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J Cosmet Dermatol. 2021;00:1–3.
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1wileyonlinelibrary.com/journal/jocd
Received: 23 Januar y 2021
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Revised: 15 June 2021
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Accepted: 6 July 2021
DOI: 10.1111/jocd.14339
LETTER TO THE EDITOR
Upward trend in number of injectable treatments in the
Netherlands 2016– 2019
To the editor
Little is known about the incidence of injectable cosmetic treatments
and adverse events associated with these treatments. The American
Society of Aesthetic Plastic Surgery (ASAPS) and the International
Society of Aesthetic Plastic Surgery (ISAPS) provide numbers on in-
jectable treatments, but the data are from their members only and
the response rates are low (5%).1,2 Therefore, these results cannot
be extrapolated to a general population.
In 2016, we published the results on the number of injectable
treatments in the Netherlands based on a postal survey sent to all
doctors in the country who performed injectable treatments.3 To
identif y these doctors, we used Google Internet Search, Dutch
Archive Data Care Register, and membership lists of all professional
specialty associations.
Using this same method, we repeated the survey for the number
of treatments performed in 2019. The search yielded a total of 305
eligible doctors. A total of 99 doctors responded (response rate of
32%), of whom 63 (64%) provided exact numbers and 26 (26%) gave
estimates. We used the same method to estimate the total num-
ber of treatments. Total numbers of botulinum toxin (BTX) and sof t
tissue filler treatments are presented in Table 1. The male/female
ratio was 1:8, and the average age was 43.2 years. Since the scien-
tific societies of all professional specialty associations recommend
treating only persons between 18 and 70 years of age, a total of
5.907.1904 women and 5.934.2774 men were eligible for treatment
in the Netherlands. Considering the male/female ratio and the fact
that treatments with BTX are usually given twice yearly and soft
tissue fillers once yearly (Velthuis et al., unpublished results), this
would mean that in 2019 one out of every 53 women (5.907.190/
(0.888 × 124.494) were treated with BTX , and one out of every 41
(5.907.190/0.888 × 162.702) with soft tissue fillers.
The numbers in 2016 and 2019 are remarkably consistent, sug-
gesting that they could represent the actual numbers in the gen-
eral Dutch population. In this 3- year period, the number of filler
treatments increased by 12%, whereas BTX treatments diminished
slightly. This is in line with the international data from ASAPS and
ISAPS.
Our estimate that 1 out of every 41 women has undergone filler
treatment was surprising, as this makes filler treatments one of the
most popular aesthetic medical intervention in terms of annual fre-
quency. We expect these numbers to be similar to those in other
Western countries or even slightly higher, thanks to the influence
of Dutch Calvinism.5 The popularity of filler treatments in Asia and
Latin America might be even higher.
Our department holds consultation hours for filler complications,
is based in the center of the Netherlands, and can be reached within
a two- hour car drive from ever y place in the country. Although we
acknowledge that not every side effec t will be referred to our clinic,
almost all serious ones are. The most serious adverse events are
vascular adverse events (VAE), which we see almost twice every
month.6 Gi ven the calculate d total number of tre at ment s, VAE occur
in 0.014%. During the last 5 years, the mean number of referred pa-
tients with other adverse events from hyaluronic acid fillers was 50
and for BTX it was 5. Hence, the calculated risk for serious HA filler
complication is 0.03% and for botulinum toxin 0.002%.
Cosmetic injectable treatment s have become an important par t
of aesthetic medicine and entail very low risks of serious adverse
events.
FUNDING INFORMATION
The authors declare no financial interest in the subject rele-
vant to the manuscript . This study has no involvement of study
sponsors.
CONFLICT OF INTEREST
The authors declare no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
AUTHOR CONTRIBUTIONS
T.D., P.V. and L.B. per formed the research. T.D., P.V., R.S and B.L.
designed the research study. D.Z., L .B., R.S. and B.L . contributed es-
sential reagents or tools. T.D., P.V. and D.Z. analyzed the data. T.D.,
P.V., D.Z., R.S. and B.L. wrote the paper.
ETHICAL APPROVAL
Research concerning anonymously non- traceable data does not
require approval by an ethics committee according to Dutch law
(WMO).
This is an op en access arti cle under the ter ms of the Creat ive Commo ns Attri butio n- NonCo mm erc ial- NoDerivs License, w hich permits use and dis tribution in
any medium, provided the original work is properly cited, the use is no n- comm ercial a nd no mod ifications or a daptations are made.
© 2021 The Authors . Journal of Cosmetic Dermatology published by Wiley Periodicals L LC.
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LE TTER TO THE EDITOR
DATA AVAIL AB I LI T Y STATE MEN T
The data that support the findings of this study are available from
the corresponding author upon reasonable request.
Tom S. Decates MD1
Peter Velthuis MD, PhD1
Danial Zarringam MD1
Luca Bruin MD1
Rutger H. Schepers MD, DMD, PhD2
Berend van der Lei MD, PhD3
1Department of Dermatology, Erasmus Medical Center,
Rotterdam, the Netherlands
2Department of Oral and Maxillofacial Surgery, University of
Groningen and University Medical Center Groningen (UMCG,
Groningen, the Netherlands
3Deparment of Plastic Surgery, University of Groningen and
University Medical Center Groningen (UMCG, Groningen, the
Netherlands
Correspondence
Tom S. Decates, MD, Depar tment of Dermatology, Erasmus
Medical Center, Postbus 2040, 3000 CA Rotterdam, the
Netherlands.
Email: t.decates@erasmusmc.nl
ORCID
Tom S. Decates https://orcid.org/0000-0002-1929-2010
Peter Velthuis https://orcid.org/0000-0002-9449-0068
Danial Zarringam https://orcid.org/0000-0003-2349-216X
Rutger H. Schepers https://orcid.org/0000-0002-7487-593X
Berend van der Lei https://orcid.org/0000-0002-3417-395X
REFERENCES
1. Decates T, de Wijs L, Nijsten T, Velthuis P. Numbers on inject-
able treatments in the Netherlands in 2016. J Eur Acad Dermatol
Venereol. 2018;32(8):e328- e330.
2. American Society for Aesthetic Plastic Surger y. Cosmetic sur-
gery national data bank statistics 2019. https://www.surge ry.org/
s i t e s / d e f a u l t / f i l e s / A e s t h e t i c - S o c i e t y _ S t a t s 2 0 1 9 B o o k _ F I N A L . p d f .
Accessed October 25, 2020.
Botulinum Toxin
Response (Calcuating
Factor) Number Given
Number E xtrapolated
T0 100% (+/−20%)
2019
Factual N = 63 Treatments (x1) 48.875 152.734
Estimate N = 26 Treatments (x1) 30.800 96.250
(77.000– 115.500)
Netherlands Total 2019 248.984
(2 29.7 34– 2 68.2 34)
Europe Total 2019 10.851.806
2016
Factual N = 60 Treatments (x1) 64 .769 175.052
Estimate N = 62 Treatments (x1) 29. 052 78.529 (62.815– 94.223)
Total 2016 253.571
(2 37. 8 67– 269. 275)
Fillers Response (Calcuating
Factor)
Number Given Number Extrapolated
T0 100% (+/−20%)
2019
Factual N = 63 Treatments (x1) 28.365 88.640
Estimate N = 26 Treatments (x1) 23.700 74.062 (59.249
– 88.874)
Netherlands Total 2019 162.702 (147.889
– 177.514)
Europe Total 2019 7.091 . 2 61
2016
Factual N = 60 Treatments (x1) 35.278 95. 345
Estimate N = 62 Treatments (x1) 15.966 43.151 (34.521
– 51.981)
Total 2016 138.496
(129.866– 147.126)
Note: For estimates, a 20% margin of uncertainty is given in brackets. European numbers are
extrapolated from the number of inhabit ants (18– 70 years of age) in Europa in 2019.
TAB LE 1 Numbers on botulinum toxin
and soft tissue filler treatments given by
respondents in 2016 (N = 122; 37%) and
2019 (N = 99; 32%), recalculated to ac tual
treatments and extrapolated to 100%
response
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LETTER TO THE EDITOR
3. International Society of Aesthetic Plastic Surgery. The International
study on aesthetic/cosmetic procedures performed in 2018.
https://www.isaps.org/wp- conte nt/uploa ds/2020/10/ISAPS
- G l o b a l - S u r v e y - R e s u l t s - 2 0 1 8 - 1 . p d f . A c c e s s e d O c t o b e r , 2 5 2 0 2 0 .
4. Dutch Bureau of Statistics. CBS. 2019. https://opend ata.cbs.nl/statl
ine/#/CBS/nl/datas et/03759 ned/table ?froms tatweb. Accessed
December 21, 2020.
5. Freudenb erg M. Economic and social ethics in the work of John
Calvin. HTS Theological Studies. 2009;65(1):1- 7.
6. Schelke L, Decates T, Kadouch J, Velthuis P. Incidence of vascular ob-
struction after filler injections. Aesthetic Surg J. 2020;40(8):NP457-
NP460. https://doi.org/10.1093/asj/sjaa086
