Some doctors will invest a lot of time and money to get education – they will go to different courses, to different injectors to get sessions with different trainers, particularly when you move onto cadaver courses, and this is, of course, very expensive. Others – let’s be honest - see just dollars in their eyes. They think, ‘the more I inject the better, and I hope nothing will happen, but if it happens once, it’s just one patient.’”
Not only is better regulation needed regarding the requirements to become a certified injector, but highlighting what different certifications mean in terms of a patient’s ability to ascertain the specialized skills a particular practitioner has obtained through this certification, so patients can better assess if a practitioner is truly qualified to be an injector and ensure they are choosing the right aesthetic practitioner for a specific treatment. “It is very difficult for the patients to actually see what the certificate of a certain practitioner involves in regard to specific treatments. Just saying because I’m a doctor I know how to do lip filler injections doesn’t mean anything - doesn’t mean I should or that I am truly qualified - unless it is supported by training and actual experience. Board certification for instance does not mean someone knows how to properly inject or that they have the specialized training for it. It isn’t included in the standard education of these board certification programs, which is why this needs to be a special regulation,” explains Dr. Pavicic.
Product Regulation: Choosing the Right HA Filler Formulation
Different regulatory thresholds for HA fillers determine how well the formulation of HA is tolerated in tissue, and thereby how the filler should be used and what patients are the best fit depending on what they are interested in having treated. When it comes to HA fillers, and particularly in relation to their use for the enhancement of a sensitive area like the lips, properly understanding the differences between HA fillers and the injection technique necessary to provide optimal outcomes is vital not only for aesthetic purposes, but also to ensure patient safety and minimize the associated risks.
Every HA filler is different, and like other aesthetic devices and products, each is only as safe as the practitioner using it. The manufacturing process and how the HA filler is modified results in different structures of HA gel. Certain HA fillers may be formulated to be less malleable, while others are designed to be used in treatments where the practitioner needs a filler that will be easier to shape. Dr. Pavicic gives the example, “If the filler is too hard you can’t really shape it and it will be palpable and visible when I move my face, especially if I have very thin skin. These all require the knowledge to develop individual treatment plans because your face looks different from mine, my skin is different than someone who is 70 years old. The age of a patient can significantly affect their response to HA fillers, as they are more likely to last longer in healthy, younger patients. In this case, it is better to inject less and wait to assess the results before injecting more.”
A patient’s facial characteristics, such as the thickness of their skin, the anatomical structure of their face, the original shape and fullness of their lips and their age, all need to be taken into consideration when choosing the right HA filler to use for that particular patient’s aesthetic and anatomical needs. Knowing what prior lip enhancement treatments they have had is also necessary to identify the right HA filler to use for further lip enhancement treatments accurately tailored to that individual patient’s features. Each of these parameters must be taken into consideration to identify how well a patient will respond to a particular formulation and choose the right HA filler for their particular lips.
Injection Technique: Artistic Eye & Aesthetic Balance
This is only part of the equation when it comes to HA fillers. An artistic eye is necessary to ensure you maintain the aesthetic balance of that individual patient’s face and their unique characteristics. Dr. Pavicic explains, “Even if you’re a very good facelift surgeon, the anatomy for injectables is a skill that is quite different. This requires knowing what filler to use for that area and patient’s individual characteristics, how well they respond to a formulation, where to put it, how deep, how much, how to shape something with an artistic eye, etc.”
This doesn’t mean just individually tailoring one treatment either. All faces are different, and they all age differently depending on environmental factors, lifestyle, genetics and more. Whether you are using HA fillers to enhance a patient’s lips or another area of their face, to preserve that individual’s beauty requires developing individualized treatment plans for each patient. Dr. Pavicic discusses her approach, “One of my main mottos is MMITP or multi-layered, multi-model individualized treatment plan. We need to have a plan as well. How are people going to look in 5 years? it should not be about going in for one treatment. This is what I see in a lot of people from seeing social media. They want their lips fixed for $200 and it doesn't matter where. They will go from one lip shop to the next, seeing a different doctor each time. I must be honest; this is also not the type of patient I want to have.”
The medical aesthetics industry is moving further and further away from the “one size fits all” mentality, and patients are expecting more highly customized treatment plans. This is particularly true with the rapid technological advances in 3D imaging, AI, AR, genetic testing and more making it possible to tailor treatments to account for even the smallest details of a patient’s particular facial characteristics and skin health needs. “I really want to develop their faces, and I always do before and after pictures using 3D cameras. I have patients that I started injecting 15 years ago who still come to me. To see how they look now, while they may have looked a bit younger 15 years ago, they still look like themselves. It’s authenticity that makes them unique, and to give that back to patients or increase this authenticity, these individual strengths, and minimize the little imperfections that we all find in our appearance is why I’m so passionate about my job,” says Dr. Pavicic.
A skilled, reputable injector will always prioritize patients' well-being and aesthetic goals and will never insist on excessive fillers or dismiss the potential risks associated with migration. Qualified medical professionals should help guide patients through the process to achieve their specific goals safely and effectively. Dr. Pavicic states, “That really takes skill that combines an aesthetic and artistic eye with all the medical knowledge you should have regarding proper technique and medical safety. I see people that look good, but their injector or practitioner is missing this artistic eye. It’s very difficult to be taught this because for example, there are people who painting beautifully, but they only reproduce other paintings, so they are good technicians but not necessarily good artists.”
Communication is a key aspect of this, as physicians are tasked with listening to what a patient may tell them they want in terms of treatment, but it is then the physician’s responsibility to assess and translate what they are and are not saying into a clear picture of their aesthetic desires. Taking patient mental and emotional states into account can help in this endeavor. Asking a patient to explain how they feel when looking in the mirror (tired, angry, sad) can point to the area of their face they actually want treated better than what they may say they want fixed.
“We have to widen our artistic view, and you can’t do this without talking to patients. In some clinics, I see patients come in, immediately sit on the treatment chair and the doctor will come and inject the same areas using the same amount of filler every time. That can’t be good for the patient, aesthetically or medically,” says Dr. Pavicic. She continues, “The treatment depends on how long the particular HA filler formula lasts, the area of the face injected, the level of movement in that area, etc. – we know that now. That’s the reason why some patients have what I call “HA faces” if they have always been injected with the same pattern, same amount, etc. This is much simpler – like when you’re in school and they teach you where to put the marker points for certain procedures - so these practitioners always follow the same process. This is of course very easy, but it can end up in a disaster.”
Patient Education & Safety
Prioritizing patient safety in conjunction with an artistic eye for maintaining aesthetic balance using individually tailored treatments designed to preserve the individual beauty of the patient is what will ultimately lead to optimal results and loyal, happy patients. Of course, aesthetic practitioners are in a somewhat challenging situation when it comes to patient education. They must deal with the disconnect between the way patients view aesthetic treatments and the role of their practitioners versus their general lack of understanding of the very real risks of seemingly minor treatments such as filler injections, as well as the need to appreciate the proper medical expertise required to perform them safely and provide optimal results.
Dr. Pavicic relates, “In the end, I am a doctor, and from the moral and ethical perspective these are my patients. From the business perspective, these are my customers, and they pay well for the services I provide. So, you should primarily be committed to science and medical responsibility – for aesthetic treatments even more than with standard medical therapeutic care because it’s retail through patients. My husband jokes with me that I am the best hairdresser in the city because as I said, on one side there is the medical and ethical responsibility, but many patients take that aspect and us for granted. They also expect us to listen to them and remember their stories about what is happening in their lives next time, which actually helps strengthen the relationship between the doctor and the patient or client. These seem like small details, but we have to ask ourselves, ‘Why do people go to a certain bar again and again?’ Because they love the barkeeper. So, we have to be this kind of barkeeper, but with all of the medical expertise that comes with this profession. Of course, we have to teach patients that they should appreciate this medical expertise.”
Looking out for the patient’s best interest when it comes to aesthetic treatments is another key point. Sometimes telling a patient “no” if they are requesting aesthetic changes based on passing social media beauty fads is ultimately better for them and you than giving in to their demands. Fads change and your priority as their doctor is to consider what is best for enhancing and maintaining their individual beauty, which lasts their lifetime. This is what makes patient education another crucial aspect of ensuring patient safety when it comes to aesthetic treatments.
“It's really important to teach the patient that not every HA filler is the same, that they are basically all different. I had a patient ask me once how much 1 mL of HA filler cost. I responded by saying, ‘Oh, you want to buy 1 mL of HA? I think the cheapest way is to look on eBay.’ She was like, ‘What do you mean? I want to be injected with it. I want to have 1 mL injected in my lips.’ I said to her, ‘How do you know it’s 1 mL?’ before adding, ‘Oh! You want me as a doctor to inject your lips, not buy one syringe.’ At first she was mad, but after reflecting on it, she said, ‘Actually you’re right.’ She became one of my most loyal clients, but I had to shock her first to get her to start thinking,” notes Dr. Pavicic.
Patients don’t always realize what can happen and what they can end up looking like if they are not in the hands of a qualified professional who has both the medical and aesthetic skills to perform these treatments. This leaves practitioners with the task of communicating the value proposition of their professional expertise and how it leads to optimal results of filler injection treatments and other aesthetic procedures. This will ultimately lead patients to trust you to be their doctor, as they will know you are looking out for their best interest, which is what a good doctor is supposed to do.
“A patient will ask, ‘There is a medical spa and they do this as well, so why do you cost double?’ In response, you have to explain, ‘Because I am going to make sure I do it right.’ We have to claim that because we’re not the loudest profession in this regard, but this is where we really should get up and say hey, we’ve invested a lot of time and money to learn how to do it effectively and safely. In certain countries filler injections are charged by the syringe, so of course injecting five syringes brings more money than if they inject just three. This is really what we need to change in our way of thinking. It’s art and art is unique. This is the thing about art; it’s not just about how much 1 mL of filler costs. This is something that injectors as well as patients, or the customer, need to know,” Dr. Pavicic explains.
5 Tips to Ensure Patient Safety
Dr. Pavicic sums it up beautifully, saying, “The two are inextricably linked. If you provide excellent patient care and results, you will in turn have loyal patients who choose you as their aesthetic practitioner.” She leaves us with these five important tips for ensuring patient safety and optimal care and treatment results, as well as for fostering a positive and healthy relationship with patients based on education and thorough, open communication.
- Set realistic expectations and educate patients on avoiding comparing themselves to others.
- Encourage patients to ask about different brands and products. Educate patients on differences in products and why one may be more appropriate for that individual instead of another.
- Inform patients of any and all possible risks (filler migration, swelling/bruising (takes time to resolve), allergic reactions/infection, discomfort, etc.).
- Avoid over-exaggeration (over-filled lips) by not injecting too often in the same place.
- Educate patients about dangerous trends encouraged by social media and photo filters (can cause infection and damage to tissue that is far more difficult to fix than the initial treatment, perception drift, etc.).
