Patient Selection and Assessment

Aesthetic treatment outcomes are dependent on a number of factors, including the products that are used and the clinician’s skill level. Perhaps just as important—or even more so—is patient selection. Modern Aesthetics® convened an expert roundtable to discuss physical and mental considerations, how to say no to patients with unrealistic expectations, and more. For additional discourse about discussing risks with these patients and the importance of animation during evaluations, go to ModernAesthetics.com.

What steps do you take during the initial evaluations, and how important is medical history when determining if a patient is a good candidate for aesthetic treatments?

Dr. Michelle Henry: Medical history is critically important. This is medical aesthetics, and above getting a fantastic aesthetic outcome, we need to prioritize keeping our patients safe and knowing when not to provide treatment. That is just as important as when we do decide to do the treatment. You need to choose your patient and not always let the patient choose you, because it really is your job to keep them safe. So, I always take a thorough medical history before I evaluate any patient, even for cosmetic treatments. If I do not see any contraindications in their medical history, then I look at them and I do their physical consultation and I look at assessing all the dynamics of aging.

Dr. Joe Niamtu: For a cosmetic surgeon, choosing the correct patient is just as important as making the right diagnosis or performing the surgery well. There are patients who want cosmetic surgery but may not be healthy. We never take chances. This is elective surgery, and it may make them look better and feel better, but it will not save their life. Conversely, if you operate on the wrong person or take chances with somebody with medical problems, the outcome could be tragic.

Doctors must be truthful and be able to back up their marketing. In this day and age of social media, so many people are making crazy predictions that they can do a minimally invasive procedure and get facelift results. You need to take everything with a grain of salt with social media; providers must be honest and patients must do their research. If something sounds too good to be true, it probably is.

Dr. Karan Lal: The first things I think about are medical conditions and medications they are on, because certain medications, such as blood thinners, can prolong wound healing. I see an older patient population, so if I am doing treatments with lasers, that means they will have more oozing, more downtime, and more bleeding. Are people immunodeficient or selectively immunodeficient? Do I need to give them antibiotics or antivirals ahead of time? Do they have an underlying autoimmune disease that would make them a slow healer or prolong bruising? Those are the things I counsel before I do any treatment. Most people complain not about the result but about not being made aware of the expectation of the wound healing process, whether it is laser, filler, or something else. For people who have certain conditions like rosacea, or a history of urticaria, getting laser treatments can cause a localized hive reaction or prolong swelling. You really need to have a thorough understanding of a patient’s medical history and the medications that they are on before you do anything because, again, it will alter that postoperative period, which is what patients actually care about.

Dr. Glynis Ablon: Connective tissue diseases such as lupus, any kind of scleroderma, etc, can impact any procedures that you do. Perhaps a condition creates antibodies to a neuromodulator, so that patient is not a good candidate for that. Perhaps fillers might not last as long as they otherwise would. I often have patients with acne, and it is really important that we resolve the acne; you may be treating acne scars, but I don’t want patients to just continue to have more acne. Rashes are important to note. We may not use lasers on someone who has severe sebhorreic dermatitis, or even psoriasis of the face. You want to make sure you are treating the medical conditions in addition to discussing any kind of aesthetic procedure they may want to do.

Dr. Jacqueline Watchmaker: I have various types of lighting in my office. I have a dermatoscope that allows me to take an up-close look at the skin as well as side lighting. After my initial evaluation, I typically hand the patient a mirror and ask them to tell me what bothers them the most. I like to address what is first on their list, even if that might be a little lower down on what I think would help improve their overall aesthetic look. We can then meld that with what I think would give them the best outcome.

Do you ever reject a patient due to unhealthy, sunburnt, or otherwise poor skin quality?

Dr. Henry: Poor skin quality alone in an otherwise healthy patient will not cause me to reject them. I may reject the procedure that they desire, but I still guide them to a procedure that might be better and safer for them. Now, when someone has unhealthy skin—infections, ulcerations, or autoimmune conditions that give me concern about proceeding with lasers and other treatments—then I would reject them. I feel very proud about that. Some of my patients say they want to create a #DrHenryToldMeNo hashtag because I often say that. It is our job to do that. So, again, poor skin quality alone will not make me say no, but I think about the reasons why they have this poor skin quality as I take my next steps.

Dr. Watchmaker: I would not say I ever reject a patient for poor skin quality. I counsel them on the importance of skin health. We can do all the in-office procedures we want, but if they don’t help maintain their skin with at least sunscreen every day, then a lot of the benefit and results that we get from the in-office procedures will be lost.

How do you differ your evaluations when considering skin of color?

Dr. Ablon: It is really important to understand that certain devices are safe for all skin types, and certain ones are not or have a lot higher risks for some. It is critical to understand what the patient’s desires are, and then I can tailor that to the kinds of devices and procedures I have in my practice that are safe on skin of color. It really varies because I have lasers that I can use on Fitzpatrick skin type VI, and I have lasers that I cannot use on skin type IV, V, or VI. You also need to understand how darker skin types will react, and to explain to the patients what you have, what options they have, and what the best options are. Sometimes, it is topicals, sometimes lasers, sometimes injectables.

Dr. Lal: I treat a lot of skin of color, and it is all about time. If it takes four sessions to treat a white person, I might need eight sessions for skin-of-color patients. We are not rushing. I tell people it will be a while. Skincare is also very important; with many skin-of-color patients, I need to reinforce sun protection. We talk about supplements such as polypodium when we are talking about hyperpigmentation. With skin-of-color patients, we are not really dealing with fine lines and wrinkles. We are dealing with more fatty redistribution and bony changes, so they are better candidates for injectables as opposed to lasers, and they do better with biostimulatories and non-invasive treatments that allow for remodeling of the skin and the deeper structures.

Dr. Watchmaker: Especially for lasers, we need to be careful. We need to turn down some settings to keep lasers on skin of color safe. There is this myth that patients with darker skin types cannot do any lasers, and that is incorrect—but they do need to go to a provider who is trained in and routinely treats skin of color, in order to keep things safe. There are a lot of different things I do to keep my patients with skin of color safe. Sometimes, I pretreat with topical brightening agents. Often, I apply a topical steroid immediately after a laser treatment to help reduce some of that inflammation, and I do always counsel on the potential increased risk of some complications.

Dr. Henry: Skin of color ages differently. It’s not that patients of color are not aging; they are just aging differently, and you need to have your eyes tuned in to what those factors are and what those changes are. They may request treatment for fine lines and wrinkles, when they actually have sinking, sagging, and volume deficits. Some of it is guiding them to see how they age differently and how we read age in skin of color, and then talking about the limitations of what we can do and what might be best for them. I talk to them about what lasers we can and cannot use, and for how long. Oftentimes, we are taking a low and long approach: low energy and more treatments to keep them safe but still attain good results. I talk to them about what their aftercare should look like, because we are worried about prolonged bruising in skin of color. We’re worried about hyperpigmentation. We also talk about pretreatment care. We are often doing skincare prophylaxis to reduce the risk for hyperpigmentation.

There is a different approach for everyone, though—even in patients who may not be historically defined as having skin of color. There are other factors I think about. How do they scar? Do they have darker or lighter hair? Is their skin more reactive? There is an element of personalization in everything; there are just some categories that I focus on more in skin of color.

How do you assess a patient’s goals and expectations regarding an aesthetic treatment?

Dr. Ablon: The first thing with an aesthetic patient is to ensure that they are very stable in what they are looking for, and that they do not have body dysmorphic disorder (BDD) or something else with their mental situation. It is very important that we get a realistic patient who is stable and understands all of the treatment options we can provide for them before starting. Just like with a patient who has a significant medical history that could cause issues with treatment options, if you have a patient who is unrealistic in their expectations, you need to be very clear upfront. The more honest you are with your patient, the happier they will be. It is not uncommon that I will turn a patient away. If I do not have the same vision as them, if I feel they are very unstable, or if I feel that mentally they are not at the level they need to be in discussing these procedures, then I will just say that I do not have the same vision as they do, and I will set them free.

Dr. Lal: It is very simple. I am a dermatologist; I can help you with your skin. Anything that is related to your skin is something I can help you with. That means the top layer of the skin, the dermis, and the fat. For anything beyond that, such as muscles, they need to go to the plastic surgeon. If we are talking about photodamage, sun damage, melasma, brown spots, redness, fine lines, or deep wrinkles, those are things I can help augment. I always tell people, we are never going to take you back to where you were, but I can make you look at least 50% better. I like to give people percentages, and we always shoot for less, but if we get more, that’s great. I also tell people that this is a journey. Achieving something in one visit is doable, but the downtime is also not ideal for a lot of people. It is about building a relationship, building a journey, and doing little things over time to promote healthy skin and healthy aging, as opposed to anti-aging. I don’t like to say anti-aging because nothing that I do will bring you back.

Dr. Evan Rieder: BDD is an uncomfortable topic, but understanding it is critically important to the wellbeing of your patients, your practice, and yourself. Patients living with BDD look good. These are not people who are overfilled or truly dysmorphic. These are people who look great, or maybe there’s something that’s slightly asymmetric that you can barely see. When a patient asks about a cosmetic procedure for something that you can’t see, your radar should go off. The one question I suggest asking is, “Is there something about your face or body that you find to be particularly unattractive?” That screening question has very, very high sensitivity and specificity for BDD. Most people say no to that, but people with BDD often say things like, “Yes, of course; it is my nose.” You can follow up with a second question: “How many hours each day do you spend thinking about that?” Most patients will say, “I look at myself in the mirror for a few minutes in the morning and when I go to bed.” People with BDD spend an hour or more each day. You should not be doing a procedure on that person, whether that is an aggressive laser, plastic surgery, or even a little bit of Botox. I have seen people with BDD say that they are irrevocably harmed from Botox, which we know almost impossible.

Are there other specific questions or strategies you utilize to get a better feel for the patient’s mental state?

Dr. Rieder: If someone is naïve to cosmetic procedures, the two questions I mentioned are really important to ask. If someone has seen other doctors, ask what their experience was with those doctors. If they were happy with the procedures they had in the past, they likely do not have BDD. However, if people had bad experiences with their doctors and are bad-mouthing them, if there is a problem with every procedure—especially if the colleagues they have seen are people you know and respect—you are not going to be the knight in shining armor who makes everything right. There is most likely something about them that makes them a difficult patient, or they are perceiving something wrong about their skin or their body.

Dr. Ablon: The first thing I do is I have my staff do an evaluation. When they are doing the intake, they are getting a feel for the patient. If my staff identifies a red flag from the beginning of the evaluation, that means something. Then, once I go in to see the patient, a lot of it is just experience and knowing what to look for in general. If the patient is complaining about the last doctor they saw, you will be the next person they complain about, so that is a really big red flag. If you have someone who looks overdone and is happy with the way they look, that is another really big red flag. A group from a reality TV show came to my practice once, and I said, “This is not what I do; this is not the aesthetic I prefer.” It is very important that you are honest with patients. It is also important that you have a good aesthetic eye because part of what we do is being able to see the nuances and identify how to tweak things to make people look and feel their best. Our goal is not to change people to look like someone else, in general. It is more about enhancing their beauty.

Dr. Henry: I ask them if they have had procedures before. I ask them if they were happy with those procedures. If they have been unhappy with every single doctor who has ever touched them before, then it is unlikely that they will be happy with me. If they are bashing those doctors viciously—every single doctor that they have encountered—I see that as a red flag. I do ask them for their goals. I say, “Show me a picture of someone who has the outcome that you want and that might be attainable for you.” If that is a wildly different outcome from what I can attain or what even a layperson could expect, then I know this is probably not the patient for me. People will reveal themselves if you just give them time and comfort to express, so I listen very clearly about what they want, what they have had in the past, and what their fears are. If they start telling me things like, “My fear is that this will not be absolutely perfect,” then I let them know immediately that I cannot promise perfection. Most reasonable people understand that, and most people who cannot are likely not the patients for me. Now, do we often get outcomes that are “perfect” or close to perfect? Yes. However, in an industry in which there are a lot of variables that I cannot control, it is something that we can never really promise.

Dr. Watchmaker: In cosmetic dermatology, we do sometimes get into the BDD category of patients, where patients are preoccupied to almost a malignant degree with their appearance. So, a lot of times, I just talk with patients and do not actually perform any treatment; I tell them what I am seeing and why I think actually not proceeding with treatment is best.

Dr. Lal: When people have unrealistic expectations, the things I think about are, “Let’s talk about skincare,” and if they can follow through and be compliant with those things. If they have unrealistic expectations, then I really do try to send them to the plastic surgeon, who will be able to give them the results they want. It is OK to have unrealistic expectations; we all do to some degree about certain things. We always want things to be better than they are. People get disappointment, but then we talk about other things we can do. It is a journey. But when people are looking for a quick fix, that is something I probably cannot provide.

Dr. Niamtu: When you are experienced, you can tell if something is off. Most patients are even a little embarrassed talking to you about their faults. If patients do not make eye contact, that is a bit bothersome. Some patients do not speak, and you need to pry things out of them, and that is a little abnormal. Other people keep asking the same questions time after time. You are doing that person a favor if you do not do their surgery for a certain reason. I tell these patients, “If you have a face and a checkbook, somebody will do something on you that you do not need.”

When something seems atypical, you need to look into it, both on the psychological side and on the medical side. Setting accurate patient expectations and clarifying inaccurate ones is imperative. Although we can improve decades of aging, If a patient says, “I want to look 20 years younger,” that’s impossible to quantify. If someone says, “I’m 55; how old will I look after a facelift?” There is not a real answer for that. My favorite motivation for a patient requesting elective cosmetic facial surgery is when they look at me, and say, “I want to look as good as I feel” or “I want to look as good as I can for my age.” When someone says, “When I look in the mirror, the person staring back at me looks older.” These are all reasonable motivations for wanting cosmetic surgery. Somebody who is doing it for the wrong reason is just a setup for unhappiness and problems.

How else do you manage unrealistic expectations on the part of the patient?

Dr. Ablon: It is critical to weed out those patients to begin with. There is no way to get all of them, but if you have someone who is unrealistic when you are talking to them, that is not the patient I want to have in my practice. There are patients you will never make happy. We are never taught about those patients in school. It is really important to me to create realistic expectations from day one. If I tell a patient, “I absolutely cannot guarantee that this will give you what you want,” and they look at me and say, “I want one session, I want this, and I want this,” then I look at them and say, “That’s not what I can tell you. I cannot guarantee that.” That may be a patient I do not treat. Sometimes, they sneak under the radar, and if they come back and are not happy, I explain that all of my consent forms say we do our very best but we cannot guarantee results. That is the reality with everything we do.

Dr. Niamtu: In terms of turning away patients, that is a really hard thing, especially for young practitioners who are going into practice and have a lot of debt but not much business. It is a hard thing even for experienced practitioners. But sometimes, it is just not a good match. We see patients who want procedures they do not need, or patients who want procedures for the wrong reasons. They may think they are going to be more hip, they will get job promotions, or they will get back on the dating scene. These are not reasons to have cosmetic surgeries. The reason is to look as good as you feel. One of the true joys of what we do as cosmetic practitioners is when you do the right procedure on the right patient and have the right outcome, and it is just a great match. But if you pick the wrong patient, it can be horrible for the surgeon and for the patient. Unfortunately, you do not learn this in residency or in school, so you somewhat need to learn it through hard knocks. Sometimes, you are wrong. You might have someone you think could be a problem, and they turn out to be great; other times, it can go the other way. It is really hard to say no, but sometimes, I just have to tell the patient, I think you’re a great person and I am really honored that you reached out to me, but I do not think I can meet your expectations and your desired precision. Like anything else in life, you have the human side of it. We do not just scrub, put on gloves, and operate. There is a human there. It is up to the cosmetic team to explain the good, bad, and ugly things that may accompany elective cosmetic surgery. We do it every day and it is crystal clear in our minds, but this may be the first or only time the patient does this. We have to bend over backward to make sure that the patient has realistic expectations. Like any other communication, some patients understand quickly while others need more intense explanation.

Dr. Henry: I address expectations very directly. If I think I cannot obtain a specific result, I directly say that I cannot. I may explain why that is not the goal, and how the goal is to make you the best version of yourself. If you want to look like a 20-year-old and you are biologically 60, I am not the doctor for you. Those are not appropriate or attainable expectations. I am also not in the business of wasting anyone’s money or time, and patients really appreciate that. I try to guide patients in a health-first approach, and if you are assuming risk in the pursuit of unattainable goals, then the benefit does not outweigh the risk. It is a really robust conversation that can be difficult, but when patients know that every decision you make is with their health, their care, and their safety in mind, it is an easier pill to swallow.