It’s a typical busy Monday and Mrs Jones, a lovely 46-year-old marketing executive has a 1:30 pm appointment to see you. She is a new patient to your office but has been happily having Botox® to her upper face for the past 3 years on a regular basis; because of scheduling conflicts, was unable to see her regular dermatologist for treatment. It’s been nearly 4 months since her last treatment and she ‘doesn’t want to let it go’. She heard you were great from her friend, who somehow has been looking better and better over the past few years, although she hasn’t a clue what you’ve been doing to her. She’s in a bit of a rush and it’s already 2:15 pm when you are finally able to examine her.
When you examine her you notice that indeed she has some movement in her upper face, the usual three areas where her doctor gives her Botox, but few lines there. However, you do notice the volume loss in her temples that contributes to sagging of the lateral brow, and she’s had bone resorbtion in the chin and mid-face causing classic sagging and folds. Her mid-face fat volume loss and widening of her orbital sockets has caused the appearance of dark circles under her eyes. These conditions cause her to appear tired and older than she could optimally appear. She is energetic and engaging, yet appears tired. There is no question in your mind that some filler or collagen stimulator to her mid-face and possibly lower face would give her greater facial balance and certainly more ‘bang for the buck’ than just treating her usual areas with Botox Cosmetic.
Two syringes of Juvéderm VOLUMA™ to her mid-face might remove the tired look that she hasn’t even complained to you about. In fact, if you were going to use a neurotoxin, you’d like to bypass her forehead (where she’s asking for it), since it is very smooth compared with the rest of her face, add more neurotoxin to the lateral brow area to open the eyes and lift the brows, and treat her depressor anguli oris and mentalis to improve her perioral area. You’ve made these calculations in your head in the first minute she’s been telling you about her prior treatments and her otherwise unremarkable medical history.
What do you do? Do you give her the best upper face Botox you can, perhaps suggesting to lift her brows a bit? Do you spend time and explain the ageing process to her, and do a facial analysis pointing out her folds, creases, areas of bone resorbtion (structural changes) and lipoatrophy so that you can suggest treating those areas today or at a future visit after she’s seen what you can do with Botox? Do you suggest that she return to her other doctor for filler treatment? Do you bring up the idea that neurotoxin might also be beneficial in her lower face and that there are other toxins on the market? Perhaps, if she is budget conscious, you might consider what ‘specials’ are available on the different toxins if you feel they are equally beneficial for her? Maybe she’s participated in Brilliant Distinctions, Allergan’s points reward programme, and that might make her excited to try VOLUMA. Conversely, maybe she’ll be in ‘sticker shock’ and suggest one vial of Radiesse® instead, since you price that lower in your office. Meanwhile, she’s been allotted 15 minutes as a ‘Botox new patient’ appointment.
Mrs Jones, of course, could be any cosmetic patient in a medical or cosmetic practice, thinking she needs anything from blepharoplasty to Restylane®. Over the years there has been a cataclysmic change in the field of aesthetic medicine, both in our knowledge of how we age and our tools for correction. I’d argue that even my ‘cosmetic surgery’ practice is mis-named, as are most of the terms we use. Patients may think they come in for dermal fillers, toxins or a face lift but, in fact, they come to you because they want to look better or to look their best.
Over the years there has been a cataclysmic change in the field of aesthetic medicine, both in our knowledge of how we age and our tools for correction.
In our office, we have so many tools at our disposal now that we can safely and effectively treat a much wider demographic to improve their looks and self-esteem, often within budgets they can afford once they learn the value of the treatments. Over the past 5 years my practice has become almost exclusively cosmetic in nature, so I’ve adopted a more time-intensive, comprehensive approach: educate the patient. I rely on a team of cosmetic consultants to help me with this process so that each patient is fully appraised of the options available to them and can consider their budget, long-term aesthetic goals, immediate cosmetic desires, recovery time, and comfort level with both me and the procedures I’m recommending. While there is no reason to take a patient who comes in for a quick Botox maintanance treatment and tell them they really ‘need’ a liquid face-lift, full-face neurotoxin, retin-A, and Ulthera to their neck, I decided early on not to simply be a Botox injector; I’m a cosmetic medical and surgical expert and patients come to me for my knowledge and skill. My patients may pay more per unit than at the medispa around the corner, but they are not getting a product, they are benefiting from a treatment tailored to make them look their best — safely and effectively.
Most of my patients are at the pinnacles of their careers and want to look youthful and refreshed. Our challenge is to educate the patients who seek a specific procedure about the way we all age and how they can expect to age. Together, we outline a rejuvenation programme that can begin at that first visit. Educating them about the paradigm of full face evaluation, treatment, maintenance, and prevention will allow them to set budgets for ‘wellness care’. However, the first step is educating your staff. Stop them when they say, there is a ‘Botox in room 3’ or ‘Sculptra® in room 6’. Teaching your staff how to look at an ageing face should be your first objective.
Mrs Jones had Radiesse, Botox Cosmetic and returned for periorbital Restylane. I recommended she have the filler with her previous doctor, but she wanted treatment with me. I have a feeling that she will be a patient for many years and only hope that if I keep her waiting a long time during one of her future appointments, she recalls the extra time I spent with her on the day we met.
There is nothing more gratifying for me than to see the breadth of patients in my office (young, old, male, female), many of whom have been coming for many years, and will hopefully come for years to come. Together, we view their medical photos and observe them looking younger and better over the years they’ve been coming for treatment.
My 95-year-old patient came in to see me and said emphatically: ‘You know I’m not vain in the least. I’m not trying to be a beauty and am not looking for a date. I’m an award-winning novelist with a sharp mind. Before I had surgery and filler, I felt invisible. People look through old people in this city. Now I feel relevant and people listen to what I have to say.’
Yes, the treatment options today are complex, the field increasingly competitive, and our patients are more demanding; it takes extra time and effort to remain at the forefront and to sift through the hype of some new devices, but we are blessed to be leading a revolution in the way we approach ageing. We profoundly improve people’s lives and for that we should be deeply grateful.