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« Medical Spa MD: End of the Road for Evolence | Main | Fake Botox or not, Discount Medspa is going to jail. »

Medical Assistant's can not inject Botox!

I've seen and head about medical estheticians, medical assistants and even front desk staff administering Botox injections.

It's not legal, as this story on the prosicution of a medical assistant clearly shows.

Betty Guerra’s monthslong nightmare is over.

The 45-year-old former medical assistant learned today from her attorney that the 10 felony counts against her on allegations of “unlawful practice of medicine” will be dismissed, she said.

“I always believed things would work out the right way,” she said tearfully. “I cannot be punished for something I didn’t do.”

Guerra’s July arrest sparked controversy over what medical assistants can and cannot do. Specifically, there was confusion over whether they are able to give shots.

Guerra was accused of unlawfully administering cosmetic injections, an act commonly performed by medical assistants throughout Nevada.

The state attorney general’s office did not specifically say charges against Guerra would be dropped but indicated it won’t be pursuing the case.

“The complaint against Betty Guerra submitted to the Attorney General’s Office by the Board of Medical Examiners has been contradicted by the subsequent actions by the Board,” Attorney General Catherine Cortez Masto said in a statement. “Therefore, it is fair for us to conclude that it would be difficult to prosecute this case beyond a reasonable doubt.”

Guerra’s attorney, Jason Weiner, said this evening that the attorney general’s office had sent him a copy of an unfiled motion dismissing the case earlier in the day. He would not be able to provide the Review-Journal with a copy of that motion until Wednesday, he said.

After Guerra’s arrest, physicians became concerned about what duties their medical assistants could perform.

Former medical board director Louis Ling said that upon reading a 30-year-old law, he concluded that the assistants could not give shots. With flu season coming on, he then attempted to draft emergency regulations that would allow them to give flu shots, but not Botox or other cosmetic injections.

However, that effort was shot down when a judge recently ruled that the board, in considering the regulations, had violated the open meeting law.

The board later reversed its position, determining that state law allows medical assistants to administer everything from flu shots to Botox. Medical assistants could give shots as long as they are under the “direct supervision” of a physician. Most health officials and doctors take that to mean the physician is on premises.

Ling resigned on Friday.

Guerra, a mother of three who was a physician in her native Peru, said she has been under incredible stress since her arrest and lost her job because of the publicity surrounding her case.

“It was a nightmare. I could not even sleep or eat all this time, wondering what was going to happen.”

Still, she said she harbors no anger.

“Now, I start all over. But it’s just another experience in my life.”

Via Review Journal story.

Reader Comments (26)

I work as a medical esthetician in a well know medical spa and skin clinic in NYC. The doctor who runs our medical spa has trained myself and one other medical esthetician to give general shots (we offer flu shots) as well as Botox injections. While we never do Restylane or Juvederm or Sculptra, we have both performed Botox injections on patients. In every case that I'm aware of the doctor was in the medspa and instructed us to do so. All of the patients also knew that it wasn't a doctor that was giving them Botox and they were OK with that. (The received a discount on the Botox.)

Am I missing something? Isn't the doctor the one who 'decides' what we're allowed to do under his supervention?

I, as an aesthetician, can emphatically say that MONTHS (even years of advanced learning) of skin related learning does NOT qualify you to inject someone. I don't care what "training" you may have had. Hell, I don't care if you are the Botox aren't legally medically schooled to inject anything into anyone. As an aesthetician who's "medically trained" I would never attempt (even as conformable and qualified as my MD thinks I am) injecting anything. The difference isn't simply if you are good at it or not at it. I work under a physician's license and She and I both respect the work we do, BUT we I know that I work under HER medical liability and out state's laws require the practice of medicine to exclude aestheticians. Let me ask you this....What makes you think that you as someone with non-medical training think that you can do something that otherwise requires a physician to sign off on. (i.e. Botox , Juvederm, must be purchased from someone with a medical license.) My advise to you is to investigate and question your legal boundaries for your own sake. You can (and WILL if the medical board investigates) have your aesthetic license taken away. It doesn't mean jack if there is an MD on site or even if he directed your hand. If HE/SHE isn't doing to cosmetic injectables than you are ALL risking at least license revocation, at worst, legal action. My advice is RUN!

I don't mean to be rude or disrespectful, but I have to agree with "Aesthetician" above. There is no way anyone without medical training should be sticking a needle in anyone for any reason in a physician's office or medical spa. I went to nursing school in NJ and I wasn't even allowed to stick a needle into a live human being until I graduated, passed my boards, and took a mandatory IV puncture course! "Botox Esthetician, you are going down a dangerous path.

And, no, it is not the physician's decision... it's State laws and it doesn't matter if the patient was "ok" with it or not. If that were the case, the physician can have a receptionist inject Botox at the counter as people are checking out. Botox, or any injectable product, should not be taken lightly. Remember it's botulinum toxin you're injecting into someone's face. You, as an aesthetician, should be aware of the fact that State laws mandate who can operate a laser as well.

Do you think it will hold up in a court of law if a patient ever sues you? What are you going to say? Well the patient said it was ok? Even worse, how will you feel ethicially if you have harmed someone? When they start teaching how to inject Botox in esthetician school, maybe you'll have a leg to stand on. But until then, drop the needle and run.

Thanks Paula! I don't mean to be insensitive. I can't lie and say I've never stuck a needle into someone, I've injected into my RN under her direct supervision (even then COMPLETELY violating our state laws and I shouldn't have done it and will NEVER do it to an patient) Again, You have no legal bearing when it comes to injecting someone. I myself as an aesthetician was very excited about the prospect of getting on the fast track into the medical field. One thig you MUST understand though is that you are an aesthetician transitioning into medical. That is very different than a medical person transitioning into aesthetics. There are many things I have schooled my RN and MD on when it comes to skin. Does that mean I am qualified to prescribe meds and preform injectables? NO. Don't take it as a slight when we "slam" your injecting, You need to realize that you don't have the medical training and schooling that is required by the state and medical boards to preform there services. There is a reason that they regulate these, and it's because when something goes wrong who are you to address these issues? You aren't medically inclined to deal with the potential issues and medical contraindications. Again, I'm not trying to slam you. You just need to realize that talent and aptitude isn't equivalent in the eyes of the law when it comes to medical procedures.

Aesthetician, you know it also goes the other way! Under PA State Law as a Nurse I cannot perform a facial for a patient unless it is deemed medically necessary and the physician has written an order for it. And, as a Dermatology Nurse, I know a lot about skin! Medical spas have been and always will continue to be a very controversial business aspect across the US. This is why we are seeing new legislation popping up all over the place.

And, Mark, the issue wasn't about a practitioner injecting Botox, it was about an Aesthetician injecting Botox.

Can we flip the coin over for a second - remove the word "Botox" from the dialog - and ask that the ones who are making arguments strictly on the basis of "sticking needles in skin" to likewise be as vigilant about the qualifications of the person sticking needles in their children who are being immunized? I can't speak for NYC, but many of the pediatric offices and PCP offices employ Certified Medical Assistants who ARE formally trained to stick needles into skin ( And the difference in our state between CMA's and nurses is that nurses can do so without the direct supervision of a physician (still requires oversight and orders). Again - we are NOT discussing Botox, but "sticking needles in skin".

The broader concern and argument should be made, not about technique of injection, reconstitution, etc., but the finer points of which muscles and how much. What is the desired outcome? How was the previous injection? What changes have occurred since last injection that inpact THIS series? If I were making an argument about why a physician or mid-level provider needs to do these injections - it would be based on the higher skills required to this... "practice of medicine". Sticking a needle into the skin is, IMO, not practicing medicine if the physician has already determined if, where, and how much.

(Sorry, this opinion DOES exclude estheticians who aren't formally trained in medical injections or vitals as part of their profession.)

11.10 | Unregistered CommenterBeth

And I'm sorry, but the title of this article - I think - is incongruous with the conclusion, with all due respect.


"The board later reversed its position, determining that state law allows medical assistants to administer everything from flu shots to Botox. Medical assistants could give shots as long as they are under the “direct supervision” of a physician. Most health officials and doctors take that to mean the physician is on premises.

Ling [former medical board director who gave unfavorable interpretation] resigned on Friday."


Am I wrong here?

11.10 | Unregistered CommenterBeth

The difference between a flu shot and Botox as I see it is that Botox is a specific treatment, not the general administration of a product that can be stuck in any muscle mass. If I were to miss an injection site with a flu shot by an inch there's no problem. But if I'm injecting Botox and put the Botox in the wrong place and I'll be causing the patient harm, and getting my medical spa and supervising physician sued. (And rightly so.)

I'm betting that there's no malpractice insurer that would cover medical assistants injecting Botox...

Malpractice Insurance carriers do not insure Certified Medical Assistants. They insure the Physicians who employ them. The physician delegates procedures/tasks as permitted by law. And again, the article above concluded with the Nevada board reversing it's previous mis-interpretation of a 30 year old Nevada State Law when ..."The board later reversed its position, determining that state law allows medical assistants to administer everything from flu shots to Botox. Medical assistants could give shots as long as they are under the “direct supervision” of a physician. Most health officials and doctors take that to mean the physician is on premises." Everything that the Certified Medical Assistant does under the order and supervision of the physician makes him/her culpable. That's why it is in his/her - THE PHYSICIAN'S - best interest to make sure that whatever task is delegated is delegated to someone who is properly trained (either formally or personally) and delivered with the same high level of care he himslef would give. Period.

Ling resigned on Friday.

11.20 | Unregistered CommenterBeth

As a medical aesthetician I have injected under a physician's supervision for nearly eight years. That is the concept of a med spa? Medical Aesthetic procedures delivered under a physician's supervision. I have more often seen patients injured by laser treatments. In fact, in a decade of working in spas that offered Botox, I've never seen serious side effect. I've seen one temporarily droopy brow, once, injected by a "diamond" injector physician.

I have been reading a lot of different questions and answers regarding "medical aesthetician's". I am currently going to school to be a licensed medical assistant, then going to school to be a aesthetician My ultimate goal is to work in a Med Spa performing all the services an aesthetician normally does, but was hoping to be trained in Botox and laser's as well. If I am a licensed Medical Assistant (which we give over 100 injections and blood draws before we graduate), will I be able to inject Botox in a Medical Spa setting once I have retained my MA and aesthetician license?

01.28 | Unregistered CommenterAJ

Please read above. You will never be able to legally inject Botox as a MA. (Being an esthetician has no effect since an esthetician license is not a medical license.) There is NO SUCH THING as a 'Medical Esthetician'. It's a made up name. You'll be either an esthetician or, in some states, a Master Esthetician. Neither of these licenses allow you to inject Botox or fillers.

However, in some states you will be able to use cosmetic lasers and IPLs under the supervision of a physician. Please read the endless number of posts and comments on this topic on this site.

Jeff, I appreciate your response. I am very aware of the amount of posts on this site, and have looked at numerous other sites. However, since you have obviously read them as well, I'm sure you noticed there was not a response from a MD which is what I was hoping for. On the different sites I have looked at, I have read many different things from RN's, estheticians, etc.. Some of the people who were medical assistants were not registered medical assistants and received only on the job training. Since I will be registered with the formal training of injections, I did not know if this would make a difference. Now I know that it does not. Also, the spa I go to has a lady whom they (even the doctor) refer to as their medical esthetician. She is a registered medical assistant and esthetician. I have never heard the term master esthetician. What is the difference between an esthetician and master esthetician? Again, thank you for the information.

02.3 | Unregistered CommenterAJ

Eh AJ, Doctors don't write the laws or get to decide what their, or their employees, scope of practice is. The term 'Medical Esthetician' is a marketing term that attempts to give an assistant or esthetician some sort of 'medical' standing. The fact that a physician is using that term is irrelevant since it doesn't mean anything.

If a physician is allowing or promoting one of their staff to perform treatments outside of that persons licensed scope of practice, they are risking their own medical license. This is illegal in every state no matter what anyone else - including any physician - tells you. MA's can not perform Botox injections or any other active treatment. It's the law in every state and if a physician is allowing that, they're headed for a messy end. It only takes one unhappy patient or disgruntled employee to alert someone that this is going on.

Still don't believe me? Call your state licensing organization and ask them if there are ANY circumstances where an esthetician or MA can inject a patient with Botox, even if the physician 'orders' them to do while the physician is standing right there. Let us all know what they say.

PS: Some states (like Utah) have a Master Esthetician license that has at least 2000 hours of training.

MA has a Master's Esthetician license that requires 1200 hrs. training


You wanted to hear from a doctor so here it goes. I do not know of ANY state that allows a mediacal assistant to inject Botox or fillers. I also do not know of any state that allows an aesthetician to inject. There are some doctors that have allowed it but they are breaking the law and as soon as they have one complaint the medical board will be on them. They run the risk of losing their medical license.

I for one would NEVER risk my medical license so that I could save a few bucks on salaries. The question I would have for you is do you want to work for someone like that. If they are willing to usurp the law, what will they do to you?

Lornell E. Hansen II, M.D.
LazaDerm Skincare Centre

02.4 | Unregistered CommenterLH

Can someone please explain to me this: Is it, or is it not legal (depending on state) for a medical assistant to give injections under a physician's supervision? I ask this because I am currently enrolled in school for MA and part of the curriculum (CT) includes PPD injections, blood draw, and medication draw ups and intramuscular, subcutaneous, and intradermal injections. I was told by our instructor that MAs, legally, are not allowed to give injections UNLESS under the supervision of a physician. If this is true, then how is an MA training in medication injections and injecting them under supervision different from an MA training in BOTOX injections and injecting them under supervision? Because I know that while training for injections, we have to know the muscles, as well as the angle and depth of each injection. Some of these previous comments make it sound like MAs are just given a syringe and told to "have at it" lol. That's not the case. We do have medical training to an extent, that's why there's a "medical" stuck in there before the assistant :) I guess that's just where my confussion is- if an MA can train and inject substances under supervision, then how is BOTOX seperate from those other "substances" to where it's suddenly not ok?

06.25 | Unregistered CommenterJessica

@ Jessica, Think of it this way. One is taking a little bit of blood out of someone's are. The other is injecting a potentially dangerous toxin into someone's face. Seems simple to the rest of us.

06.25 | Unregistered CommenterDBA

Botox and fillers injection are not hard.
But, one has to respect the law regardless who can or can not inject.

one being the cosmetic surgeon does not mean he or she can inject better than the medical assistant or the nurse who injects 10-20 times a day.

who's to blame?
The local health authority or the FDA or local law enforcement agencies who fail to lay out a clear black and white regulation.

06.25 | Unregistered CommenterMary

@DBA- clearly you did not read all of my comment- becuase I mention that in addition to blood draw, the MA ALSO INJECTS MEDICATIONS UNDER SUPERVISION. My question was what makes injecting meds and injecting BOTOX different if still done under supervision. @ Mary, thank you for reading all of my comment and answering my question :)

06.26 | Unregistered CommenterJessica

it is such a grey area.
if a law stating that only doctors can inject fillers or botox, then be prepared to brace for a big change in the medspa industry.
I personally will not have such time to attend to all the botox, filler consultation and injection.
Honestly my experience level may not be as good as my MA or PA as they are doing over 20 cases a day. My clients (not my patients as they are not ill ) come to me because they want to look better. They want the best result and I dont think they care if the injectors are doctors or not. Me as a doctor will and may only have the time to focus on the lasers and excision.
My lovely MA / PA will focus on botox. My public relation ladies will focus on up selling. My receptionists will entice our clients to come to us.

if such law such as only doctor can inject, we will see drastic reduction in the sales of botox and fillers. Many PA or MA will lose their jobs. This again will burden our already super weak economy. I think we have not seen the bottom of our economy yet.

06.26 | Unregistered CommenterMary

I guess my question to you Mary, are you qualified to handle the complications???? I am a physician, by law i can do cardiac surgery. I am not trained therefore I would never do it?? There is more to this than putting a needle into a muscle.

06.26 | Unregistered Commenterlaserdoc

Just because one is a physician, does not mean they qualify to perform cardiac surgery, is that correct? Each person studying in the medical field to become a doctor eventually spans out into different fields and specialties to continue residency in those departments with further training, is that correct? I think the point you're getting at is physicians, RNs, and PAs can be trained in BOTOX injections. But from what I understand, these BOTOX courses are of the same dimension to all who take it. Therefore, a person who has been trained in the integumetary and muscular systems and injection procedures such as medical personnel, including MAs (because we are also trained in that) who all take the training course are all, at that point, on the same level. I would like to know what more a physician knows than an MA about injection procedures, because no matter how extensive one's education is, injection procedures remain the same whether being taught to a physician or anyone else. Clearly so, because some physicians are instructing their MAs to do so in some offices.

06.26 | Unregistered CommenterJessica

It's scary just how out of control this stuff really is! imo botox needs to be reined in and left in the hands of experienced medical providers (doctors and mid-levels only). I think physicians using MA's to inject botox must be cutting corners or something? And "all is well, as long as all is well"...but if someone gets hurt, is it ever really worth the risks to one's business or practice? or reputation?

I don't understand how non physicians and/or mid-levels inject botox, they are not allowed to see patients and diagnose a condition, they're not suppose to determine the injection dosages needed per such individuals. I am under the impression a patient is suppose to have an actually physical "face to face" encounter, be seen by a provider each and every time botox is administered. i.e. Direct Supervision for any non-providers like for an RN for example...

So how are they getting around all this direct supervision stuff? And isn't this an unnecessary liability for a physician to take on? And I can't imagine any patient requesting for, or wanting to pay for an MA to inject their face! It's crazy what the public perceives as a good service. I bet if patients knew more about this overall they'd not be so quick to let just anyone inject them. If something goes wrong who is held accountable? an MA? yea and I got swamp land for sale...just call me and i will make you a great deal! lol

06.27 | Unregistered Commenterrkn

@rkn- Injection procedures are the same for a physician right down to us MAs. If a physician trained in injections and an MA trained in injections both went through the same BOTOX training course together, they would come out with the exact same knowledge as one another about BOTOX injection procedures. You defiantly are right though- it still remains an unnecessary liability. No matter what your levels of training background are, if you do not carry the proper titles to perform this procedure (physician, RN,PA,) then you are putting the office/clinic at risk for litigation. What's really scary, is how much MAs are being misled to believe that they are eligible to give BOTOX injections, as there are a select few classes that are available to us- also there are the MAs who are trained "on site" at the workplace then instructed by the physician to perform these procedures. I think initially the doctor does see the client, makes an observation, then makes the base decisions for the procedure (if the procedure is needed, how much, where injection sites are,) then hands the charts off to the next employee who is to "finish the job." To answer your question about cutting corners- I think that even though the client knows the physician will not be performing the procedure, they do NOT know of the laws and regulations that stand within the medical clinic. I'm sure if the physician were to say "This is Jessica, she's an MA and trained in BOTOX injections.., but legally she's not supposed to be doing this," the client will defiantly think much longer and harder about having the procedure done LOL!

06.27 | Unregistered CommenterJessica

You All sound silly, I'm a Medical Assistant, with 9 years of experience, and I have given hundreds of thousands of injections to patients. I previously worked in Pediatrics for six years, and I gave childhood immunizations, to many children. This is clearly an issue of the old "hiearchy syndrome" where the RNs and LPNs think Medical Assisants arent qualified to do what we were trained to do as Medical Assistants. THE LAW CLEARLY STATES THAT MEDICAL ASSISTANTS CAN GIVE INJECTIONS,OR PERFORM ANY TASKS THAT A LICENSED HEALTHCARE PROFESSIONAL CAN AS LONG AS THE MEDICAL ASSISTANT IS UNDER THE DIRECT SUPERVISION OF THE PHYSICIAN. It's GA law!

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