Patients' reasonable expectations key to better cosmetic results

Key Points

"If a consult presents at age 55 expecting to look the way she did at 25, this is not a good fit. Realistic expectations are the key to great cosmetic outcomes, and everyone's going to be disappointed," she says.

Patient assessment

"Any patient who I'm going to see for a procedure has a consultation first," Dr. Hirsch says. During this visit, she asks patients about their specific goals and discusses in detail the best options to achieve those goals, making certain that the patient understands that it is a process.

During the consultation - and throughout the preoperative process - Dr. Hirsch and her staff ask patients very detailed questions, obtaining a full medical and anesthetic history.

For example, they inquire whether patients have had previous injectable procedures. To do the best possible job for patients, physicians need to know exactly what they have had done previously and what the results were.

"When you don't know exactly what's been done before to somebody's face, that's a potentially big problem," she says.

With recent treatment advances, patients who formerly would have had cosmetic surgery as their initial treatment may be able to delay surgical procedures by opting for new alternatives, such as injectable or laser treatments. Furthermore, patients who would have been averse to cosmetic surgery may be more open to in-office procedures, Dr. Hirsch says.

Rules for excluding patients from surgery are not always hard and fast, she says. Surgery is contraindicated in patients who are not in good health or have certain medical conditions or allergies.

Physicians may be able to work around some relative contraindications, she says.

"As an example, when you're going to do injections of filler material, if someone has a history of developing cold sores, he or she can be treated safely, but you need to pretreat him or her with prophylactic medication first," she says.

It's also vital to identify patients who have unrealistic expectations about procedure outcomes or those expected to be noncompliant with preoperative and postoperative regimens.

Ongoing documentation

During each subsequent visit, Dr. Hirsch and her staff ask patients multiple times about their medical condition, medication use (including nonprescription medications), the possibility of pregnancy and other issues.

"Patients will rarely mention that they're taking a baby aspirin every day or that they go to the health food store and take all sorts of supplements," she says. "A lot of those supplements - baby aspirin as well - are things that are actually prone to make you bleed."

At each visit, Dr. Hirsch also reviews the side-effect risk-ratio profile and informed consent with the patient.

Veto power

Dermatologists should think a lot about the importance of veto power in considering whether a patient is a suitable candidate, Dr. Hirsch says.

After reading about procedures on the Internet, patients may want to skip quickly through the informed consent, believing they understand the treatments.

"Always assume that it is your job as the physician to make sure that patients understand that these are elective cosmetic procedures," she says. "Inherent to them all are risks of side effects and complications. If that is not something they are comfortable with before anything is done, then they are not candidates for a procedure. Period."

Many patients who have a consultation in Dr. Hirsch's office are not actually treated with procedures, which is part of the reason her practice continues to thrive, she says.

"By helping patients see at the very start of the process what their options and realistic outcomes are, we are able to really achieve wonderful results that lead to happy patients.

"By helping those who would not benefit from our treatments understand that before they go down that road, we gain appreciation for time and money saved, and people respect that. When you have a very happy patient who brings you her best friend or her mom, that's the best possible way to build a practice," she says.

Consequently, Dr. Hirsch says she is very conscientious about identifying suitable candidates. "We take it really seriously, as I think most ethical, good cosmetic dermatologists and plastic surgeons do," she says. "If you are somebody's doctor, when you're injecting something or doing surgery on them, at the end of the day you are really beginning a very long-term relationship, and just as your mother said when thinking about prospective mates, don't do that casually."

Disclosures: Dr. Hirsch reports no relevant financial interests.