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Managing Cosmetic Complications

Jennifer Holman, MD, and Chris Surek, DO, presented on tips for managing complications from cosmetic procedures at the 2019 Fall Society of Dermatology Physician Assistants Conference. Dr Holman is a dermatologist with US Dermatology Partners and Center for Aesthetic and Laser Medicine in Tyler, TX. Dr Surek is a plastic surgeon, an assistant professor of anatomy with Kansas City University, and affiliated with US Dermatology Partners in Overland Park, KS.

Both Dr Holman and Dr Surek emphasized the importance of providers anticipating and knowing how to treat complications associated with cosmetic procedures. They divided their presentation into 3 sections: unhappy patients, complications with neurotoxins, and complications with fillers.

Unhappy Patients

According to Dr Holman, seeing an unhappy patient is common, especially if a provider performs a lot of cosmetic procedures. One of the most common reasons a patient is unhappy with a procedure is due to unrealistic expectations. Dr Surek recommended underpromising and overdelivering when consulting with patients, as well as try to anticipate what a patient’s the expectations may be and if they are deliverable.

The 3 most common complaints covered by Drs Surek and Holman were resting lines following neurotoxins, expectations of what one syringe can cover, and patients wanting surgical result without surgery.

For addressing patient’s unhappiness with resting lines, Dr Holman said she uses an analogy for exercising to attain a 6 pack. It takes consistency to improve the appearance of resting lines similar to how body builders achieve a 6 pack, she said.

Setting patient’s expectation is also important for talking to patients about the effectiveness of one syringe, Dr Holman said. Spreading one syringe too thin will not achieve the desired results, both she and Dr Surek noted. They recommended prioritizing with patients what their top 3 concerns are to illustrate the impact of one syringe. Dr Surek also noted that there is only time to address about 3 concerns in the first consult. On the flip side, he added, some patients may freak out if the number of syringes needed is higher than they expected.

For patients who want surgical result without surgery, Dr Surek stated that there are no short cuts for the face, similar to dieting and exercise to achieve weight loss. Minimally invasive procedures can achieve some short-term improvements, but cannot do it all, he said. Attempting to use these procedures in place of surgery can make it harder for the provider and is a disservice to a patient, he added.

According to Dr Surek, the 3 areas that may require surgical intervention include the jawline, cheeks, and lips. The liquid face lift might be effective for someone with minor aging changes, he said, but overfilling the face with filler will not address gravitational changes. If patients have jawlines caused by gravitational changes and aging, then it will need a gravitational solution, he further emphasized. Another area is the neck, he said, noting that most of the time the neck requires surgical treatment. He also discussed the importance of knowing what the skin can tolerate. For example, young skin can retract and may be better candidate for liquid face life. Patient selection is critical for certain treatments, he added.

Dr Holman reviewed red flags for patients who may never be happy with cosmetic procedures. These include patients undergoing life transitions, such as divorce, costs, and body dysmorphic disorder (BDD). It is always ok to say no, she said, adding that providers should not budge once they say no to a patient.

She recommended providers have the tough emotional conversations with patients and ask them what they want to accomplish if they are going through a life transition. While not all patients experiencing major life changes need to be turned away, she did recommend providers tell patients to come back when they are more emotionally ready for a cosmetic procedure if it sounds like they are not in a good place.

“Pawn shop lips,” as Dr Holman referred to them in the lecture, is another red flag. Some patients she has seen said they took out a loan or hocked their jewelry for filler or neurotoxin. While $500 might not seem expensive to a provider, for these patients it is a very big investment, she noted. She tells patients she does not want them to put themselves in financial hardship for these procedures. The more the patient sacrifices, she said, the higher the risk they will be unhappy. Dr Surek noted that he hears similar stories on the plastic surgery side.

BDD was predominately an issue in plastic surgery, said Dr Holman, but as fillers become more mainstream with social media it is now becoming a bigger problem in dermatology. That is a “no” patient, said Dr Holman, adding that cosmetic procedures are never going to fix BDD. She recommended questionnaires available on the BDD website, as well as referring patients to that website for information on their condition. Important diagnostic criteria for BDD is overly fixating on a flaw, which interferes with quality of life, work productivity, and social activities. These patients will usually have taken several pictures of the flaw, which is either not that big or not visible, added Dr Holman. For patients who score high on the BDD questionnaire, she recommended counseling and tells them she is very concerned about them and their fixation on their flaw. Another red flag for BDD is seeing other providers for the same procedure they want you to treat, she added. Be kind and say no with kindness, Dr Holman reiterated.

Dr Surek added that providers should be good listeners when consulting with patients, especially for identifying those with BDD. He suggested telling patients with BDD, “I am not sure I can deliver the results you are looking for,” as a way to let them down softly.

Dr Holman also recommended all providers get explicit consent before procedures, take before and after photos, as well as do “halftime shows” (treating one side first), in order to show patients subtle changes from filler. She also encourages providers to do rebate programs and have a makeshift photo studio in rooms for taking photos.

Gradual changes from fillers patients will not notice, she said. Having before and after photos can show the changes and reassure patients who are unhappy with treatment that the fillers worked. Similar with the “halftime show,” which shows patients the subtle changes from using fillers, added Dr Holman.

In addition, Dr Holman suggested providers be subtle, gradual, and natural with treatment, adding that that she does not want anyone asking her patients who performed their fillers.

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