I came to aesthetic medicine late, and not for the reasons people assume.
I am vain. I always have been, and I am not going to apologise for it. My father was the same, a man who cared how he was groomed and how he was dressed, every day of his life. I learned it from him.
What drew me in was finding out how much the field had grown. For most of my career the options were a needle or a knife. That is no longer true. I had spent thirty years looking at faces as surfaces: what is bleeding, what is swollen, what is broken. Aesthetic medicine taught me to read the same face as a structure. Skin over fat over muscle over bone, each layer changing on its own schedule, and the sag you see at the surface often belonging to a layer well beneath it. Once you see a face that way, you cannot unsee it.
I will admit what I thought at the time: after years in emergency and critical care, this would be the gentler chapter. Calmer days. Easier medicine.
That is not what I found. The science had moved quickly. The rules governing who may practise it had not moved at all.
I spent sixteen years arguing about rules like these, seven on a regional medical advisory committee and nine as chief of emergency, usually to the irritation of the room. I did not expect to be doing it again in a field I joined to relax.
So this essay does something my others do not. First it sets out what the regulators actually say, in their words, with nothing added. Then, separately and clearly marked, it gives you my opinion.
Nova Scotia has a written position on this, and most people have never read it.
The Nova Scotia College of Nursing, since 30 June 2026 amalgamated into the Nova Scotia Nursing and Midwifery Regulator, publishes a practice document titled Nurses Who Provide Aesthetic Services to Clients, revised in September 2025. It applies to licensed practical nurses, registered nurses, registered psychiatric nurses and nurse practitioners. It covers dermal fillers, volume enhancers, collagen stimulators, lipolysis and neuromodulators such as Botox.
Four things in it are worth knowing.
It states that these are not benign procedures. The College's own language is that aesthetic services pose potential risks to clients, including an increased risk of morbidity. That is the regulator's assessment, not mine.
It states that every client requires an initial assessment. Not by any clinician, but by a qualified nurse practitioner or physician who has appropriate competence in aesthetic medicine. Every client. There is no exception in the document for a straightforward case or a low dose.
It requires further assessment when things change. A subsequent assessment by a qualified nurse practitioner or physician is required when a client is not achieving the intended outcomes, or when there is a change in dosage. Where a nurse practitioner is the prescriber, the document describes reassessment and a new prescription when subsequent treatment involves new injection sites or dosage adjustments.
It requires an authorising mechanism, and a prescriber who is reachable. That mechanism may be a direct prescriber order, a pre-printed order set specific to that client, or a care directive. Alongside it, an appropriate and authorised prescriber must be available for consultation, which the document says may include being available to assess the client on site.
The College of Physicians and Surgeons of Nova Scotia governs the other half of the arrangement. Its policy on change in clinical scope of practice requires a physician making a significant change to consult the College first and demonstrate, to the College's satisfaction, sufficient training and experience to practise the new scope safely and competently. The policy names moving into cosmetic medicine as an example of exactly that kind of change.
Search the College's catalogue of professional standards and guidelines today and there is nothing specific to cosmetic or aesthetic practice, and nothing addressing the delegation of cosmetic injection to a non-physician. A search for delegation returns seven documents, covering collaborative care, prescribing, consent, post-surgical care and the supervision of clinical observers. None of them speaks to this.
That was not always so.
The College once held a Professional Standard Regarding Care Directives in Aesthetic Medicine, re-approved with significant amendments in March 2013, and titled before that Policy Regarding Delegated Medical Functions in Aesthetic Medicine. It is three pages long and there is nothing vague about it.
It states that a physician who works with non-physicians to undertake aesthetic procedures bears ultimate responsibility for those procedures, whatever the procedure and whatever the facility. It states that a doctor-patient relationship exists in every situation where a physician orders an aesthetic procedure. And it sets out what the College expected of that physician: interview the patient, perform an assessment, make recommendations, assess contraindications, determine the injection sites, discuss the risks, obtain informed consent, and be present for the initial injection of Botox.
For later Botox treatments the physician had to be readily available for consultation, though not necessarily on site. Where a later treatment involved new injection sites or a different dose, the physician had to re-assess the patient. For dermal fillers the requirement was stricter still: on site for the initial administration and for every administration after it. The name of the ordering physician had to be communicated to the patient and posted in the facility.
Set that beside the rest of the country and it stands up. It is stricter than Alberta requires now. It is stricter than British Columbia. It is stricter than the change Ontario is currently consulting on.
It no longer appears in the College's catalogue. The document itself remains on the College's own server; it is simply not among the standards a physician is directed to read. The companion standard it refers to, on the qualifications required to perform certain cosmetic procedures in Nova Scotia, returns a page-not-found error at its own address.
Neither disappeared by accident. At its meeting of 14 October 2022, the College's Council approved a motion to retire both the Professional Standard Regarding Care Directives in Aesthetic Medicine and the Professional Standard on Qualifications Required to Perform Certain Cosmetic Procedures in Nova Scotia. The decision is recorded in the College's own Report from Council for that meeting, in a single line, between the welcome of two new Council members and the approval of the licence fee schedule for the following year.
No reason is given there, and I have not found one published anywhere else.
So the written expectation that a client be assessed before treatment appears today in the nursing college's document and not in the physicians'. It once appeared in both.
Two things follow, and they should be kept apart.
What is clear. Botulinum toxin is a prescription drug. Most dermal fillers are not; they are regulated as medical devices, which is a separate framework. But the toxin sits squarely inside the prescribing rules. The College's standard on prescribing requires that, before prescribing, a physician have knowledge of the patient's clinical status, arrived at through an assessment and a diagnosis. That standard makes no exception for cosmetic use. It applies to this drug as it applies to every other, and it has applied all along.
What is not clear. Prescribing a drug and authorising another person to perform a procedure are two different acts. Injection below the dermis is a controlled act in its own right. Nothing in the College's current published standards addresses whether, or on what terms, a physician may authorise someone else to carry out that act on a patient the physician has never assessed. That question is not answered anywhere in the record.
This is not only a Nova Scotia conversation.
In Ontario, the College of Nurses published a new practice guideline on aesthetic services in June 2026, announcing it on 3 July. Among the aims it set out for the guideline was clarifying delegation responsibilities. The College then consulted on going further, moving away from directives that cover many clients and toward orders written for a named client. That consultation has closed and no decision has been published. Under the heading A look forward, the College says it continues to review how authorising mechanisms, including directives and delegation, are used in this area of practice. Opposition has been organised and loud, including a petition with thousands of signatures, and much of the argument against has been about the effect on business models that depend on authorising treatment remotely.
Quebec went further, and earlier. From 1 May 2017 the Collège des médecins ended collective prescriptions for aesthetic injection. Every client seeking such injections must first be medically assessed so that a physician can establish an individualised treatment plan, and that requirement was applied even to patients who had already been injected under a collective prescription. The position is set out in the College's guide to aesthetic medicine, published in 2020: a nurse may administer a treatment only where it is the subject of an individual order specific to the condition of the person treated, and she assesses the patient before each treatment to confirm there is no contraindication.
In May 2024 the Quebec colleges of physicians and of nurses issued a joint notice reaffirming that position, and set out what had prompted it. Among the practices they described were physicians issuing injection orders for patients they had never assessed.
That is the record. Now my opinion.
I agree with the standard, and I want to be precise about why.
An assessment before a first injection is not paperwork. It is the step where harm is prevented, because it is the only point at which anyone asks the questions that matter. What is actually causing this. Has anything been injected here before, and what was it. Where do the vessels run in this particular face. Is this person a candidate at all, or is the honest answer no.
None of that is visible to someone holding a syringe who has not been asked to consider it. And none of it can be answered by a document written in advance for a category of client rather than for the person in the chair.
A protocol written for the average face is not an assessment of the face in front of you.
The phrase I would draw your attention to is the one about competence. The standard does not merely require a physician or nurse practitioner. It requires one with appropriate competence in aesthetic medicine. Those are different requirements, and the second is the one that carries the weight. A signature from a clinician who has never assessed a face for this purpose satisfies the letter of an arrangement while leaving the patient exactly where they started.
I would say the same thing about my own signature. Being a physician does not qualify me to assess a face for injection. Thirty years in emergency medicine did not qualify me. What qualifies anyone is training in this specific thing, and the willingness to be judged on it.
Which raises the obvious question, and it deserves an honest answer: trained where, and judged by whom.
There is no accredited Canadian credential in aesthetic medicine. No residency, no Royal College subspecialty, no College of Family Physicians certificate in it. Physicians, nurse practitioners, nurses and dentists who inject have all learned it in the same place: private courses run by commercial providers, most of them measured in days.
Nor is this only a question about those of us who came from outside. A published survey of Canadian dermatology residency programmes, canvassing both faculty and residents, was framed on the premise that current constraints may prevent residents from reaching competency in aesthetic dermatology during training, and that this carries consequences for patient safety. The specialty closest to this work is asking the same question about itself.
So when a standard requires competence in aesthetic medicine, there is no external mark to point at. That is not a criticism of the people who wrote the standard. It is the state of the field. But it means the requirement rests entirely on the individual, and on what that individual is prepared to have examined.
There is a reading of that withdrawal I find persuasive, and I offer it as a reading rather than a fact. With no cosmetic-specific standard on the books, cosmetic prescribing has nowhere to sit except inside the general prescribing rules, which require an assessment and a diagnosis and make no exception for anyone. A separate document invites the thought that this is a separate kind of medicine. Its absence makes that harder to argue.
What the absence does not do is replace what the old standard said about presence. A physician at the first injection, and on site for every filler, is not something the general rules ask for. That part went, and nothing took its place.
There is one more point, and it is the one I find hardest to argue past.
In therapeutic medicine we accept a degree of risk because there is a disease, and leaving it untreated causes harm. That trade is the whole basis of treatment. In cosmetic medicine there is no disease. Nothing is being cured. Nobody gets worse by not having it done.
Which means the tolerance for avoidable risk here should be lower than in the rest of medicine, not higher.
Let me state my own position plainly. Where a Canadian regulator has issued a rule addressing a genuine concern for public safety, my conviction is to adopt it and apply it, whether or not it binds me here, unless my own standard is already stricter.
I hold that view for a reason beyond this field. We accept in this country that access to care should be universal. If that principle means anything, then safety in care must be universal too.
A patient's protection should not depend on which provincial border they happen to be standing behind.
Do not follow impulse. Do not follow trends. How you look is part of who you are, and caring about it is not vanity, it is your wellbeing.
Which is exactly why it deserves the same care you would give any other medical decision. Not a reaction to a video, or a promotion, or the feeling that everyone else has already done it. Take your time. Ask who is assessing you. Make an informed decision.
Nobody is worse off for waiting.
Sources. Nova Scotia College of Nursing, Nurses Who Provide Aesthetic Services to Clients, revised September 2025; the College amalgamated into the Nova Scotia Nursing and Midwifery Regulator on 30 June 2026. College of Physicians and Surgeons of Nova Scotia, Report from Council, meeting of 14 October 2022. College of Physicians and Surgeons of Nova Scotia, Professional Standards and Guidelines Regarding Prescribing, reviewed May 2022, and Change in Clinical Scope of Practice. College of Nurses of Ontario, Aesthetic Services, June 2026. College of Physicians and Surgeons of Nova Scotia, Professional Standard Regarding Care Directives in Aesthetic Medicine, re-approved March 2013, no longer listed in the College's catalogue and retrieved from the College's server. Collège des médecins du Québec, Guide d'exercice sur la médecine esthétique, August 2020, and the joint notice of the Collège des médecins du Québec and the Ordre des infirmières et infirmiers du Québec, 30 May 2024. All are published by the regulators named and are publicly available.