Botox injections - who is qualified to administer them?

In the state of California, Botox may be administered to a patient by an MD, Physician Assistant (PA), or Registered Nurse (RN).

PA's and RN's must work under the medical direction of a physician in order to inject Botox. RN's may inject Botox only after the patient has first been seen by the physician or physician assistant.

This is an answer as to the regulatory qualification. From the perspective of who is most qualified, you should consider the training and experience of the professional that you choose to administer your Botox.

Because Botox is as much about facial shaping as it is about relaxing wrinkles the provider should be well trained in facial anatomy. A board certified plastic surgeon is highly qualified to teach and train physician extendors (PA's and RN's). The most qualified provider is one who uses their knowledge to safely and individually consider each person's facial shape and animation in deciding on the treatment.

In my practice, I administer Botox as well as my PA's and RN's. Each of the PA's and RN's must complete a formal training with me in the use of Botox as well as dermal fillers. They are taught directly by me and are required to inject under my direct supervision during the training.

Continuing education is also important as we are constantly trying to improve our skills.

The issue of who can legally inject Botox is decided by the laws of each state. As far as who is qualified, that is a much more complicated issue.

It is not difficult to learn how to mix Botox and how to inject it. The far more difficult part to learn is how to treat a patient with Botox to get the desired results. Issues that need to be understood include (but are not limited to):

• Static wrinkles vs dynamic wrinkles
• Facial anatomy
• How the facial muscles interact with each other
• How the size of the muscle affects the dosage
• Desirable aesthetic qualities in women vs men
• How to treat complications
• How to avoid complications
• How a person's age affects where you can inject Botox
• ...and many, many more issues.

It takes about 10 minutes to memorize a chart of where typical Botox injections are placed. It takes months or years to develop the skill to assess the patient's face to determine how to get the desired result while minimizing the risk.

If you are choosing an injector, and they try to tell you over the phone how much they are going to charge you to do 1, 2 or 3 areas, keep shopping. If they can tell you over the phone, without seeing you, how much Botox they are going to inject, then in my opinion they do not understand the issues well enough to be considered "qualified".

Basically, anyone can inject it, but to inject it well... that is another matter entirely.

Unfortunately, Botox isn't quite as simple as just putting it into you. It takes skill and technique to get the really good results and typically that means that you have to have an MD, and usually a good dermatologist or cosmetic surgeon, to do it. What I see is that many people are going to fly-by-night clinics for their Botox and it is being diluted significantly and frequently done so poorly that their results make them look worse rather than better.

Trust me, as a board certified dermatologist, I perform all of my own Botox treatments. It is that important to me and it should be that important to the surgeon you use.

So, basic answer: If you go to a clinic that is run by a reputable dermatologist and/or cosmetic surgeon, they should be the ones doing the Botox. If you look on the Botox website, you will find a listing based on how much Botox the doctor does. Usually a higher listing means they do more, but always look to make sure that they are the actual injectors rather than the not-so-impressive 'nurse-injectors'.

Lastly, if you hear something that is too good to be true (incredible prices, deals galore), run - don't walk - away!

Plastic Surgeons, ENT/Head & Neck Surgeons, Dermatologists and RN Practitioners specifically trained in the aforementioned fields are the obvious choice.

At Berger Medical Aesthetics, we don't fill cavities, fit braces or retainers, perform pelvics, deliver babies, make bunion orthotics or clip toenails... the point is, facial anatomy and physiology can be learned by anyone, but the aesthetic aspects are best left to aesthetic physicians.

I firmly believe that the rash of recent highly publicized complications of Botox, and the general "mask-like" results obtained by application of one-size-fits-all amounts of the substance, would drop like a rock were the non-aesthetic practitioners culled from the herd of treaters.

There is no disagreement that one should seek a practitioner who is qualified and trained to inject Botox. A good place to start would be the Allergan cosmetic website, which lists qualified practitioners by locale. One has to show proof of training before they can buy Botox from Allergan and be listed there. Of course as a consumer you should ascertain that the listed individual is indeed the one who does the injections.

Like all other cosmetic procedures, the better practitioners tend to be those who continue to perform the procedure in fairly large numbers (a relative term indeed) and invest in continuing education. That may well be a nurse or physician's assistant in a particular locale. I agree it has to be someone with medical training and done at a medical facility. To imply that only certain medical specialties are qualified to inject Botox or indeed perform any cosmetic procedure is misleading.

The exponential growth of the medical cosmetic industry, particularly in non-invasive and minimally invasive procedures, has been only within the past five to ten years in the US. The older ones among us had long since completed formal postgraduate training (residency) by then. Residency programs in the traditional cosmetic specialties of plastic surgery, dermatology and ENT did not spend a significant time on cosmetic lasers and injectables in the past. So, cosmetic surgeon or not, the majority of physicians practicing cosmetic medicine today have had to train after residency.

Learning a new skill is not bestowed upon any one specialty. Rather what is important is for the practitioner to be well trained, perform the procedure regularly, seek ongoing training and adhere to accepted standards.

Ultimately it's the results that matter. Every practitioner should be willing to show before and after pictures of their work. References from prior patients should also be available.

Unfortunately some consumers choose to price shop and choose the cheapest provider they find. Whereas the cheapest may also be very good or indeed the best, choice of a cosmetic provider ought to depend on a lot more than price.

The important thing is first to recognize that Botox injection is a medical procedure, so it must be done by a medical professional.

Some believe that it must be done by a medical doctor, or by a nurse under the on-site supervision of an M.D., but the truth is that there are nurse injectors who are extremely talented and experienced.

There are no uniform standards for training, but it is best to make sure that it is done in a clinic setting, where it is clear who the supervising doctor is, such as we do at Calidora Skin Clinics.

Hi Nicole,

Botox injections are a medical procedure. You will find that just about anyone with a nursing, dental, or medical degree (and even some without a degree of any sort) is injecting Botox and other facial fillers. There have been unscrupulous providers who have even used "Botox for Experimental Animal Use".

The recent stir about the safety of Botox has nothing to do with the cosmetic use of the anti-wrinkle miracle drug. It is still as safe as ever to have a few of your wrinkles erased by Botox. We have used Botox over the past 30 years without any of these recent adverse effect reports.

The FDA is reviewing botulinium-based drugs used to treat cerebral palsy and other ills. There have been reported cases of breathing and swallowing problems in pediatric cerebral palsy patients, and even a reported death in a CP child who subsequently died of pneumonia. These patients are receiving Botox in doses that are many, many times larger than the small dose that is used for cosmetic treatments. Botox is used in these unfortunate CP patients to relieve muscle spasms in their legs, arms, and necks. Even the physicians who use Botox to help CP patients are saying that the overdoses are likely from injectors who don't know how much to use and are using the wrong dosing of the drug.

This news is a reminder that Botox is a potent drug and that injecting it is a medical procedure that should be performed by a board certified physician in a medical setting - not in a salon, spa, hotel room, or friend's house. There is also other advice on RealSelf regarding this.

Stay safe.
Dr. P

This is an interesting question and comes at a time when we are seeing doctors from many different specialties providing Botox treatments, and sadly, we are seeing many non-doctors and in some cases, beauty and skin technicians giving Botox!

Botox is an amazing and revolutionary drug and, when used correctly and by properly trained specialists, is wonderful. However, when it is not used by properly trained and educated specialist physicians, it can cause severe adverse events and has even been reported to cause death.

While it may look easy to administer Botox, this is a specialized medical procedure that requires medical education in the anatomy and physiology of the facial muscles, nerves, blood vessels, etc. You must know exactly where to place it and how much to use. You must know that if you place it in the correct location, it will correct wrinkles, but if you are off by a quarter inch, you can cause the eye to close or the eyebrow to droop. If used incorrectly, the patient can look as if they have had a serious stroke and if used in the neck improperly, it can cause the inability to swallow.

It is very important that when you seek Botox treatment, you select a well-qualified, well-trained specialist physician/surgeon. Among the specialists who are considered experts in the administration of Botox (providing they have been trained) are plastic surgeons, dermatologists, head and neck surgeons, occulplastic surgeons, facial plastic surgeons, and cosmetic surgeons.

This is probably not a procedure you should have administered by a pediatrician or OB-GYN or skin care technician.

Too many people are motivated by money. Some doctors are motivated to make it and some patients are motivated to save it.

Listen as Dr. Julius Few, spokesperson for the Physicians Coalition for Injectable Safety, describes warning signs to look for when choosing a cosmetic injectable provider. 

According to Dr. Few, anyone buying Botox or other cosmetic injections should watch out for providers who:

• Won't disclose which substance(s) they are injecting
• Won't openly discuss the risks and benefits of the treatment
• Try to pressure you into buying treatments you don't want

Dr. Few also stresses the importance of using extra caution when receiving an injection at a location other than a doctor's office.

This question is up for HOT DEBATE in recent days. It is not just a question of the degree behind your name for some but also the sub-specialty of medicine that you practice in for others. This has been sparked, I believe, by the fear that someone will take a profitable business out of the hands of a certain group that feels that only they should benefit from it.

I believe there is enough interest in Botox to keep injectors busy in all types of settings. This does not mean that just anyone should be doing it. I believe that a licensed medical professional should be performing the procedure. I believe that the laws of your particular state should be followed as to who that can be for your scope of practice. In some states it may be only a doctor and for others it may be a nurse, nurse practitioner or certified physician assistant.

Besides your state's requirements for approval of the injection, it is important that the injector have the proper training. This is not a particularly difficult procedure but it not without its risks and adverse effects if not used properly. A basic hands-on training course should be done covering botulinum toxin, the muscle groups to inject, reconstitution, injection techniques, different amounts to inject, and treatment decisions before practicing on any patients.

Finally, and probably most importantly, the injector needs to be good at what they do. It is possible to be trained and not be good at something. Cosmetic procedures require a certain artistic approach in order to give the best outcome. This comes with many many injections and practice as well as something from the inside that cannot be practiced.

So I don't believe your title qualifies you to inject botox as much as your training and experience qualifies you to inject, within the bounds of your states laws.

There are good arguments on either side of this issue. My feeling, as a physician and surgeon, is that an adequately trained RN, is more than capable of providing safe and effective cosmetic injections (Botox & Fillers). I also feel that RNs should perform such treatments ONLY with a trained physician present on site.

Although an allergic reaction is not a common reaction from Botox, it certainly can happen with fillers, as can other complications such as intravascular injection with tissue necrosis or blindness. Most states are coming up with legislation addressing the issue of cosmetic injections by RNs and PAs.

Although I agree with the fact RNs administer much more dangerous injectables (narcotics, chemotherapy agents, etc.), they are typically not doing so in a strip mall or in the back room of a Spa.

{Editor's note: this post has been moved from "How does a Botox Brow Lift work?"}

I recognize Ms. Haney’s enthusiasm and passion for aesthetics, including Botox injections. However, it’s my professional opinion that Botox is a medical procedure, not simply part of an “industry”, and should be performed by a medical doctor with extensive experience in Botox treatments. Virtually every day, patients come to see me, and the story is always the same: they want to be treated by the doctor. There’s a good reason for this preference. The American Society of Plastic Surgeons has noted that medical doctors are best suited to treat complications of Botox treatments, the most dangerous of which is anaphylaxis. In a situation where complications can arise, care administered by a medical doctor is essential. Having a medical director nearby is of some help, but treatment by the physician personally is always preferred.

Again, I appreciate Ms. Haney’s input. I have found myself in quite the opposite position as Ms. Haney- patients experienced a bad outcome after injection by non-physicians, leading them to question, “Where was the doctor, anyways?” This is why I, like most experienced physicians, have dedicated extensive time towards our education regarding Botox. I will admit, there are many practitioners, including some doctors, who lack experience and education and should not be performing this procedure.

I am glad to hear of the fact that a nurse has been appointed a national educator for Botox Cosmetic. Almost all such educators are normally physicians. There are non-physician practitioners with fine technique and education. I believe Ms. Haney is one of them.

Regarding anaphylaxis, although rare, this is, in fact, the most concerning negative side effect of Botox treatments. Although not reported to date, this does not mean it simply cannot happen. The ASPS has raised this concern; this is not my lone opinion.

When an urgent situation appears, this will require physician intervention. Nurses are usually the first at the bedside. However, they require orders from a physician to administer medications, and cannot simply start prescribing medications for anaphylaxis themselves. Sometimes, standing orders by a physician are not adequate to treat a particular situation. The relative exception is the nurse practitioner, who still requires a supervising physician to co-sign orders.

A good doctor will always value the role of the registered nurse as a medical professional, usually the nurse is the first on scene to identify a change in patient condition. I’m concerned with the sentiment sometimes voiced that other practitioners can simply “take the place” of doctors. If patients feel this way, they should see the practitioner they choose. Patients seek out my practice because they know they will always consult with, and be treated by, a medical doctor with extensive experience in non surgical cosmetic medicine.

I’m sure the debate will continue. Ultimately, patients must do their homework and make their choice. I appreciate Ms. Haney’s time and effort that she brings to this discussion, and her valued opinion on RealSelf.com.

Updated Apr. 24, 2008

I’ve reviewed the most recent responses to this question, and I respect the opinions expressed. Our healthcare system does rely heavily on nurses to carry out standing doctor’s orders when physicians are not on site. One great example is home health care, as noted by another respondent.

Why is performance of medical treatments such as Botox different? The main difference is that Botox treatments require initial consultation, physical exam, discussion of risks and benefits, review of post-procedure care, and ability to handle side effects of treatment. Botox should not simply be injected on patients according to “standing orders;” every patient is unique, and unique patient situations require individualized treatments.

Physicians are trained extensively in diagnosis, physical examination, evaluation and treatment of patients. I feel Botox is a medical procedure, and patients should consult with, and receive treatment from, a medical doctor experienced in the use of Botox Cosmetic.

In home health care, doctors are not usually on-site. Is this the situation with Botox treatments? Absolutely not. Patients can locate an office where the doctor performs injections him- or herself on-site. All that’s needed is a few phone calls to doctors' offices in your area.

Others respondents have also noted that Botox should be done under the care of health care professionals, and patients should take caution to watch out for “those looking to capitalize on the business aspect of these treatments.” This is an excellent point.

Beware of the up-and-coming businesses in malls and elsewhere that offer Botox, or as some refer to these establishments, “McBotox!” I advise avoiding businesses that offer “Botox” treatments with no doctor on-site. These centers are often owned by non-physicians, and their primary concern appears solely to be the bottom line.

My best advice is to seek an experienced practitioner that you feel comfortable with. My patients, given the choice, want to be evaluated and treated by a medical doctor.

{Editor's note: this post has been moved from "How does a Botox Brow Lift work?"}

I've become a broken record in this forum by reiterating that the majority of the audience members at numerous workshops, seminars, and lectures are registered nurses. Nurses have quite a reputation for being passionate with the technique and artistry that comes with these treatments. I often find that it is this group of practitioners that also enjoy the education process with the patients in helping them achieve their goals. Let us not forget that nurses administer chemotherapy, cardiac medications, insulin, blood transfusions, and are involved in countless high tech procedures to promote health and save lives.

Thank you Dr. Caschette for your respected opinion. The term "industry" is better substituted with "aesthetic practice"...I agree. Because registered nurses carry out "medical procedures" routinely, there is no reason to assume that they are not competent in administering Botox. From the feedback we receive from new patients about poor experiences and outcomes - it is very fair to say that it is not uncommon to hear that the procedure was carried out by a physician. However, I would never want to assume or imply that this then means only non-physicians are more competent. It only reflects on how important injector technique is. I would like to point out that a fellow colleague of mine (a registered nurse) was recently appointed as a national educator for Allergen - the manufacturer of Botox Cosmetic. She presents advanced training workshops for physicians, PA's, and registered nurses alike. Quite an honor, indeed.

As to your concern about anaphylaxis - let's not alarm consumers - there has never been a report of this in the history of Botox Cosmetic. This is clearly documented in the numerous safety reports published by Allergen. In fact, research supports that consumers have a higher risk for an adverse reaction to Aspirin than Botox. Rest assured, registered nurses are trained to respond to anaphylaxis as well as other life threatening conditions as they are often the first ones at the bedside. It is our understanding that the American Medical Association has addressed this issue by formally stating that those administering Botox should be competent, trained, under the supervision of a Medical Director, and working under Standardized Procedures and Protocols. This position would seem to indicate recognition of RN's, NP's, and PA's as being quite competent and skilled. Despite our different views, I truly enjoy this forum to educate consumers, and I very much appreciate your feedback.

With all due respect to you and all licensed medical practitioners,
Lori Haney, RN

Updated Apr. 22, 2008:

When I offered the example that registered nurses routinely are involved in administering treatments and medications that carry a high risk for side effects, I was doing so not in the context of administering Botox and such in the back of a strip mall. I would agree that that scenario is not appropriate for any medical procedure.

The analogy was used to demonstrate that our entire health care system relies heavily on experienced, licensed registered nurses, LVNs, NPs, and PAs that carry out standing orders when there is not a physician on site. For example, I was a home visiting nurse for quite some time wherein a physician never comes to the home. With standing orders and set protocols, I am trusted to use my critical thinking skills and carry out complex wound and tracheostomy care, IV infusions, end-of-life care, and much more. Why then would that trusted relationship by the overseeing (off-site) physician be any different when discussing medical cosmetic procedures?

Yes, we are in need of updated legislation that will be current with the pace of technology. However, we all need to realize that licensed heatlh care professionals that are responsible, ethical, and trained are extremely valuable and should not take second place to those looking to capitalize on the business aspect of these treatments.