Tips to Train NPs, PAs in Neuromodulators, Dermal Fillers

Training nurse practitioners (NPs) and physician assistants (PAs) to provide some of the most requested nonsurgical aesthetic procedures, such as injections of neuromodulators and dermal fillers, and manage patient expectations can help dermatology practices meet today’s fast-growing patient demand for noninvasive solutions and drive incremental revenue.

In 2020 alone, patients spent more than $3 billion overall on these types of procedures. Neuromodulators and dermal fillers topped the list of the most performed procedures in this category. The more than 2.6 million neurotoxin, 1.3 million dermal filler, 15,000 dermal filler removal, and 2200 facelifts using dermal fillers generated more than $2 billion in revenues in 2020.¹ As this market continues to expand, physicians who are already time-pressured are looking for effective staffing solutions that will satisfy patients safely and effectively. NPs and PAs can fill this gap, provided they receive proper training and supervision.

Suneel Chilukuri, MD, FAAD, FACMS, director of cosmetic surgery with Refresh Dermatology in Houston, Texas, led a track that offered a detailed beginners’ walkthrough for NPs and PAs on these in-demand procedures as part of the live pre-conference program for Maui Derm NP+PA, held September 29, 2021, at the Omni Grove Park in Asheville, North Carolina.²

He and fellow presenters Kevin Pinski, MD, president of Pinski Dermatology & Cosmetic Surgery in Chicago, Illinois; and Amber Blair, PA-C, director at large of the Society of Dermatology Physician Assistants, in Orlando, Florida, offered a day-long session and hands-on workshop covering the essentials of toxins and fillers, injection techniques, patient expectation management, and strategies for remedying unwanted or unsatisfactory outcomes.

Chilukuri discussed some of the panel’s key takeaways in this exclusive interview with Dermatology Times®.

Q: What is the first step in training an NP or PA to treat patients who want aesthetic procedures such as neuromodulators or dermal fillers?

Suneel Chilukuri, MD: Go through the consultation process. Talk with the patient about their expectations and learn to manage those expectations. If a patient in mid-life brings in a photograph of themselves as a teenager, the NP or PA needs to open a conversation about realistic results from these nonsurgical procedures. Some of the verbiage we discussed in today’s track is as simple as saying, “It took you 50 years to get to what you look like today. Give us 18 or 24 months to start reversing that process.”

Another discussion point the panelists gave is to tell the patient that it's not just about what they can do in the office in a limited 15-30 minute or even 1-hour span. Instead, they should point out the improvement that’s possible with getting that treatment every 3 months. NPs and PAs should give patients homework on what they need to do at home to enhance the results. So again, we're emphasizing the consultative approach.

Q: With so many products and treatments available, what tips do you have for developing the optimal treatment plan for each patient?

As part of the hands-on workshop today, we brought in some patients and demonstrated how to conduct a facial assessment. The NP or PA needs to know how to evaluate the bone structure, skin laxity, skin radiance, and photodamage. For example, severe photodamage can be a challenge when determining the best solutions for improving skin’s appearance. Typically, for a patient with good bone structure, the NP or PA could suggest fillers or neuromodulators to produce positive outcomes. But, I don’t think we can meet the real expectations of a patient with severe photodamage without a CO₂ laser. Consider the patient’s goals, then present information on the various options available and involve them in making those choices. Show them before and after photos for the outcomes of the procedures being discussed. That also helps them visualize the range of actual results.

Q: Has social media helped or hurt the effort to manage patient expectations?

One of the problems is that social media posts often occur immediately after an injection and that's what the patient thinks is going to be a long-term result. In today’s session, we discussed the importance of taking patient photos showing how their individual results look on day 1, week 1, week 2, and at 3 months. Practitioners can build their own slides and their own before and after photos to share with their prospective patients.

Q: What breakthroughs do you see on the horizon and what recommendations can you offer for maximizing their outcomes?

One of them is DaxibotulinumtoxinA for Injection (DAXI; Revance Therapeutics), a botulinum toxin type A [formulated with a novel peptide excipient]. Hopefully, that's going to be as much of a game changer as we think for those patients who are able to regenerate their nerve endings faster than with acetylcholine and is going to last longer for them than some of the options currently available. Instead of lasting 6 weeks to 2 months, we're going to be able to get 3.5 to 4 months. However, the company’s statements on the possibility of a 6-month result can be good or bad.

Here's the bad portion of it, and where I'd be cautious. An inexperienced injector who’s used to injecting the usual dose of onabotulinumtoxina (Botox; Allergan Aesthetics) to the forehead and is not familiar with how to inject a heavier dose of something like DAXI could cause long-term brow ptosis, meaning that the brows are depressed and that patient can't see as well. I'm nervous about that, for sure—very, very nervous in fact. We're also looking at other new products being introduced to the market, such as the RHA Collection (Revance Aesthetics) dermal fillers [the only FDA-approved hyaluronic acid fillers for dynamic wrinkles and folds].

Q: What are some of the most common mistakes you see?

Some products are being used in an area that's not ideal for them. For example, treating the tear trough. People are finding that they look great on day 1 and maybe up to day 10 or even day 14. But these products seem to be hydrating and we're finding that there's more of tear trough deformity out there due to an atherogenic deformity caused by the injector. So, I know it's always sexy to inject in certain areas like the lips and inside the tear troughs, but those are 2 of the most visible and least forgiving areas.

Q: How should beginners avoid those problems?

What we're cautioning everybody about in this course, is to start with the things they know are going to be home runs, like nasal labial folds. No, they're not sexy, but you can see what that product is going to do.

For new products, our panelist advised creating a trial using a member of the office team or a family member—someone they can observe almost daily. Put a product they typically use on one side of the face and put the new product on the other. Report a comparative analysis at the 1-day mark, the 7-day mark, and the 2-week mark. Again, take photos to show to potential patients.

Q: How much should practice owners expect to invest in training and how do dermatologists convince patients that an NP or PA is expert enough to get the same results as the experienced physician?

Let’s start with the second half of that question. I don't think it's an easy conversation. In some practices, dermatologists decide to bring somebody else on the team “to make their job easier.” I think it can make their job harder. In certain instances, we've unfortunately dumbed down some of the procedures that we're creating with inadequate education. That's why we are seeing greater complications right now. So if the dermatologist or the plastic surgeon is the one who's bringing somebody on, do they just throw the person into the deep end? We've seen it happen on a regular basis, and it's disappointing. But again, the end sufferer is going to be the client. We want to make sure that when we have opportunities like this course, we're able to share real experience and have hands-on instruction. This afternoon we had 3 different chairs being used at the same time so attendees could rotate from 1 to the next to see 3 injection techniques. While we were showing how to do injections, the attendees were asking questions. Still, education has to be combined with experience. Injectors have to put the syringe in their own hands and learn to work with it. Another suggestion that we gave was to utilize the resources of the pharmaceutical companies. Galderma, Allergan, Revance, Merz—they all have expert trainers that they've contracted, but it's shocking how many people don't utilize that that amazing training and education capability.

Q: How many people should a practice consider hiring from the outside or training if they’re already on the team?

One—and train the daylights out of them and be prepared to provide supervision. I don't think there's any substitute for education or experience.

Disclosures:

Chilukuri has worked as a consultant and speaker for Alastin, Aerolase, Allergan, Bellus, BTL, Cynosure, Dominion Lasers, Eclipse, Galderma, InMode, Lutronic, Merz, PCA Skin, Revance, Sinclair, Sente, Skin Medica, Theravant, Under Skin, and ZO Skin.

References:

1. Chilukuri S, Blair A and Pinski K. Neuromodulators and Dermal Filler Aesthetic Workshop for Beginners. Session presented at: Maui Derm NP+PA Fall 2021 Pre-conference Program; September 29, 2021; Asheville, North Carolina.
2. The Aesthetic Society. Aesthetic Plastic Surgery National Databank Statistics 2020. Accessed September 29, 2021. https://cdn.theaestheticsociety.org/media/statistics/aestheticplasticsurgerynationaldatabank-2020stats.pdf