It is no secret that injectables are a lucrative addition to the medical aesthetic practice. However, according to Guidepoint Qsight, 2024, there are approximately 70,000 injectors in the U.S.,1 which can make standing out seem like a nearly impossible undertaking. In this feature some of the top injectors are sharing their pro tips on how to become a successful injection practice in a saturated market.
Tips for Education and Training
Any medical professional can choose to offer injectables, which makes training each practitioner’s responsibility. That means seeking out education and guidance from expert, reliable resources.
“Whether you are just starting or want to add injectables to your practice, some of the best training you can get today is provided by the manufacturers,” reported Brooke Nichol, RN, CANS, owner and founder of Saving Face (Austin, Texas). “I have been an Allergan trainer for 10 years and I think they do an incredible job of getting you started. Third party trainers are also great resources. The Aesthetic Immersion provides well-rounded training, and Palette Resources is a great platform to learn about multiple brands and off-label techniques.”
According to Gideon Kwok, DO, co-founder of The Aesthetic Immersion (Rancho Cucamonga, Calif.), training starts with the fundamentals. “New injectors should always begin with a good foundation,” he explained. “We offer numerous courses at The Aesthetic Immersion both onlin
e and in-person training, including a live course at The Aesthetic Show (Las Vegas, Nev.), which teaches the foundations of injecting. One of our most popular training courses is the cadaver dissection webinar for both new and experienced injectors to help providers safely and confidently take their injection skills to the next level.”
“I believe courses like [those offered at] The Aesthetic Immersion are good to develop foundational knowledge, like anatomy, technique and safety procedures,” reported Alexander Rivkin, MD, cosmetic surgeon and owner of RIVKIN Aesthetics (Los Angeles, Calif.). “But after your initial training, it is an ongoing process. I run training courses and have a one-day conference for high-risk injection areas, and we offer shadowing and proctoring for intermediate and advanced injectors. As an experienced injector, I go to five or six conferences a year because it is important to stay updated on new aesthetic approaches, safety, techniques and products. It is a quickly evolving field and you never stop learning.”
Nicole Frontera, FNP, owner of Nicole Frontera Beauty (Rockaway Park, N.Y.) and The Formula (Rye, N.Y.) agreed that beginning with the fundamentals is important and added this tip for new injectors: “Cadaver 
classes really help you to understand the anatomy in the areas you inject. Start by learning the basics and then inject only the most common areas for neurotoxins and fillers until you have some experience,” she stated. “Once you feel confident with the basics, then move to more advanced injectable courses and techniques.” After completing a basic injectables course, it is helpful to reach out to injectable product manufacturers and have their reps visit your practice to teach you how the products in their portfolio work, Ms. Frontera added.
Ms. Nichol echoed this approach. “Product manufacture
r portfolios are extensive and most of their training deals with the rheology or the viscosity of their products,” she explained. “You can also reach out to the manufacturer’s medical science liaison (MSL) who will send you published articles about how to mix or combine them and off- label uses that some of the reps do not have access to.”
Tips to Avoid Complications and Maximize Safety
“There are some complications associated with injectables,” Ms. Nichol asserted. “A detailed understanding of anatomy, including the vasculature and how deep products can safely be injected, will help you avoid the danger zones and minimize adverse events. Also, educate yourself and be prepared to treat adverse events. For example, hyaluronidase can dissolve and reverse hyaluronic acid (HA) dermal fillers. Having this on hand can help you feel more confident knowing you can keep your patients safe.”
“The most feared complication from HA dermal fillers and collagen stimulators is vascular compromise,” said Steve Yoelin, MD, an ophthalmologist in Newport Beach, Calif. Dr. Yoelin, who has conducted
dozens of aesthetic clinical trials and is the author of numerous peer-reviewed journal articles, explained, “This complication – as well as necrosis, asymmetry and granulomas – are extremely rare, but providers should hone their anatomy skills and be able to recognize and treat adverse events.”
Botulinum toxin injections can also sometimes result in undesirable effects such as facial asymmetries. While the effects are temporary, patients still have to wait months for them to wear off. In search of a solution, Mary Gardner, founder and chief executive officer (CEO) of DelNova (Chicago, Ill.), recently completed the first-in-human clinical trial that demonstrated the safety and effcacy of a new drug ReViVox®. “This trial was a pilot proof-of-concept study with a limited cohort of healthy volunteers,” Ms. Gardner explained. The drug works by restoring the balance of neurotransmission within the paralyzed muscle. According to Ms. Gardner, ReViVox will be used to correct conditions such as eyelid or brow ptosis or other undesirable outcomes that may arise after the original botulinum neurotoxin procedure takes effect. Our reversal innovation is expected to improve patient satisfaction and overall patient outcomes.”
Adverse events and safety are an important part of injectable training
, but do not let it be a deterrent, Dr. Rivkin advised. “We talk a lot about the risks and side effects of injecting and ways to avoid and manage adverse events. While it is important to have these conversations, what we do is inherently very safe and gives great results, so providers should not be afraid of doing injections.” Dr. Rivkin’s advice to new injectors is this: develop a safety protocol and follow that protocol every time you inject. He also advised that new providers be well-informed about serious complications such as blindness, stroke and necrosis. “Those are extremely rare, especially if you inject conservatively,” he added.
“Complications from poor injection technique are far more common than these others that we talk about,” Dr. Rivkin continued. “I see a lot of over injecting, asymmetry and many missed areas that should have been injected. You must train your eye as you learn about injection techniques, sharpen your aesthetic sense by being observant, and understand which features are considered beautiful. Break the face down to areas, like A, B, C and so on, to help classify them in your mind.”
Tips for Natural Looking Results
Every provider’s goal should be to achieve optimal results with the products they inject. “Begin by analyzing the health and thickness of the patient’s skin because this often determines which products you will use and at what depths,” Ms. Nichol clarified. “I sometimes place products a little more 
superficially for product economy so that we can use less to show more. But this depends on the quality of the skin. I am also a fan of keeping products on bone, so they look more natural with movement. Deep product placement keeps the patient looking natural even if it is going to take a little more product to get the desired outcome.”
Technique and knowledge of basic protocols are also essential to becoming a successful injector. According to Dr. Kwok, breaking down the face into layers helps to create a naturallooking overall result. “Every layer of your face ages. The bone, fat on top of bone, muscle and skin each play a role in facial aging. If you do not address all of these layers, you may end up making mistakes, like over-filling. Learn how to use toxins to relax the muscle, fillers to replace the lost bone and fat, and treatments like threads to reposition fat and address superficial skin laxity. Finally, you may need to do a laser treatment to tighten up the skin. Altogether, using these lifting and filling tools in the right combination and in the right areas can create a natural look.”
Tips for Standing Out
“Find your niche, your market and what you are passionate about. New providers should define their style and be consistent with it,” advised Ms. Frontera. As one of the first providers to bring Attiva® Subdermal Induced Heat (S.I.H.) Technology from Reveal Lasers (Las Vegas, Nev.) to the U.S. market, she consistently strives to balance innovation with her injection skills. “Attiva is a new technology that stimulates collagen for immediate lifting. After some time, I plan to use injectables to maintain the results and continue to stimulate collagen production,” she said.
“I am known for doing nonsurgical, permanent rhinoplasty and I have had great success with it,” Dr. Rivkin shared. This treatment helped define Dr. Rivkin’s brand. “I first do a nonsurgical rhinoplasty treatment with an HA filler to lift [the tip of the nose]. If it is exactly what they want, I offer them a more permanent solution with polymethyl-methacrylate (PMMA) when they come for a touchup. After one year, I do one more PMMA treatment and they are done. I see patients ten years later and the results are still there.”
Be cautious of new trends, Dr. Rivkin warned. “What you accept into your practice carries your stamp of approval. When you adopt a new product or technique, it means something to your patients and to your brand. Every time you say something is good, it should be good because that is your reputation on the line.”
Tips for Staying Ahead of the Curve
“While botulinum toxins and HA dermal fillers have long dominated the injectable aesthetics industry, these procedures only treat the symptoms of aging,” Dr. Yoelin explained. “I think that new procedures and products will eventually address the problems caused by aging. To monitor new trends and 
products as we move in this direction, injectors can network within the industry among seasoned injectors by attending educational conferences, reading peer-reviewed articles and industry trade journals.”
Ms. Nichol confirmed that the aesthetic community has significant interest in regenerative medicine. “I believe that regenerative medicine with biostimulators and exosomes are notable as we continue to address patients’ desires for a more natural outcome. We see regenerative medicine in hair rejuvenation and for skin quality. Some of us are injecting exosomes off-label, which I believe are on a trajectory to become an incredible asset to our industry. I believe they have an ability to turn on the cellular matrix and support cellular growth as well as turn off the aging process.”
Product Watch
While not currently approved for injection, exosomes can be used as an adjunct therapy to enhance healing after medical aesthetic procedures. AnteAGE MDX® Exosome Solution from AnteAGE (Irvine, Calif.), is a hybrid solution derived from human bone marrow and umbilical cord stem cells. It is designed to complement ablative and non-ablative aesthetic treatments. MDX Exosomes also reduce redness at injection sites and stimulate a regenerative compound effect in the skin, leading to a cascade of lasting, anti-aging benefits.
JuveXO® from Congela Biocosmetics, LLC (Miami, Fla.) is another exosome-based topical serum designed to enhance aesthetic procedures as well as revitalize and rejuvenate the skin by activating the body’s natural regenerative response. JuveXO is rich in HA, collagen, elastin, other essential proteins and more than 100 billion exosomes that target damaged and aging tissue at the cellular level.
For biostimulators, aesthetic injectors now have an off-the-shelf treatment that can help to replace age-related volume loss in the face, hands and body. Renuva® by MTF Biologics (Edison, N.J.), uses a matrix of adipose-derived stem cells designed to gradually replace the body’s own fat and may be a viable alternative to fat grafting and a longer lasting alternative to HA fillers. According to the manufacturer, Renuva is also being used in reconstructive procedures such as craniofacial and breast reconstruction, with research underway for other potential uses.
Belotero Balance® from Merz Aesthetics (Raleigh, N.C.) is a versatile HA dermal filler that is FDA-approved to smooth moderate-tosevere facial wrinkles and folds and improve the appearance of under-eye hollows in adults over the age of 21. Its patented Dynamic Cross-Linking Technology (DLCT) creates a smooth, flexible gel that can be used to seamlessly integrate into the natural structure of the skin tissue. Clinically proven safe and effective, Belotero Balance feels and looks natural, maintains normal facial movement and expression, and injects and spreads evenly for natural-looking results. It is fully cohesive for optimal tissue integration, smoothness and low risk of gel migration. For increased patient comfort, Belotero Balance is available with lidocaine. With a well-established safety profile, it has a history of safe, effective and predictable results.
Reference:
1. Guidepoint Qsight. (n.d.). https://qsight.guidepoint.com/
