Development of Objective Structured Assessment of Technical Skills in facial cosmetic procedures: Botulinum toxin neuromodulator and soft-tissue filler injection
Authors: Kathleen C. Suozzi, Nour Kibbi, Kachiu C. Lee, Brandon Worley, Karina C. Furlan, Bianca Y. Kang, Sarah A. Ibrahim, Emily Poon, Murad Alam
Journal: Journal of the American Academy of Dermatology (2021)

To the Editor: The Accreditation Council for Graduate Medical Education requires dermatology residents to demonstrate competence in and practical exposure to common cosmetic procedures.1ACGME program requirements for graduate medical education in dermatology. Accreditation Council for Graduate Medical Education.https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/080_Dermatology_2020.pdf?ver=2020-06-29-161626-133Date accessed: January 14, 2021Google Scholar Although the Accreditation Council for Graduate Medical Education does not mandate particular measurement tools, ideally these should identify specific areas for improvement and convey constructive feedback. Objective Structured Assessment of Technical Skills (OSATS) are one of the best accepted methods for skill assessment intended to evaluate and constructively critique procedural skills.2Alam M. Nodzenski M. Yoo S. Poon E. Bolotin D. Objective structured assessment of technical skills in elliptical excision repair of senior dermatology residents: a multirater, blinded study of operating room video recordings.JAMA Dermatol. 2014; 150: 608-612https://doi.org/10.1001/jamadermatol.2013.6858Crossref PubMed Scopus (32) Google Scholar The purpose of this study was to develop OSATS checklists, including a global rating scale, for 2 injection procedures: (1) botulinum toxin (ie, neuromodulator) for facial dynamic lines; and (2) soft-tissue augmentation (ie, nonpermanent prepackaged fillers, including hyaluronic acid, calcium hydroxylapatite, and poly-L-lactic acid).Methods and Results are detailed in Supplemental File 1 (available via Mendeley at https://data.mendeley.com/datasets/t3j9mtwbdr/1) and Supplemental Table III (available via Mendeley at https://data.mendeley.com/datasets/bjnfspn68z/1), Supplemental Table IV (available via Mendeley at https://data.mendeley.com/datasets/ycrv7gcxf5/1), and Supplemental Table V (available via Mendeley at https://data.mendeley.com/datasets/ycmggp8d4n/1).A literature review was performed to develop long lists of technical items, which were refined by 13 expert dermatologists and plastic surgeons. Items were then rated by 28 expert dermatologists (Supplemental Table IV) in 2 Delphi rounds, with items deemed important by 70% being provisionally included. Items were retained if rated important by ≥80% of physicians in 2 virtual consensus meetings.The final OSATS for botulinum toxin (17 items) and filler (22 items) are presented in Tables I and II, respectively. The global rating scale (11 items) is presented in Supplemental Table V. These OSATS were designed for commonly treated sites in the upper portion of the face (eg, forehead, glabella, and orbicularis oculi) but may be adapted to other anatomic sites (eg, lower face). The global rating scale is applicable to either injection procedure and includes more comprehensive items such as overall flow of the procedure, respect for vasculature, and control of pain and anxiety.Table IObjective Structured Assessment of Technical Skills for botulinum toxinBotulinum toxin∗The items were developed for the dermatology resident or fellow trainee or for the board-certified dermatologist and should be administered by dermatologists who are experts in these procedures themselves. Training requirements for other physician specialists and nonphysician injectors may differ. Individual items may or may not be specifically approved by the US Food and Drug Administration.1. Assess the facial muscles at rest and in dynamic motion, including symmetry, distribution, strength, and size.†Assessment of strength and size in the clinical setting is subjective. In general, facial muscles are larger and stronger in men than in women, and those with finer features or smaller faces may also require less neurotoxin.2. Before treatment, photograph the face at rest and with facial expressions.3. Based on the preceding facial assessment and a discussion with the patient, develop a treatment plan, including appropriate dose for each anatomic site.4. Select an appropriate product.5. Reconstitute or dilute, if appropriate.6. Select syringe size, needle length, and needle gauge.7. Fill syringe(s) with appropriate quantity and eliminate dead space.8. In a designated area, using aseptic technique, assemble materials, including gauze, antiseptic cleansing agent, and syringes.9. Clean the treatment area with an antiseptic agent.10. Position self and patient to allow ergonomic access to injection sites.11. Insert the needle at correct anatomic locations (avoiding inked marks, if any).12. Advance needle tip to appropriate depths and locations.13. Inject product slowly with precise number of units per injection.14. Ensure that the syringe is stable during injection procedure.15. Avoid injecting into or through visible vessels.16. If bleeding occurs, apply localized pressure to the injection site after the injection or ask assistant to apply such pressure.17. Document the procedure (eg, by making a drawing or otherwise recording the number of units and anatomic locations).∗ The items were developed for the dermatology resident or fellow trainee or for the board-certified dermatologist and should be administered by dermatologists who are experts in these procedures themselves. Training requirements for other physician specialists and nonphysician injectors may differ. Individual items may or may not be specifically approved by the US Food and Drug Administration.† Assessment of strength and size in the clinical setting is subjective. In general, facial muscles are larger and stronger in men than in women, and those with finer features or smaller faces may also require less neurotoxin. Open table in a new tab Table IIObjective Structured Assessment of Technical Skills for soft-tissue fillerSoft-tissue filler∗The items were developed for the dermatology resident or fellow trainee or for the board-certified dermatologist and should be administered by dermatologists who are experts in these procedures themselves. Training requirements for other physician specialists and nonphysician injectors may differ. Individual items may or may not be specifically approved by the US Food and Drug Administration.1. Assess facial shape, proportions, symmetry, volume and contour at rest and in dynamic motion.2. Before treatment, photograph the face at rest and with expressions.3. Based on the preceding facial assessment and a discussion with the patient, develop a treatment plan, including quantity and depth of placement for each anatomic site.4. Select the filler type based on patient characteristics and treatment area.5. Reconstitute or dilute, if appropriate.6. Estimate total product volume needed (ie, pretreatment assessment of number of syringes).7. Select needles or cannulas of an appropriate length and gauge. If cannulas are selected, also select an appropriate incisional instrument, if required.8. If injecting hyaluronic acid filler, ensure hyaluronidase on hand.9. In a designated area, using aseptic technique, assemble materials, including gauze, antiseptic cleansing agent, and syringes.10. Position self and patient to allow ergonomic access to injection sites.11. Clean the treatment area with an antiseptic agent.12. Be prepared with gauze for holding pressure.13. Insert the needle or cannula at correct anatomic locations (avoiding inked marks, if any).13a. If using a needle, insert the tip into the plane of injection.13b. If using a cannula, identify the entry site, create an entry aperture with an instrument or a needle larger than cannula size, and insert the cannula into the plane of injection.14. Use appropriate injection techniques.14a. If using a needle, select from compatible injection techniques (eg, serial puncture, linear threading, fanning, crosshatching, bolus deposition, depot, fern, and cone).14b. If using a cannula, reposition the cannula and inject additional areas, while minimizing the number of cannula insertion sites.15. Inject slowly with small volumes per pass.16. Ensure that the syringe is stable during injection procedure.17. Avoid injecting into or through visible vessels.18. If bleeding occurs, apply localized pressure to the injection site after the injection or ask assistant to apply such pressure.19. Fill to appropriate correction. Avoid overcorrection.20. Maintain or improve symmetry.21. Avoid visible or tactile nodules, and if they occur, treat them (eg, with focal massage).22. Document the procedure (eg, by making a drawing or otherwise recording product volume and anatomic locations).∗ The items were developed for the dermatology resident or fellow trainee or for the board-certified dermatologist and should be administered by dermatologists who are experts in these procedures themselves. Training requirements for other physician specialists and nonphysician injectors may differ. Individual items may or may not be specifically approved by the US Food and Drug Administration. Open table in a new tab To minimize the complexity and duration of the assessment, reduce the need for highly subjective evaluations, and allow stylistic variation, only items imperative for safe and effective procedural performance were included. As such, all items in each OSATS apply to each trainee. OSATS can generally be adapted to particular practice levels (ie, years of experience, particular institutions, and practice styles). OSATS do not constitute a standard of care, as individual patient needs are paramount.Nontechnical considerations (eg, informed consent, patient history knowledge of anatomy, postoperative care, and adverse events) are also important. In particular, needle/cannula length, gauge, and tip shape can impact the risk of vascular occlusion, with smaller diameter cannulas behaving more like needles.3Pavicic T. Webb K.L. Frank K. Gotkin R.H. Tamura B. Cotofana S. Arterial wall penetration forces in needles versus cannulas.Plast Reconstr Surg. 2019; 143: 504e-512ehttps://doi.org/10.1097/PRS.0000000000005321Crossref PubMed Scopus (43) Google Scholar,4Goodman G.J. Magnusson M.R. Callan P. et al.A consensus on minimizing the risk of hyaluronic acid embolic visual loss and suggestions for immediate bedside management.Aesthet Surg J. 2020; 40: 1009-1021https://doi.org/10.1093/asj/sjz312Crossref PubMed Scopus (29) Google Scholar Among trainees, it may be helpful to consider using cannulas.5Alam M. Kakar R. Dover J.S. et al.Rates of vascular occlusion associated with using needles vs cannulas for filler injection.JAMA Dermatol. 2021; 157: 174-180https://doi.org/10.1001/jamadermatol.2020.5102Crossref PubMed Scopus (15) Google Scholar Aspiration (ie, to evaluate whether a blood vessel has been pierced) was excluded as a technical item due to its questionable utility.4Goodman G.J. Magnusson M.R. Callan P. et al.A consensus on minimizing the risk of hyaluronic acid embolic visual loss and suggestions for immediate bedside management.Aesthet Surg J. 2020; 40: 1009-1021https://doi.org/10.1093/asj/sjz312Crossref PubMed Scopus (29) Google ScholarThese OSATS were validated through a complex developmental process that included literature review, qualitative data extraction and synthesis, informal consensus, and formal Delphi consensus. Additionally, much of the architecture of these OSATS was based on that of previously validated OSATS, including dermatologic surgery OSATS.2Alam M. Nodzenski M. Yoo S. Poon E. Bolotin D. Objective structured assessment of technical skills in elliptical excision repair of senior dermatology residents: a multirater, blinded study of operating room video recordings.JAMA Dermatol. 2014; 150: 608-612https://doi.org/10.1001/jamadermatol.2013.6858Crossref PubMed Scopus (32) Google Scholar However, further work may include validation through use in a clinical setting.Dermatologists have long been regarded as pioneers in the field of minimally invasive and noninvasive cosmetic procedures. The development of tools that objectively assess performance of these procedures helps dermatology trainees hone these skills. To the Editor: The Accreditation Council for Graduate Medical Education requires dermatology residents to demonstrate competence in and practical exposure to common cosmetic procedures.1ACGME program requirements for graduate medical education in dermatology. Accreditation Council for Graduate Medical Education.https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/080_Dermatology_2020.pdf?ver=2020-06-29-161626-133Date accessed: January 14, 2021Google Scholar Although the Accreditation Council for Graduate Medical Education does not mandate particular measurement tools, ideally these should identify specific areas for improvement and convey constructive feedback. Objective Structured Assessment of Technical Skills (OSATS) are one of the best accepted methods for skill assessment intended to evaluate and constructively critique procedural skills.2Alam M. Nodzenski M. Yoo S. Poon E. Bolotin D. Objective structured assessment of technical skills in elliptical excision repair of senior dermatology residents: a multirater, blinded study of operating room video recordings.JAMA Dermatol. 2014; 150: 608-612https://doi.org/10.1001/jamadermatol.2013.6858Crossref PubMed Scopus (32) Google Scholar The purpose of this study was to develop OSATS checklists, including a global rating scale, for 2 injection procedures: (1) botulinum toxin (ie, neuromodulator) for facial dynamic lines; and (2) soft-tissue augmentation (ie, nonpermanent prepackaged fillers, including hyaluronic acid, calcium hydroxylapatite, and poly-L-lactic acid). Methods and Results are detailed in Supplemental File 1 (available via Mendeley at https://data.mendeley.com/datasets/t3j9mtwbdr/1) and Supplemental Table III (available via Mendeley at https://data.mendeley.com/datasets/bjnfspn68z/1), Supplemental Table IV (available via Mendeley at https://data.mendeley.com/datasets/ycrv7gcxf5/1), and Supplemental Table V (available via Mendeley at https://data.mendeley.com/datasets/ycmggp8d4n/1). A literature review was performed to develop long lists of technical items, which were refined by 13 expert dermatologists and plastic surgeons. Items were then rated by 28 expert dermatologists (Supplemental Table IV) in 2 Delphi rounds, with items deemed important by 70% being provisionally included. Items were retained if rated important by ≥80% of physicians in 2 virtual consensus meetings. The final OSATS for botulinum toxin (17 items) and filler (22 items) are presented in Tables I and II, respectively. The global rating scale (11 items) is presented in Supplemental Table V. These OSATS were designed for commonly treated sites in the upper portion of the face (eg, forehead, glabella, and orbicularis oculi) but may be adapted to other anatomic sites (eg, lower face). The global rating scale is applicable to either injection procedure and includes more comprehensive items such as overall flow of the procedure, respect for vasculature, and control of pain and anxiety. To minimize the complexity and duration of the assessment, reduce the need for highly subjective evaluations, and allow stylistic variation, only items imperative for safe and effective procedural performance were included. As such, all items in each OSATS apply to each trainee. OSATS can generally be adapted to particular practice levels (ie, years of experience, particular institutions, and practice styles). OSATS do not constitute a standard of care, as individual patient needs are paramount. Nontechnical considerations (eg, informed consent, patient history knowledge of anatomy, postoperative care, and adverse events) are also important. In particular, needle/cannula length, gauge, and tip shape can impact the risk of vascular occlusion, with smaller diameter cannulas behaving more like needles.3Pavicic T. Webb K.L. Frank K. Gotkin R.H. Tamura B. Cotofana S. Arterial wall penetration forces in needles versus cannulas.Plast Reconstr Surg. 2019; 143: 504e-512ehttps://doi.org/10.1097/PRS.0000000000005321Crossref PubMed Scopus (43) Google Scholar,4Goodman G.J. Magnusson M.R. Callan P. et al.A consensus on minimizing the risk of hyaluronic acid embolic visual loss and suggestions for immediate bedside management.Aesthet Surg J. 2020; 40: 1009-1021https://doi.org/10.1093/asj/sjz312Crossref PubMed Scopus (29) Google Scholar Among trainees, it may be helpful to consider using cannulas.5Alam M. Kakar R. Dover J.S. et al.Rates of vascular occlusion associated with using needles vs cannulas for filler injection.JAMA Dermatol. 2021; 157: 174-180https://doi.org/10.1001/jamadermatol.2020.5102Crossref PubMed Scopus (15) Google Scholar Aspiration (ie, to evaluate whether a blood vessel has been pierced) was excluded as a technical item due to its questionable utility.4Goodman G.J. Magnusson M.R. Callan P. et al.A consensus on minimizing the risk of hyaluronic acid embolic visual loss and suggestions for immediate bedside management.Aesthet Surg J. 2020; 40: 1009-1021https://doi.org/10.1093/asj/sjz312Crossref PubMed Scopus (29) Google Scholar These OSATS were validated through a complex developmental process that included literature review, qualitative data extraction and synthesis, informal consensus, and formal Delphi consensus. Additionally, much of the architecture of these OSATS was based on that of previously validated OSATS, including dermatologic surgery OSATS.2Alam M. Nodzenski M. Yoo S. Poon E. Bolotin D. Objective structured assessment of technical skills in elliptical excision repair of senior dermatology residents: a multirater, blinded study of operating room video recordings.JAMA Dermatol. 2014; 150: 608-612https://doi.org/10.1001/jamadermatol.2013.6858Crossref PubMed Scopus (32) Google Scholar However, further work may include validation through use in a clinical setting. Dermatologists have long been regarded as pioneers in the field of minimally invasive and noninvasive cosmetic procedures. The development of tools that objectively assess performance of these procedures helps dermatology trainees hone these skills. None disclosed.