Case Study with Risk Management Strategies
Presented by NSO and CNA
Case study: Alleged improper performance of cosmetic injections resulted in tissue necrosis, nerve damage and scarring.
Medical malpractice claims may be asserted against any healthcare provider, including nurse practitioners (NPs) as well as the practices that they own. The insured in this case was an NP who was the owner and sole employee of a medispa. At the time of the incident, the NP had been performing aesthetic procedures for approximately five years. Before transitioning into aesthetics, she spent a decade working as a dermatology certified NP in an office practice setting. A collaborating physician with a specialization in plastic surgery—who also served as the medical director of the spa—was involved in the case.
Summary
A 60-year-old male patient presented to the medispa seeking a non-surgical aesthetic treatment to reduce submental fat and improve the appearance of a “double chin.” After evaluating the patient’s concerns, the NP recommended deoxycholic acid injections—an FDA-approved injectable therapy indicated for the reduction of submental fat. Prior to initiating treatment, the NP conducted a comprehensive assessment, noting the presence of significant facial acne scarring. The patient’s medical history was reviewed and documented, including diagnoses of hypertension and severe cystic acne. The patient reported using topical acne medications but denied undergoing any prior cosmetic procedures.
Based on the clinical evaluation, the NP determined that the patient was an appropriate candidate for deoxycholic acid treatment. She provided a detailed explanation of the procedure and conducted a thorough informed consent discussion. This included a review of common side effects such as localized swelling, discomfort, and numbness, as well as more serious potential complications including nerve injury, skin ulceration, and tissue necrosis at the injection sites. The discussion was documented in the patient’s healthcare information record. The patient confirmed his understanding of the risks and benefits, agreed to proceed with the treatment, and signed a written consent form that outlined the risks that were discussed.
Following the informed consent discussion, the nurse practitioner (NP) proceeded with the treatment, administering multiple deoxycholic acid injections to the patient’s submental area. Shortly after the procedure, the patient reported experiencing numbness in the lower lip. The NP assessed the affected area and noted no abnormal clinical findings. She informed the patient that localized numbness is a recognized side effect of the treatment and typically resolves within a few hours. The patient was discharged from the medispa in stable condition. Approximately one hour after the patient left the medispa, the NP contacted the patient to follow up. The patient answered the call in distress, reporting that the skin beneath his chin had turned black and that the lip numbness persisted. The NP immediately consulted her supervising physician, who arranged for the patient to be evaluated by a plastic surgeon the same day. The patient was seen later that day by the plastic surgeon who diagnosed the patient with tissue necrosis from the deoxycholic acid injections. As a result of this complication, the patient subsequently underwent revision surgery and multiple scar reduction treatments.
One year following the revision surgery, the patient (plaintiff) filed a lawsuit against the NP asserting the following:
- Improper injection technique
- Delay in post-procedure wound treatment
- Inadequate informed consent
The medispa business and the medical director were also named in the lawsuit with assertions of improper monitoring and supervision. The plaintiff claimed to suffer from permanent scarring and ongoing numbness in his lower lip as a result of the alleged substandard care.
Risk Management Comments
The plaintiff’s expert witness, who was also the treating plastic surgeon, testified that the NP used improper injection technique. Specifically, he opined that the injections were likely administered at an improper depth, preventing the medication from reaching the targeted fat layer. He explained that when injected superficially, deoxycholic acid can cause skin necrosis. The plastic surgeon stated that the patient’s lip numbness, which he believed to be permanent, resulted from incorrect needle insertion that caused dissolution of the marginal mandibular nerve.
The plaintiff testified in deposition that the nurse practitioner (NP) did not disclose the potential risks associated with the administration of deoxycholic acid injections and that had he been made aware of those risks, he would not have consented to undergo the procedure. He further alleged that the NP was not operating under the supervision of a physician, as required by state law, citing the absence of a physician examination at the time of the procedure. However, during cross-examination, the plaintiff acknowledged several key points:
- A physician affiliated with the NP’s medispa contacted him following the procedure and facilitated a same-day referral to a plastic surgeon for evaluation.
- A written consent form outlining the risks of the procedure was signed. (The plaintiff testified that he did, in fact, sign the consent form, but claimed he did not fully understand it.)
- A history of multiple facial cosmetic procedures, including the placement of acellular dermal matrices (cadaver skin implants) to address severe acne scarring and enhance jawline contour were not disclosed to the NP by the plaintiff. (The plaintiff admitted to intentionally withholding this information from the NP, expressing concern that full disclosure might have led to denial of treatment).
The defense presented a strong standard of care argument, asserting that the tissue necrosis resulted solely from the plaintiff’s deliberate omission of critical information regarding prior cosmetic procedures—not due to the nurse practitioner’s injection technique. The NP’s qualifications were validated through documentation of her continuing education, certifications, and specialized training in aesthetics, reinforcing the defense’s position. Additionally, expert testimony from a board-certified plastic surgeon confirmed that the plaintiff’s history of cadaver-derived dermal implants represented a clear contraindication to the use of deoxycholic acid and that this was the proximate cause of tissue necrosis. Notably, deoxycholic acid carries explicit warnings against use in regions previously subjected to aesthetic interventions due to an elevated risk of ulceration, tissue necrosis, and nerve injury, all of which the plaintiff claims to have sustained. The NP testified in her deposition that she would not have offered the injections had she known of the plaintiff’s history of receiving cadaver implants. She further testified that she explicitly discussed the risks and benefits of the procedure, and the plaintiff stated that he understood and opted to proceed. The NP documented the informed consent discussion including questions asked and answered in the healthcare information record.
Resolution:
This case was voluntarily dismissed by the plaintiff based upon the contributory negligence of the plaintiff and the fact that the defense experts were able to demonstrate that the standard of care was provided. The NP’s ability to demonstrate competence through documented certifications and continuing education coupled with vigilant post-incident care and thorough documentation contributed to the successful resolution.
Total Incurred: More than
$50,000 in defense costs.
Figures represent only the outcome for the insured NP and the medispa and do not include any payments that may have been made by or on behalf of other involved providers or companies.
Risk Management Recommendations for Nurse Practitioners
- Maintain competency and engage in ongoing education regarding new cosmetic procedures and equipment. Consider preceptorship/mentorship programs and/or shadowing experienced providers before offering a new procedure. Training and certification classes offered by device/product manufacturers may be limited in clinical content regarding identification and treatment of complications and adverse outcomes.
- Adhere to national guidelines and state-specific regulations regarding medical supervision, scope of practice and delegation of procedures.
- Establish a provider-patient relationship and conduct a screening assessment on all patients to determine if they are an appropriate candidate based upon age, current health conditions, medications, and past medical history, among other criteria.
- Discuss the proposed treatment plan and reasonable expectations for outcomes with patients to ensure their understanding of the proposed treatment and their responsibilities.
- Consider risk factors which may influence the treatment choice and document the informed consent discussion.
- Document the treatment contemporaneously, factually and comprehensively and include details regarding patient selection and screening. Objective and concise documentation is essential for the defense of a potential malpractice claim. Often, a comprehensive healthcare information record is the best legal defense.
- Provide follow-up care and referrals, as needed, for patients who experience adverse outcomes/complications.
Risk Management Recommendations for Nurse Practitioner Business Owners
- Comply with state/ federal laws and regulations for medispa businesses, including, but not limited to licensing, scope of practice, supervision of unlicensed staff and collaborative agreements with physicians.
- Adhere to state-specific “Corporate Practice of Medicine” doctrines which dictate whether or not a medispa can be non-physician owned.
- Ensure the quality of products/equipment purchased for patient use. Sequester equipment involved in an adverse event or resulting in patient injury.
- Consult with legal counsel regarding the process for sequestering medical devices/equipment and disclosure of information to patients in cases in which there were complications.
- Refrain from copying or distributing incident reports to anyone other than your legal counsel or professional liability insurance carrier and never place an incident report in the patient healthcare information record.
- Ensure all website content and marketing materials accurately reflect the services offered. Avoid using superlatives or making promises about outcomes. All messaging should be clear, factual, and aligned with the actual capabilities and scope of services provided.
Disclaimer
The information, examples and suggestions presented in this material have been developed from sources believed to be reliable as of the date they are cited, but they should not be construed as legal or other professional advice. CNA, Aon, Affinity Insurance Services, Inc., NSO, or HPSO accepts no responsibility for the accuracy or completeness of this material and recommends the consultation with competent legal counsel and/or other professional advisors before applying this material in any particular factual situations. This material is for illustrative purposes and is not intended to constitute a contract. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. All products and services may not be available in all states and may be subject to change without notice. Certain coverages may be provided by a surplus lines insurer. Surplus lines insurers do not generally participate in state guaranty funds, and insureds are therefore not protected by such funds. The claims examples are hypothetical situations based on actual matters. Settlement amounts are approximations. Certain facts and identifying characteristics were changed to protect confidentiality and privacy. Any references to non-CNA, non-Aon, AIS, NSO, and HPSO websites are provided solely for convenience, and CNA, Aon, AIS, NSO and HPSO disclaim any responsibility with respect to such websites. “CNA” is a registered trademark of CNA Financial Corporation. Certain CNA Financial Corporation subsidiaries use the “CNA” trademark in connection with insurance underwriting and claims activities. This material is not for further distribution without the express consent of CNA. Copyright © 2025 CNA. All rights reserved.
Nurses Service Organization is a registered trade name of Affinity Insurance Services, Inc., a licensed producer in all states (TX 13695); (AR 100106022); in CA, MN, AIS Affinity Insurance Agency, Inc. (CA 0795465); in OK, AIS Affinity Insurance Services, Inc.; in CA, Aon Affinity Insurance Services, Inc., (CA 0G94493), Aon Direct Insurance Administrators and Berkely Insurance Agency and in NY, AIS Affinity Insurance Agency.