How Cosmetic Doctors Are Approaching Injectables in a World That Calls for Masks
Allure explores the growing debate over mask-off injectable treatments.
By Jolene Edgar
It began in late April — the trickling of comeback posts into our feeds. As states began lifting stay-at-home orders, some cosmetic doctors tentatively took to social media to announce their reopenings amid the coronavirus pandemic, signaling a precarious sort of sea change.
With what many describe as a mix of emotions — relief, anxiety, excitement, uncertainty — dermatologists and plastic surgeons are bracing for a new normal: skeleton staffs and streamlined schedules, COVID-19 screenings and temperature scans, obsolete waiting rooms, masks for all, modest chitchat, next-level disinfection rituals. What isn't often posted for public consumption, however, is doctors' stance on aesthetics treatments — fillers, in particular — that will require patients to do the unthinkable: unmask in a public place.
Off the (Instagram) grid — on Zoom calls with colleagues and society-led webinars — physicians are debating the safety and necessity of mask-off treatments. "The question is how to proceed with injections in the lower face and around the mouth," says Christian Subbio, a board-certified plastic surgeon in Newtown Square, Pennsylvania. "Each practice is going to be determining their own level of comfort in approaching these areas."
The Divide Over Mask-Off Injections
Beyond the sheer intimacy of these procedures, there are practical considerations in play — a major one being how to handle the facial assessment that customarily precedes such injections.
"I personally think it'll be safe to examine patients without a mask on for a few short minutes with their mouths closed, so we can see the entire face from all angles," says Sarmela Sunder, a board-certified facial plastic surgeon in Beverly Hills, California. Of course, in consultations predating coronavirus, she'd have patients animate as part of the exam — observe them talking and laughing to see how their features morph when in motion — but given the current respiratory risks, she notes, "This aspect of the assessment will be lost for now."
Papri Sarkar, a board-certified dermatologist in Brookline, Massachusetts, is scheduled to return to her clinic on June 22. As things currently stand, "Every patient coming to see me [next month] is a return visit — I know them already, I have in my head what they'll need, and none need lower-face work," she says with assurance. She'll primarily be tackling a backlog of skin-cancer surgeries while also injecting the upper face with neurotoxin and strategically spot-treating with filler (temples and earlobes mostly) all of which can be managed with masks on, she says.
She's asking new patients aiming to get on her calendar to agree to a free Zoom consult beforehand, as she noted that it can take a little while to evaluate a face. "I like to watch people speak and smile so I can see the effects of their different muscles," she says. A video chat will safely allow for this while curtailing iffy in-person interactions when the patient eventually comes for treatment.
In Medford, Oregon, board-certified dermatologist Laurel Geraghty is already back at work. "The demand for dermatology where I live is completely unmet, so after the lull, we have a crush of patients wanting and needing to get in."
In her office, too, the lion's share of immediate cases involve delayed skin-cancer treatments. "We have an obligation to prioritize medical needs before cosmetics, make sure the pandemic curve remains relatively flat without a lot of new case spikes, and ease our way slowly back into aesthetics," she says.
Once Geraghty feels ready to pick up a syringe again, she says the patient is going to have to wear a mask to have injections. "Botox and other neurotoxins will be the first cosmetic treatments to return in my practice," because they take less than five minutes to perform and typically target uncovered expanses like the forehead, crow's feet, and glabella between the eyebrows.
For skilled injectors, she doesn't foresee an eyes-up approach presenting a barrier to getting beautiful results. However, some have questioned this piecemeal method: Could treating the upper face alone while temporarily ignoring the lower two-thirds lend a lopsided look? The physicians we spoke to don't seem to think so. "An artist can unquestionably produce a more beautiful picture when the whole canvas is available," says Lara Devgan, a board-certified plastic surgeon in New York City. "But that doesn't mean there isn't value in addressing the face one area at a time."
"We have an obligation to prioritize medical needs before cosmetics, make sure the pandemic curve remains relatively flat without a lot of new case spikes, and ease our way slowly back into aesthetics."
Echoing her sentiment, Sunder points out that in everyday practice, "It's very common to stagger treatments and address different areas [at different times] — upper face in one visit; chin and jaw during a separate appointment; midface, cheeks, tear troughs in a third — to achieve a globally unified look in the end."
What's more, experts say, certain issues, like sunken temples, are frequently corrected in isolation anyway and don't necessarily need to be offset by other shots to create a harmonious effect. "I certainly think this is a reasonable approach," says board-certified Bryn Mawr, Pennsylvania, board-certified facial plastic surgeon Jason Bloom — "especially if that's the area that is most concerning to someone," as this is typically where he likes to start building results.
Why a Filler Reboot Raises the Stakes
In many practices, fillers will simply take longer to reenter the rotation. Though it may seem like these gels can be placed with the same ease and efficiency as Botox, they typically take longer to inject, according to Ashley Gordon, a board-certified plastic surgeon in Austin, Texas — particularly in zones that demand meticulous sculpting, like the jawline and chin.
"We also have to think more about potential complications with fillers," she notes. If an errant needle stick were to block a blood vessel, restoring circulation could require urgent and time-consuming care, additional appointments, or even a trip to the ER — unnerving in ordinary times, and unacceptable during a pandemic.
Doctors also worry about the fate of filler patients who may fall ill post-injection. Some cases of delayed inflammatory reactions — bumps and nodules — have been reported in those who contract viruses, like the flu, after getting filler. "This is definitely a possibility with COVID-19," Sunder says. "The likelihood of it happening is very low, as it is with other viral illnesses," she notes; however, "We're amending our consent forms to include this theoretical risk."
Providers who plan on rolling out injectables without restrictions are sparing no expense to safeguard themselves, their staffs, and their patients. Bloom just upgraded all of his treatment rooms with powerful medical-grade air purifiers that circulate the air in the room 15 times an hour, cleaning it with a high-tech fusion of UV light, HEPA filters, and negative ions. "When someone breathes, that air is totally circulated out within three to four minutes," he says.
Subbio is also investing in equipment that can hopefully mitigate the risks associated with injecting the unmasked. "We've ordered a few machines that will create a suction field directly over the head of a patient getting facial injectables, thereby helping to clear the air of any potentially infectious particles," he explains.
Doctors (along with staff) will be performing injectable treatments in full PPE — masks (N95 respirators if available), gloves, scrubs, gowns, and eye protection. In keeping with the new AesCert guidance recently published in Facial Plastic Surgery & Aesthetic Medicine, they'll also be minimizing small talk to reduce the risk of airborne transmission through speaking and keeping appointments brief.
"I'm going to be offering all injectables when I start back — toxins, fillers, Kybella — and erring on the side of extreme caution, focusing on low-risk, minimal-downtime procedures on healthy patients under age 60 to pilot test our new practices with procedures and patient populations who have been determined to be lower risk should a COVID-19 infection occur," says Devgan. "We'll then analyze our approach to make sure no disease spikes or problems have occurred before returning to normal practice."
Devgan and her team will be donning N95s and face shields or goggles. Her patients will have masks on when getting upper-face injections. For lower-face treatments, she's considering having them wear large face shields that she can dexterously work gloved hands behind when injecting. "I've simulated this, but not yet tried it in real life, so I don't know if it will be practical, but I do think it could be possible," she says.
Exercising what Sunder calls "an abundance of caution," many of the surgeons we spoke to plan on sterilizing the skin of injectable patients, much like they would in surgery, when masks come off. "We're going to disinfect everyone's skin and swab the insides of their nostrils with a hypochlorous acid solution, which kills pathogens on contact," explains Gordon. "We'll also have patients rinse with a hydrogen peroxide-based mouthwash before certain treatments, like lip fillers, once we get to that point." Other surgeons have shared similar prep strategies — Betadine-and-Listerine gargle, anyone? — for high-risk areas.
"I'm going to be offering all injectables when I start back, and erring on the side of extreme caution, focusing on low-risk, minimal-downtime procedures on healthy patients under age 60."
Really, though, what isn't "high risk" when there's but a syringe-length space between your face and a stranger's? "While the nose and mouth are certainly the areas where the coronavirus particles are in highest concentration, we have no evidence to suggest that the viral transmission is meaningfully different if we're treating, say, the forehead versus the nose," says Devgan, who specializes in nonsurgical rhinoplasties. "In both situations, the practitioner is standing within one foot of the patient."
Even so, she's making antiseptic chlorhexidine mouthwash and nasal swabbing part of the new protocol for procedures of the nose and mouth, she says.
Navigating uncharted waters, doctors are relying on industry advice, societal guidelines, and their own gut instincts to steer them. Formulaic Instagram posts aside, ethical providers are truly striving to create the most copasetic experience possible, while confronting an undeniable truth: "The entire return to aesthetic noninvasive treatments in the near future is going to involve some sort of compromise," says Subbio. "Every decision we make must be tempered with a degree of humbling responsibility to place safety above appearance, safety above results."
For your go-to injector, that could mean anything from an all-out moratorium on cosmetic procedures to postponing lip fillers for a stretch or taking extreme (even strange-seeming) precautions when getting up close and personal. Ultimately, Subbio adds, "If an injector feels uncomfortable unmasking a patient for a lower-facial treatment, they shouldn't be criticized or made to feel like less of an 'artist.' Safety always comes first."
More on cosmetic procedures:
8 Tips for Keeping Skin Smooth and Plump While You Can't Get Injectables
Restylane Kysse, New Hyaluronic Acid Filler, Was Just FDA-Approved for Lips
How a COVID-19 Diagnosis Changed This Plastic Surgeon's Perspective on Aesthetic Medicine
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Keywordsinjectablescosmetic surgeryplastic surgeryfillersdermatologistBotoxdermatologistsCOVID-19coronavirussocial distancingface maskinjections