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Function and Form by Rich Smith: Babak Azizzadeh, MD, FACS, combines facial paralysis repair with top-notch rejuvenation Dr. Azizzadeh, Facialplastics.info Cosmetic Surgery Brochure Dr. Babak Azizzadeh's Book on Amazon Read Chapter 1: The Aging Face Consultation or Chapter 10: Short-Flap SMAS Rhytidectomy Surgery starts steps to mend Beloved's face Dr. Azizzadeh on ABC News: MFG (Multilevel Fat grafting) Does the doctor listen to you? While your cosmetic surgeon's previous work can be an excellent indicator of his or her abilities, the most important thing is the quality of work the surgeon can provide you with. It is important to choose a cosmetic surgeon who takes the time to understand your goals and needs. Talk to your surgeon about what results you're looking for, explain your preferences you will know when you have found the right cosmetic surgeon when you feel that they understand you 100%. Learn more Choosing the right cosmetic surgeon for your procedure is a crucial aspect in achieving the results you want. If you are considering a face, nose, or eye procedure, contact Dr. Azizzadeh to schedule an initial consultation. Cosmetic surgeon Dr. Azizzadeh focuses on facial procedures and has provided wonderful results to many patients in the Los Angeles and Beverly Hills, California area. Dr. Azizzadeh discusses concepts in facial rejuvenation in Chicago for American Society of Plastic Surgeon's Nursing AssociationThe Aesthetic Consult for Dermal Fillers – Planning for Success Highlights of a symposium held Saturday, November 1, 2008 in Chicago, Illinois FacultyBabak Azizzadeh, MD, FACS The Center for Facial & Nasal Plastic Surgery Tracey Hotta, RN, BScN, CPSNNursing Manager and Aesthetic Specialist for Mitchell Brown, MD Faculty Disclosure StatementsIt is the policy of Medical Education Resources (MER) to ensure balance, independence, objectivity, and scientific rigor in all its educational activities. All faculty participating in our programs are expected to disclose any relationships they may have with commercial companies whose products or services may be mentioned so that participants may evaluate the objectivity of the presentations. In addition, any discussion of off-label, experimental, or investigational use of drugs or devices will be disclosed by each of the faculty members. The faculty reported the following:
Babak Azizzadeh, MD, FACS, reports that he has received consulting honoraria from sanofi-aventis, Bioform Medical, and Galderma, and he reports no conflicts of interest. Tracey Hotta, BScN, RN, CPSN, reports that she has received consulting honoraria from Allergan, and she reports no conflicts of interest. Judy Akin Palmer PhD, RN, CPSN, PHN, reports that she has no financial relationships or conflicts of interest. Continuing Education InformationTarget AudienceThis educational activity is designed for nurses who are interested in a comprehensive overview of dermal fillers and planning for patient consultations. Learning ObjectivesUpon completion of this educational activity, the participant should be able to:
Nursing Accreditation StatementMedical Education Resources is an approved provider of continuing nursing education by the Colorado Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Acreditation. Table of ContentsCurrent Options and Selection of Appropriate FillersBabak Azizzadeh, MD, FACS IntroductionOver the past 20 years, the field of facial rejuvenation has grown and changed tremendously. Most patients who walked through a plastic surgeon’s office in 1988 were offered surgery and nothing else. Today, the trend is toward customized programs that utilize surgical and nonsurgical options, along with skin care programs designed to suit each patient’s needs and wishes. The approach to each treatment plan is individual, with many tools and techniques available to achieve successful and satisfying results. With the availability of more tools, the artistry of the field has improved so that patients can be offered a range of procedures that can produce subtle to substantial changes in their facial appearance. Changes in Facial Rejuvenation TreatmentThere has been a significant shift in the past two decades in facial rejuvenation treatments. In 1988, surgery was the single treatment available to patients seeking facial rejuvenation, and surgical procedures were aggressively performed on specific areas around the eyes, mouth, and chin to tighten sagging skin. Brow-lifts were performed using a traumatic coronal procedure, and many deep-plane and composite face-lifts were performed. Facial lipoatrophy was not addressed at all. Overall, the results were less than optimal, the risks were higher, and recovery time was longer than it is today. In 2008, facial aesthetic procedures are much less aggressive and produce better outcomes.1 A conceptual change in the approach to facial aesthetics has occurred, with a shift in focus from face-lifts to volume restoration (Table 1), as experience has shown that atrophy in the midface and other regions is responsible for the most pronounced appearance of aging. Table 1. Comparison of Treatment Options For Facial Rejuvenation: 1988 vs. 2008
Understanding Facial AnatomyIt is important for plastic surgery nurses to understand the facial anatomy in order to better treat their patients. The skin rests on the surface of layers of nerves, muscles, and ligaments that determine facial contours and control expression. One of these layers, just below the skin, is the superficial muscular aponeurotic system (SMAS), which envelopes the entire musculature of the face (Figure 1). The SMAS is extremely important to comprehending the facial aging process. The SMAS form a delicate network across the face, connecting to both the muscles and skin.2 The facial nerve has five branches that go to the forehead, eye, midface, lower face and neck muscles, all of which impact on facial expression (Figure 2). Beneath the SMAS lie the retaining ligaments and underlying muscles that define the facial contours. Certain areas such as the pre-jowl sulcus, the nasolabial fold, and the zygomatous region are more likely to show signs of aging. The concept of fat distribution in the face has changed in recent years. A study by Rohrich and Pessa confirmed the observation made by many practicing surgeons that subcutaneous fat in the face lies in distinct subcompartments that do not allow for significant shifting.3 Over time, however, these fat deposits begin to lose volume, causing hollows and troughs to form between the compartments and contributing to the sagging appearance of the skin. In looking at Figure 3, which shows the compartmentalization of fat around the orbital area, it is easy to see how lipoatrophy of this area is involved in the aging appearance of the upper and lower eyelids. What Is Beauty?The concept of facial beauty is one that has remained relatively constant over thousands of years: It is a concept of symmetry, along with high, arched cheeks; an angular jaw; full volume in the cheeks and eyes; and a strong presence in terms of the overall face. Gaunt, hallowed cheeks and sunken eyes are perceived as making someone look less attractive and older. Currently, the practice of plastic surgery may lean toward volumizing in order to compensate for atrophy, as facial fullness is very important to the concept of beauty. An article in the August 2008 issue of New York Magazine explored the notion of the “new new face” where volumizing and fullness have taken the place of the more traditional tightening and shrinking type of facial surgery that was popular in the 1980s and 1990s. The article, which is subtitled “Out with the gaunt and tight, in with the plump and juicy,” cites examples of Madonna and Demi Moore as women who have had more novel, combined volumizing procedures. Observers can only note with admiration that they have had “something” done, although it is difficult to tell what that might have been. These “restuffed” faces are compared to the tight, harsh, reshaped faces of stars of the past all of whom came away from their procedures looking quite different than they had before, rather than recapturing a more youthful version of their own appearance. As the article points out, the current beauty trend seems to be a search for “baby fat,” which is equated with a youthful look. Source: Van Meter J. About-Face. New York Magazine. August 2008. Available at: http://nymag.com/news/features/48948/ Aging and the Face
The pathophysiology of aging is the result of multiple processes, including loss of skin elasticity, facial atrophy resulting from fat shrinkage and bone resorption, gravitational laxity of the muscles, and dynamic processes in the muscles involved in facial expression that contribute to age lines. Over the course of a lifetime, these processes all increase the appearance of wrinkles; expression lines around the nose, mouth, eyes, and forehead; a heaviness of the eyelids; thinning lips; and sagging skin all over the face, particularly in the areas of the jowls, chin, and neck. Environmental factors such as sun exposure, smoking, and poor diet can accelerate the aging process. The goal of facial rejuvenation treatment is to reduce these signs of aging in ways that are natural in appearance and have a lasting impact. Today’s treatments are remarkably successful in achieving these goals, as long as the patient has realistic expectations and is well prepared for the surgery and recovery afterward. For this reason, the consultation is extensive and thorough. Optimizing the Patient ConsultationThe consultation provides information in two directions: It educates the patient about the procedures, risks, and requirements for recovery, while providing the aesthetician or physician with an understanding of the patient’s goals and readiness for the procedures. Given the broad range of aesthetic tools and procedures available, the patient needs to understand that each practitioner has a unique approach to treatment, and that there are many options available. A crucial aspect of the initial consultation is a complete analysis of the face, which provides important information for the development of a treatment plan. People who are born with good bone structure often benefit most from rejuvenation surgery. Most patients will need a fairly comprehensive treatment plan that addresses aging while compensating for less-than-perfect structural elements. These patients often have a heightened awareness of a single flaw and subsequently believe that correction of the offending issue will miraculously address other aging issues. For instance, a patient may request a rhinoplasty without realizing that the single correction will then draw attention to a weak chin. It is the plastic surgeon and nurse’s function during the consultation to help patients see how each element of the face can be enhanced or improved to achieve the results they are anticipating. Simply explaining this to patients can help them make appropriate and satisfying decisions, both financially and aesthetically. When consulting about injectable treatments, it is important to inform patients about potential off-label uses of products, especially in the United States. For example, botulinum toxin (Botox® ) is only indicated for use on the glabella region above the brows, but currently is used off-label to treat crow’s feet and lines on the forehead. Additionally, patients should be realistically prepared to understand how many units of Botox® may be needed to achieve the results they are expecting, and what the outside costs might be. The Facial ExaminationIt is important for any facial rejuvenation practitioner to examine the proportions of the face in order to develop a treatment plan. Issues such as mandible weakness or temporal atrophy can affect the appearance of the whole face. In profile, you want to look at the forehead, midface, and lower face in equal fashion to assess not only the individual characteristics of the facial structure, but also to identify natural asymmetry and age-related changes. This assessment should be shared with patients to help them understand how the procedures they are requesting will or will not address these issues. For a global facial assessment, the face is viewed in thirds (Figure 4). The upper third is traditionally considered the eyes and forehead, and today it seems more appropriate to include primarly the upper eyelids and brow in this region. The lower eyelids, cheeks, nose, and nasolabial fold fall into the middle third. The lower third includes the jowls, chin, neck and the prejowl sulcus, located just in front of the chin. Each of these regions has special considerations for treatment.4 Some patients may require only regional treatment plans, while others should be viewed globally for a successful rejuvenation plan.5 Overall, however, it has become clear that volume repletion must be a primary consideration for any patient looking for facial rejuvenation. Ultimately, the goal of facial rejuvenation treatment is to create harmony without creating any major discrepancies. Treatment ConsiderationsFacial rejuvenation plans include three primary types of treatments:
Skin ResurfacingThe impact of aging on the skin is substantial: It loses elasticity, and expression lines go from being dynamic (as when smiling) to static (and permanent). The effects of sun exposure, smoking, and dietary choices on the pigment and texture of the skin, as well as natural flaws and skin tone, need to be considered in any rejuvenation program. While it may not be the primary concern of plastic surgery nurses, it is important for skin care to be included in the treatment plan to ensure the most successful outcomes for patients, and to help them maintain their results. Facial ContouringThe area of the midface has received a great deal of attention in recent years as facial contouring techniques have improved and expanded with the use of injectable volume enhancers.6 This region is particularly susceptible to large-scale, age-related changes resulting in a general flattening of the midface with increased shadowing and areas of concavity that give a gaunt appearance. A Facial Lipoatrophy Panel convened in 2006 to examine the causes of such facial changes related to aging attributed it to "loss of facial fat due to aging, trauma or disease, manifested by flattening or indentation of normally convex contours."7 For treatment purposes, the group recommended assessment of these changes by measuring three criteria―contour, bony prominence, and visibility of musclature―according to a proposed grading scale of increasing severity from 1 to 5, while noting that assessment of facial lipoatrophy is both subjective and qualitative. Treatments to restore midface volume loss are achieved using an increasing range of injectable fillers, which are minimally invasive (Table 3).8 Patients can have the procedures done in the office and usually return to work the same day without noticeable scarring or bruising. These products can be classified as neurotoxins, short-, medium-, and long-term fillers, and permanent fillers. Table 3. Injectables: Neurotoxins:
Surgical AlternativesSurgery may become part of a plastic surgery treatment plan for a number of reasons. Many patients have specific flaws or weaknesses in facial contouring that require more substantial restructuring of the support structures with facial implants or procedures such as rhinoplasty. Midface implants may also be necessary in cases of severe lipoatrophy to support volume-enhancing injectable products. [Dr. Azizzadeh: Can you please specify locations for these types of implants?] SUMMARY Given the extensive range of products now available, and the many ways they can be used, it is important to make sure facial rejuvenation patients are well prepared for their procedures in order to meet their expectations. The patient consultation is a crucial part of the overall treatment. In our office, a first consultation is conducted by the nurse, who gathers all of the information needed to develop a treatment plan. As the treating physician, I repeat much of the same information with the goal of fully informing patients of the benefits and risks of chosen procedures. This patient preparation process contributes greatly to the success of the procedures we perform. References 1. Fedok FG. Advances in minimally invasive facial rejuvenation. Curr Opin Otolaryngol Head Neck Surg. 2008;4:359-368. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18626256?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum 2. Ghassemi A, Prescher A, Riediger D, et al. Anatomy of the SMAS revisited. Aesthetic Plast Surg. 2003;27:258-264. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15058546?ordinalpos=12&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum 3. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and implications for cosmetic surgery. Plast Reconstr Surg. 2007;119:2219-2227. Available at: http://www.ncbi.nlm.nih.gov/pubmed/17519724?ordinalpos=7&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum 4. Carruthers JD, Glogau RG, Blitzer A; Facial Aesthetics Consensus Group Faculty. Advances in facial rejuvenation: botulinum toxin type a, hyaluronic acid dermal fillers, and combination therapies—consensus recommendations. Plast Reconstr Surg. 2008;121(Suppl 5):5S-30S. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18449026?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum 5. Klein AW. Soft-tissue augmentation 2006: Filler fantasy. Dermatol Ther. 2006;19:129-133. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16784511?ordinalpos=6&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum 6. Rohrich RJ, Pessa JE, Ristow B. The youthful cheek and the deep medial fat compartment; Plast Reconstr Surg. 2008 Jun;121(6):2107-12. http://www.ncbi.nlm.nih.gov/sites/entrez 7. Ascher B, Coleman S, Alster T, et al. Full scope of effect of facial lipoatrophy: A framework of disease understanding. Dermatol Surg. 2006:32;1058-69. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16918569?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum 8. Downs BW, Wang TD. Current concepts in midfacial rejuvenation. Curr Opin Otalaryngol Head Neck Surg. 2008;4:335-338. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18626252?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum The Preliminary ConsultationJudy Akin Palmer, PhD, RN, CPSN, PHN Nurse Educator West Region Director, American Society of Plastic Surgery Nurses Chair, Southern California Chapter American Society of Plastic Surgery Nurses Newport Beach, California Although practices vary from one office to another, the facial rejuvenation patient experience always begins when patients arrive at the office. Every staff member contributes to the patient experience, from the receptionist to the clinical staff, in making patients feel comfortable, helping them work through a treatment plan, and listening to their needs. For some patients, the plastic surgery nurse may perform all procedures, while for other patients, the nurse helps in prepare the patient for more extensive facial rejuvenation techniques and surgery. In all cases, the nurse provides the first and most thorough consultation to educate patients about the treatment process. The Patient InterviewThe patient interview is an important process that includes three phases: preparation, introduction, and interaction. Preparation Preparation starts with the nurse, who needs to become familiar with each patient’s file before they sit down for the interview. The nurse should have current knowledge about facial rejuvenation products and procedures and have the most recent brochures at hand. The initial patient packet should contain the general health and skin health forms for patients to complete. These forms should be filled out in the waiting room prior to the consultation. Later, it is extremely helpful to go through the general health and skin health forms with patients, as there may be things they don’t understand or information they fail to provide that could affect their treatment outcome. Introduction It is important for the nurse to appear friendly, and focus on each patient, regardless of what else is going on in the office. Introduce yourself and your role in the practice with an attitude that is confident and helps to elicit trust. Provide patients with contact information so they immediately know who to call if questions or concerns arise later. Set aside a place that is uncluttered and quiet where patients can talk with you privately. Above all, strive to make the initial experience calm and relaxing, as in that kind of atmosphere you are likely to gather more information from patients and they will feel more confident of the information being received in return. Interaction At all times during the consultation, it is important to speak slowly, clearly, and concisely, while giving patients information they can understand and remember. You want to maintain a relaxed and confident manner to engage patients in sharing information that might otherwise be withheld. The information you learn here will help you design a treatment plan with each patient that meets his/her specific needs. It is important to find out what products and procedures patients are interested in and what their current level of understanding is about them, and then build on the existing knowledge. Take a Complete History As with any consultation, the more information you gather, the better. Make sure to have patients fill out the questionnaires and ask them about any incomplete or missing information. In addition to asking questions about their medical history regarding allergies, cold sores, pregnancy or breastfeeding, you should also inquire about previous treatment experiences, including inflammation or infection at a previous treatment site, and whether patients have undergone previous laser treatments or chemical peels. Skin Assessment After a general health assessment, perform an analysis of the condition of the skin. Document facial moles, lines, and scars, and discuss these with patients to make sure they are aware of them. The aging process is certainly hard on the skin, which becomes thinner and drier, and naturally less supple over the years.2 Photoaging compounds the aging process as a result of long-term sun exposure, which can manifest in loss of translucency and elasticity, a sallow coloring, and the development of rhytids, lentigines, keratoses, and enlarged capillaries. Two scales provide very effective ways to document skin condition relative to aging and sun damage. These are the Fizpatrick Scale of Sun-Reactive Skin Types (Table 1), which classifies skin types according to skin pigmentation and known reaction to ultraviolet rays, and the Glogau photoaging scale, which provides an assessment of wrinkling and discoloration (Table 2).3-5 [DR. PALMER: COULD YOU ADD A SENTENCE OR TWO DESCRIBING HOW YOU USE THESE SCALES? FOR INSTANCE, HOW DO THE FINDINGS AFFECT THE OUTCOME OF PROCEDURES—EG, WILL PEOPLE WITH LIGHT SKIN BE AT RISK FOR MINIMAL ALTERATION IN PIGMENTATION, WHILE THOSE WITH DARKER SKIN BE AT GREATER RISK AS A RESULT OF UNDERGOING PROCEDURES? ALSO, CAN PEOPLE WITH HIGHER GLOGAU SCORES EXPECT GREATER BENEFITS THAN THOSE WITH LOWER SCORES?] Table 1. Fitzpatrick Scale of Sun-Reactive Skin Types3,4
Table 2. Glogau Scale of Photodamage5
Document Facial Asymmetry No face is perfect, and slight asymmetries are common to us all. Sometimes patients may only notice an existing asymmetry after they have had a procedure done, at which point it is cause for dissatisfaction. It’s much better to help them see these irregularities beforehand, so they will be realistic about the results of their procedure and you can open a discussion of potential corrections for the problem as well. To document facial asymmetry, have patients hold a mirror about 1 foot from the face and point out and document any asymmetries you find. Take photos to clearly note them. Managing Expectations The final discussion in the consultation involves preparing patients on what to expect after the procedure. With injectable fillers, the concept of full correction is one that is usually only achieved over multiple visits with use of several syringes of product. Some patients come in and want to try one syringe in one area, and then are disappointed to find that it is not enough to make the change they were seeking. You might explain that the first injectable treatment sets the ground work and more product may be needed closer to the surface to further correct the defect and achieve their goals. For full correction, they may need a touch up in 2-4 weeks. Suggest that it is a good idea to book that appointment before they leave the office today. Some practices apply a cost reduction to the next syringe if it is scheduled within 4-6 weeks. Table 3 highlights the types of products that are used in different regions of the face. Make sure patients understand what products are best suited to their needs and how many syringes they will likely need to achieve a full correction. Table 3. Injectable Treatments by Facial Region
Explain Basic Post-Injection InstructionsPatients also need to be told in advance about the accommodations they should make in the days and weeks after their procedure and the reactions they might experience, which they may want to consider when scheduling their appointment (Table 4). Table 4. Post-Injection Instructions
Closing the Consultation After making sure patients understand everything they have been told, and giving them the opportunity to ask questions, you will want to finish with a discussion of consent forms. Detailed consent forms for each product used will need to be signed before any procedure can begin. Patients should read the brochures you have provided on each product and then the consent form for that product, which will detail any risks involved. When patients returns for the procedure, review the consent forms with them again. Before you close the consultation, conduct a final review of the paperwork, and then bring patients to the plastic surgeon so a treatment plan can be devised. References
The Nurse/Patient Interaction Tracey Hotta, RN, BScN, CPSN Nursing Manager and Aesthetic Specialist for Mitchell Brown, MD Incoming patients may inquire about a large number of facial rejuvenation products that are available on the market today. Nurses who perform aesthetic facial consultations and treatments need to be knowledgeable about the use of botulinim toxin A (BotoxÆ) as well as a range of facial fillers. They also need to have a strong understanding of facial rejuvenation surgical procedures, as some patients will need more than injectable treatments alone. The ConsultationEducation is a primary function of the patient consultation. Patients need to be made fully aware of all the options, and the risks, recovery time, and cost involved in any procedure before it is undertaken. The consultation is a lengthy process of an hour or more where the aim is to arrive at a treatment plan that meets the patient’s desires and expectations at an affordable cost. A complete history of medical conditions, medication use, allergies, and family history is important, and no questions should be skipped. Sometimes you have to delve into a patient’s history to find relevant information that he or she may have withheld due to embarrassment, such as previous procedures. Patients may also have forgotten to note something significant on their medical form, such as a relative with Von Willebrand’s disease, a common inherited coagulation disorder that could signify the potential for excessive bleeding during procedures. Just as important is your understanding of a patient’s rationale for having the procedures. Plastic surgery is a field where patients drive the treatment, often with highly unrealistic expectations. The initial desire for the treatment is as important as the treatment itself, as it may not be the full solution to the problem. Hidden agendas, like a recent breakup, or the belief that the procedure will save a marriage, need to be uncovered and discussed. The next step is to develop a treatment plan with patients, based on their stated wishes and the available products [see box]. Commonly Used Injectable Fillers
Anesthesia should be fully discussed. The FACE survey done in Canada showed that 32% of patients cited pain as the reason for avoiding treatment.1[Ms. Hotta: Can you please provide the reference article as a pdf? Or alternatively, a full citation? We haven’t been able to locate it. Thank you.] Topical creams such as TAC (tetracaine, epinephrine, and cocaine), LET (lidocaine, ephinephrine, and cocaine), and EMLA (lidocaine and prilocaine) are very effective, as is ice applied to the injection site.2,3 Iontophoresis can also be used, in which a small current is applied to a lidocaine-soaked patch of skin, providing a deeper anesthetic than topical creams.3 When vibration technology is applied to a certain area around an injection site, it will distract the patient from the pain of the injection itself. Assuring patients that different kinds of anesthesia can be used to minimalize discomfort during an office procedure will help them make the final decision about going forward. Informed consent for all procedures, as well as consent to take before and after photos, should be obtained at this time. Pretreatment Preparation Documentation of the baseline condition of the face is very important to both the success of the treatment and to setting reasonable patient expectations of what can be achieved. Patients see themselves in their own terms. Frequently, they are focused on one or two areas that trouble them and don’t see small anomalies or asymmetries that could affect the overall look of their face. Taking pictures during the consultation allows us to show patients a realistic image of their face, and show them things they may not have noticed previously. The digital cameras available for aesthetic treatment practice today are extremely sensitive and sophisticated, and can provide a range of useful photos that help to provide standard and consistent photos.5 Using the equipment in our Toronto office (Figure 1—MS. HOTTA: CAN WE REPRINT THIS PHOTO?), I can take a picture animating where Botox® treatments may be given, or ultraviolet photos that show areas of sun damage on the skin for the skin care consultation. Tools such as this offer a number of invaluable benefits to an aesthetic treatment practice, including easy and extensive storage and retrieval of large numbers of files, and the ability to provide instant images to our patients at the time of the consult.6 Additionally, digital photos are easily manipulated for comparison to other photos, and enhancement tools are available to provide specific images of contours, skin quality, and fat distribution. Before patients leave the initial consultation, it is a good idea to show them around the procedure room. Ask patients not to wear make up on the day of the procedure, or to plan to take it off when they arrive at the office. Suggest that they bring make-up with them to put on if they are returning to work. During the Procedure The primary concern during an in-office procedure is patient comfort. During the procedure, it’s a good idea to sit patients up and show them one side that has been corrected. This makes patients feel like they are part of the treatment process. Documentation throughout the procedure is important, including the specific products and lot numbers, quantities, and needles used. This information often becomes invaluable after the procedure to determine what, if any, follow-up procedures need to be considered, and to evaluate potential adverse reactions. Before the procedure is completed, begin to give patients an understanding of what to expect immediately afterwards. Informed patients are more compliant patients. Explain that the reason they should not exercise is to avoid redistributing the product and increasing the potential for bruising. Patients should be prepared for some residual tingling or mild pain. Let patients know that you will be massaging the area immediately after treatment to ensure even distribution of the product but that they should not touch the treatment area themselves. After the final correction is achieved by massage, inform patients that you are cleansing with a sterile saline solution. After the filler is injected, ice can be applied to the site to minimize swelling and other skin reactions. Patients can be instructed to continue to apply ice at home as needed. Posttreatment Before patients leave the office, give them a cell phone number that they can call over the weekend or during evenings if there is a problem. Patients should not be left without a contact at the plastic surgery office, but should have ready access to a nurse or other qualified professional to address any concerns that arise. A follow-up appointment should be scheduled for 2 weeks to reassess the treatment area, consider the possibility of further treatment, and take postprocedure photos for the files. This final follow-up appointment is a good time to elicit any questions or concerns that may still remain, and to get patients’ reactions to the results. Maintaining strong patient contact helps to improve patient satisfaction. References
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