On behalf of the Virginia Dermatology Society (VDS), we respectfully submit the following comments regarding the final adoption of amendments to 18VAC60-21 governing training requirements for dentists administering cosmetic botulinum toxin injections and oral and maxillofacial surgeons administering dermal fillers. The Virginia Dermatology Society recognizes that the General Assembly has enacted legislation authorizing certain dentists to perform cosmetic botulinum toxin injections subject to regulatory training requirements. However, VDS remains deeply concerned that the currently proposed training standards are insufficient to ensure patient safety and do not adequately reflect the complexity, risks, and medical judgment required to safely perform these procedures. Botulinum toxin injections and dermal filler procedures are medical procedures involving FDA-regulated products capable of altering or damaging living tissue. These procedures require comprehensive knowledge of facial anatomy, vascular anatomy, patient selection, sterile technique, complication prevention, and emergency management. Potential adverse outcomes include vascular occlusion, tissue necrosis, infection, dysphagia, visual compromise, blindness, and stroke.

The American Medical Association has adopted policy recognizing “the threat posed to patient safety when dentists and dental hygienists are authorized to practice medicine and administer procedures outside their level of education and training.” The AMA further states that cosmetic medical procedures, including botulinum toxin injections and dermal filler injections, constitute the practice of medicine. Similarly, the FDA has advised that patients seeking cosmetic injectables should be treated by licensed providers experienced in facial anatomy, complication management, and the risks and benefits of these procedures. Physicians who routinely perform cosmetic neurotoxin and dermal filler procedures typically complete:
• Four years of medical school;
• A minimum of one year of postgraduate internship training;
• Three or more years of residency training in specialties such as dermatology, plastic surgery, facial plastic
surgery, or oculofacial plastic surgery;
• Thousands of hours of direct patient care and procedural training involving skin, soft tissue, facial anatomy,
and management of medical complications;
• And, in many cases, additional fellowship training in cosmetic and procedural medicine.

Board-certified dermatologists receive extensive residency-based education and supervised procedural training in cutaneous surgery, facial anatomy, cosmetic injectables, laser procedures, adverse event recognition, and complication management. This training occurs over years within an accredited medical training environment under physician supervision and with ongoing competency assessment. By comparison, the current regulation would permit cosmetic botulinum toxin injections after completion of a limited short-course training program. The Virginia Dermatology Society does not believe that abbreviated didactic or procedural courses can reasonably substitute for the depth and breadth of physician medical education and residency training required for the safe performance of these procedures. Accordingly, VDS respectfully requests that the Board adopt substantially more rigorous safeguards and competency requirements before authorizing cosmetic injectable procedures by non-physician providers. At minimum, VDS recommends consideration of the following:
1. Expanded supervised clinical training requirements substantially exceeding the currently proposed minimum hours;

2. Mandatory hands-on training involving comprehensive facial anatomy, vascular anatomy, complication recognition, and emergency management;

3. Demonstration of competency through objective assessment and supervised case minimums of live-patient injections;

4. Formal competency assessment;

5. Clear limitations restricting injections to anatomical regions directly related to the dentist’s formal education and training;

6. Explicit prohibition on injections involving high-risk vascular territories including the periorbital, forehead, temporal, and glabellar regions;

7. Mandatory protocols for emergency recognition, referral, and management of vascular occlusion and other serious adverse events;

8. Ongoing continuing education requirements specific to cosmetic injectables and complication management. The Virginia Dermatology Society strongly supports maintaining the highest patient safety standards for cosmetic medical procedures performed in the Commonwealth. Our concerns are not intended to diminish the important role dentists serve in oral healthcare, but rather to ensure that expansion into cosmetic medical procedures occurs only with training and competency standards commensurate with the medical risks involved. Thank you for your consideration of these comments and your continued commitment to protecting the health and safety of Virginia patients.

Sincerely,

Patrick S. Rush, DO, FCAP, FASDP, AAAD
President | Virginia Dermatology Society