A woman’s lip cells were on the brink of dying off and she was given a smile she “hates” after a nightmare botox and lip filler appointment.
The Deputy Heath and Disability Commissioner Dr Vanessa Caldwell ruled a nurse and a doctor at an unnamed North Island beauty clinic did not provide their client with an acceptable standard of care.
They did not act fast enough when the injections – known as a lip flip – went terribly wrong.
Known as “Ms A,” the woman went to the clinic looking for a small amount of filler – less than the standard 1ml dose the clinic offered, she told the Health and Disability Commissioner (HDC).
But the nurse doing the procedure talked her into having a full dose as well as some botox, to achieve a lip flip – a fuller, more defined upper lip.
The nurse told her she had a “gummy smile” and the procedure would fix that, the commissioner’s report said.
But the woman developed a complication of the procedure, vascular occlusion, where the blood supply is cut off or slowed.
Over a period of days that worsened, with symptoms including pustules, bruising, swelling and a lacey appearance on the skin.
She had repeatedly raised concerns with the nurse and clinic doctor who listened and stayed in touch.
But the HDC report, released today, found they took too long to start the injections that can reverse the condition by breaking down the filler.
A doctor reviewing the case for the HDC, Teresa Cattin, was critical of the clinic doctor who consulted on the woman’s case remotely.
“Dr C did not seem to recognise that the appearance of pustules indicated impending necrosis and needed immediate attention,” Cattin said in the report.
The report showed the nurse had been concerned about possible occlusion when Ms A first left the clinic but was reassured because she did not seem to show one of the main symptoms of a lack of blood flow.
The nurse had taken care to stay in touch with her client and sought advice from the clinic doctor.
But the deputy commissioner found occlusion was evident at least as early as the same evening of the procedure and the reversal treatment should have started then.
It actually took days, with the client taking herself to hospital, rather than the beauty clinic.
The nurse offered to help the emergency department doctor but they came up with a plan to do the dissolving at the clinic.
Even once that medication started, the condition worsened.
Eventually more dissolving injections were given to fully dissipate the filler.
A nurse giving expert advice to the HDC said that initial consultations for injectibles should not be given on the same day as the treatment.
That allowed patients to have a “cooling off” period to fully consider the risks and benefits.
“Many clinics only allocate 30-45 minutes for an initial consultation, as this fits their business model. I believe there are few practitioners who would consider this sufficient time for an accepted standard of consultation and filler treatment on a new patient,” the nurse expert said.
Deputy commissioner Caldwell picked up that point.
“I also note Ms A’s comment that she was left with a smile that wasn’t hers and which she hates,” she said.
“Accordingly, I remind [the nurse] of the risks of amending the treatment plan at the same time as the planned treatment, and to ensure that if a client comes in with a treatment in mind, the client is provided with the risks and benefits of all treatment options and given time to consider the options, so that they do not feel they need to proceed with further treatment if they are uncomfortable doing so.”
Caldwell recommended both the doctor and nurse formally apologise to Ms A.
They had both made changes to their care since the case, including doing more training on how to recognise vascular occlusion.
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