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Are Nurse Injectors the New Norm?
Kevin H. Small, MD, Kathleen Kelly, B.A., Henry Spinelli, M.D..
New York Presbyterian Hospital, NYC, NY, USA.

Purpose: As Botox® and filler use has rapidly increased in recent years, a growing number of non-aesthetic doctors (e.g., gynecologists, dentists) and allied health professionals (e.g., nurses, technicians) have emerged to perform these procedures. Since studies have shown that patients identify training and expertise as the most important factor in considering these procedures, this study seeks to summarize the perspective of plastic surgeons regarding these paradigm shifts.
Methods: In the summer of 2013, an anonymous online 8-question survey was sent to members of the International Society for Aesthetic Plastic Surgery (ISAPS), American Society for Aesthetic Plastic Surgery (ASAPS), and American Society of Plastic Surgeons (ASPS), which represents approximately 26,113 plastic surgeons globally. The initial 2 questions assessed location of practice and membership affiliation. The remaining questions assessed the capability of various healthcare practitioners for administration of different injectables: (1) Botox®, 2) fillers, and 3) vaccines (control). Healthcare practitioners included (1) plastic surgeons and dermatologists, (2) gynecologists, (3) dentists, (4) nurses in plastic surgery and dermatology, or (5) nurses in other fields.
Results: On three separate email notifications, a total of 14,184 plastic surgeons, uniquely identified by IP address, opened the survey (average of 4728 surgeons per email), and 882 answered the survey. Of the responses, 36.6% were from North America, 29.1% from Europe, 12.9% from South America, 10.0% from Asia, 4.5% from the Middle East, 3.4% from Australia, 1.9% from Africa, and 1.6% from Central America. ISAPS members encompassed 54% of the responses, and 46% did not. In the database, 77% believed nurses were not as capable as physicians in administering Botox®; 81% had a similar answer for fillers. Conversely, 85% agreed that nurses were as capable as physicians in administering vaccines. When asked to rank capability in administering vaccines, plastic surgeons ranked nurses in other fields (48%) as most capable, then plastic surgeons and dermatologists (43%), nurses in plastic surgery and dermatology (9%), gynecologists (3%) and finally dentists (<1%). When asked the same question regarding Botox® and filler administration, responders overwhelmingly ranked plastic surgeons and dermatologists (97%) most capable, followed by nurses in plastic surgery and dermatology (3%), gynecologists (<1%), dentists (<1%), and nurses in other fields (<1%). When asked to rank capability according to patient perception, the order of capability remained the same.
Conclusion: Based on responses from over 880 plastic surgeons globally, we found that the vast majority of plastic surgeons consider themselves (plastic surgeons) and dermatologist as the most capable injectors of both Botox® and fillers, followed by nurses in plastic surgery and dermatology, gynecologists, dentists, and finally nurses in other fields. Despite their somewhat contrary view of facial injectables by nurses in other fields, plastic surgeons still believe these nurses to be the most capable of administrating vaccines. These findings may provide a foundation to further investigate the relationship of patients and their injectable provider. Also, this preliminary study may define the role of various practitioners in an increasingly more competitive injectable environment to improve patient satisfaction and outcomes.

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