Injectable Fillers: Principles and Practice

By Derek H. Jones

Dermal fillers are the fastest growing tools in the cosmetic physician's armamentarium for refreshing the appearance of patients. This book demonstrates effective, best-practice use for superb patient results. Augmented by a DVD of procedural videos, it shows you how to match patient, treatment, and filler for maximum results.

Taking a patient-centered approach, Dr. Jones reviews the advantages and disadvantages of each filler according to anatomical application. Opening chapters cover the cosmetic patient consultation and guidelines for local anaesthesia in the use of injectable fillers, followed by individual chapters on:

• Hyaluronic Acids
• Calcium Hydroxylapatite Microspheres
• Evolence and Evolence Breeze
• Sculptra
• Liquid Injectable Silicone
• Hydrogel Polymers
• Artefill

An extensive chapter on complications from soft-tissue augmentation of the face explains how to avoid and manage peri-procedural issues. Closing chapters supply a cheek enhancement guide for the aesthetic injector and a review of the clinical applications of hyaluronic acids, which are currently the most commonly used fillers.

With careful coverage of basic science, safety and efficacy data that have led to FDA approval, safe and effective injection techniques, and appropriate indications for each filler, this concise volume provides a dependable source of important information for dermatologists, aesthetic medicine practitioners, plastic surgeons, and all practitioners who work with injectable fillers.

• Language: English
• Publisher: Wiley
• Release date: Aug 31, 2011
• ISBN: 9781444360455

Book preview

CHAPTER 1

The Cosmetic Patient Consultation

Phil Werschler

Department of Medicine/Dermatology, University of Washington School of Medicine, Seattle, Washington, USA

As aesthetic, or cosmetic, dermatologists, an integral part of successful practice includes the cosmetic patient consult (CPC). Although this term is used liberally, its actual definition remains somewhat nebulous. Certainly, there are portions that are universally agreed upon, such as consent form signing, price quotation, and pre-treatment photographs. However, there are many more less well-defined components to the process that are equally important to both the treating provider and the treated patient for optimal outcome.

For the purposes of this introductory chapter, certain assumptions will be made about the CPC process. Chief among these is the accomplished skill set of the treating provider, whether a physician, mid-level provider, registered nurse, or aesthetician/office staff. It is assumed that the CPC will not be performed for the benefit of training the staff in the particular procedure. It is also assumed that the office possesses the requisite resources and capabilities to fully perform and complete the particular procedure being offered. Finally, it is also assumed that the CPC is being conducted in good faith, i.e. with full disclosure of the training, experience, and outcomes of the same or similar procedures being fully discussed.

Cosmetic office practice

With that as a background, the next step is to determine the cosmetic office practice (COP) level of the dermatology practice. First proposed in the mid-1990s by Craze and Werschler,1 this is a simplified method of determining the relative contribution of resources that a practice devotes to the development of desire dermatology. Using a four-point scale, this descriptive methodology is capable of generally categorizing the relative level of sophistication of a dermatology practice toward the delivery of elective cosmetic services.

Briefly, the four levels are described as follows:

1. Non-cosmetic, i.e. no particular skills, resources, equipment, marketing, or other efforts made beyond that of the usual general disease focused dermatology practice.

2. Some cosmetic, usually represented by a particular focus of expertise of equipment, skills, or other assets that provide elective services. A good example of this would be a center of excellence in lasers within a dermatology practice.

3. Balanced, or blended, practice of disease and desire dermatology: usually represented by a broad range of skills across multiple areas of expertise, all being considered in the core scope of dermatology and dermatologic surgery. Many practices in the USA and Canada are considered balanced.

4. All cosmetic, or a practice that typically offers only elective services that would be considered cosmetic in nature. These practices may exceed the usual scope of dermatology to reflect the unique skill sets of the providers. Examples of this could include facelift and breast augmentation procedures.

Considering that most dermatology offices today operate at the second and third levels of COP (focused or balanced) and those that aspire to these levels all share the same basic challenges, the following discussion targets COP levels 2 and 3.

The three components of CPC

The three essential components to a successful CPC consist of the setting, education, and assessment. These three integrated pieces are the proverbial three-legged stool: if any one is missing, the result is an unbalanced and hazardous situation. Of the three, the provider is most crucial in the assessment and, in some cases, assessment cannot be performed without the treating provider. Depending on the personal preferences of the provider, both the setting and education can be either a hands-on or hands-off affair.

Setting

Understanding organizational selling is the first step in achieving a proper setting for the CPC process. Although many physicians mistakenly believe that the initial face-to-face contact is the most important step in the process of a successful CPC, it is actually close to the last step of the process.

For most cosmetic dermatology practices, there is a preframed geographically determined catchment area. If the practice has been in existence for any significant length of time, there is usually limited general public awareness of the types of procedures and products available. This awareness may be founded on reputation, advertising, marketing efforts, location, etc. Identifying and controlling this general awareness is really the first step of the setting for the CPC.

Although this chapter is not intended to discuss marketing, advertising, and communication efforts for cosmetic dermatology practices, suffice it to say that this is a commonly overlooked area of practice development. Expert consultation is certainly available for those interested in pursuing further evaluation in this area.

What organizational selling means to the cosmetic dermatology practice is the education of all employees on the products, services, and procedures offered by the business. Organizational selling does not mean that every office employee is a salesperson; indeed the actual selling of a product or service needs to be a tightly managed affair.

Organizational selling is the systematic, methodical process of educating internally on the resources and capabilities of the entire office. This includes the unique assets of the providers, the equipment, the office setting, design, accreditation, etc. In its truest form, it means that any employee, from the billing clerk to the records clerk to the Mohs’ technician to the medical assistant, is capable of responding to a question, a request, a phone call, or even a third party inquiry about the services offered. This type of education takes dedicated training and frequent communication from the leadership of the office to be relevant and effective. It is essential to the success of the cosmetic dermatology practice.

This type of staff training also facilitates the entire process of the setting in that it allows the prospective cosmetic patient to progress seamlessly from being an interested party to an office visitor without receiving any conflicting information.

Organizational training also supports collateral information dissemination, such as telephone information scripting, patient handouts, brochures, internet presence, etc. Ideally, the prospect (individuals are not patients until they are actually treated; during the consultative process they are technically a prospect) continues to receive the same, non-conflicting information flow from the first contact with the office (internet, telephone, direct mail, etc.) to their first visit, to the actual consultation, to the day of procedure, and finally to the time of completion of follow-up of any procedure(s) performed. This process should be seamless from the patient’s perspective.

Once the patient reaches the office for the scheduled consultation, great care should be taken to ensure that he or she is promptly and politely received. As dermatology differs so greatly from plastic surgery in terms of office patient numbers and flow, it is recommended that consultations not be scheduled during busy clinic hours if performed by the provider. In addition, consideration should be given to alternate times and days of the week, including weekends, for scheduling of the CPC. Further, certain types of procedures or services may be offered in a group setting, such as an evening office information seminar. A good example of this would be new skin care products or services that are generally applicable to larger number of individuals.

The actual consultation may be performed by a dedicated patient cosmetic coordinator or by the treating provider, depending on the particular preferences of the office and the nature of the procedure. Certainly, the information needed for a simple botulinum toxin injection requires a more basic level of education than that needed for liposuction.

There should be a defined time limit for the consultation; this avoids the potential issue of not enough time in the patient’s mind. Commonly, this is 30 minutes and can be varied for different types or combinations of procedures. More than 30 minutes may be excessive, and can actually be counterproductive if the conversation is not kept tightly focused.

The actual location of the CPC needs to be carefully evaluated. Although there is no actual correct or incorrect way to locate the consultation, it is generally felt that a separate room is best. This can be the physician’s office, an exam room, or ideally a dedicated space within the office. Sometimes referred to as the closing room, a dedicated space provides optimal comfort for both the prospect and the consultant.

The dedicated consultation room also has many advantages, including privacy, d é cor, and ready access to all materials including printed, video, internet, and even photographic. The space is kept free of staff transit during the consultation, and generally there is a different ambiance in the room. Here, patients feel much more comfortable discussing their personal desires and fears, feel more relaxed, and less nervous than in an exam room.

The room should be well lit for exam and use of a mirror. Mirrors should include hand-held, magnifying, and full-length varieties. Some offices even use a dressing room-style three-way mirror, especially if body work such as liposuction is discussed. The furnishings should include as a minimum one or two large comfortable chairs and perhaps a small couch. Remember, frequently a cosmetic consult consists of more than just the prospect, and can include spouse/partner, family member(s), or friend.

The room may have a completely different interior design and color scheme to the rest of the office, including floor coverings, window treatments, and furnishings. It should be equipped with the necessary hardware and software to access and schedule the patient procedure in private. All necessary collateral materials, including consent forms, lab requisitions, release of information requests, etc., should be readily on hand.

The room should be kept spotless at all times and be supplied with fresh bottled water and possibly hot water/coffee for patient convenience. The room should be very quiet, even adding extra soundproofing materials if necessary. The necessary diplomas, certificates, awards, etc. should be displayed as a form of external reference for the reassurance of the client.

Finally, it is recommended that a clock be prominently displayed in easy view. This helps to establish a timeline for both parties. Consultations can always be extended and/or rescheduled if more time is necessary.

With regard to the actual time scheduling of consultations, it is recommended that they not be performed on a back-to-back timeline. This is because the consultant should have sufficient time between clients to perform the needed chart documentation, write any personal notes, including a thank-you note to the client, and prepare for the next consultation. Generally, 15 minutes is sufficient for these tasks. Also, this 15 minute block in the schedule helps to maintain an on-time performance for late-arriving patients, phone messages, follow-up calls, etc.

Education

The ideal CPC is really an exercise in patient education. Generally, in dermatology, the prospective patient will arrive with a narrow set of desires and expectations. They may not know which dermal filler they desire, but they know that they would like bigger lips or higher cheekbones. They usually have some limited education and knowledge from a friend who has had a similar procedure or from a fashion magazine or internet site. Their primary purpose of the consultation is to determine three things: Do you do this procedure (skill)? Do you want to do it to me (appropriate candidate)? How much does it cost?

The role of the consultant is to answer these three questions in an expanded format and to include risks, benefits, and alternatives available, whether through this office or another (fillers vs facelift; plastic surgeon vs dermatologist) more appropriate specialty. In addition, the consultant needs to help determine if the patient has the appropriate mental capacity and awareness to give consent and be able to comply with any needed follow-up care or visits. Although the treatment provider will ultimately make this decision, the consultant can play a vital screening role in the process.

Once the prospect has been given the basics of education, support materials may be used, such as brochures and consents. These are add-on materials, and should not be used in place of a consultation. Some offices use additional customized materials such as DVDs and photograph albums. Others use reprints of journal articles, website printouts, etc. Regardless of the materials used, all should be documented in the patient chart, and all CPCs should result in a medical chart, even if the prospect has never been and is never treated in the future by the office. This is thorough record keeping, and is an essential part of smart medicolegal practice.

For some procedures this entire education process is a simple matter. It may be accomplished in a few minutes, documented, and scheduled or performed before the patient leaves the office. For other procedures, it may be just the first step in a lengthy process that may include several pre-treatment visits and sessions to include photography, review of lab work, consultation with referring physicians, and pre-procedure physical examination and even psychological screening questionnaires.

With regard to price quotes, there are generally two schools of thought: the first is that every patient is a unique treatment challenge, and prices are individually determined based on these unique attributes. The other is to use a predetermined price list, and if deviations are needed these are explained to the patient individually. Dermatology offices, given the nature of the procedures performed, typically use price lists. Regardless of the approach, the price quote needs to be openly discussed and agreed upon by the patient before performing the procedure.

The best method to accomplish this is with the use of consultation sheets. These are two-or three-piece carbon-copy-type forms with a listing of procedures and prices typically hand written on a graphic of the face and/or body. The patient receives a copy of the completed form either at the end of the consultation or in the mail in a day or two after the consult. The other copy is placed in the chart. For price quotes, there is typically a 90-day guarantee that the price will be honored. This allows the prospect to have a reasonable time to consider the options and the procedure before committing. If they have additional questions, they can follow up with a phone call or a second consultation. For the actual cosmetic consultation, office policies very widely with regard to charging: most offices do not charge when the consultation is not performed by the physician. When the physician is using his or her time to do the actual 30-minute consult, it is common to charge a fee. Typically, this ranges from US$100 to $500. This fee is applied to the first procedure. Somewhat different from our plastic surgery colleagues, most cosmetic dermatology procedures are less than $5000, with many in the $1000–2500 range. Therefore, the rationale is that it is difficult to recoup lost revenue with these smaller charges, and the consult fee is one method to minimize these lost fees.

The cosmetic coordinator should follow up in 7–10 days (with permission) if the prospect has not scheduled the procedure or contacted the office for additional information. This closure provides for a call to action, and increases the efficiency rate of the cosmetic coordinator. Frequently prospects have a few remaining questions and, if answered to their satisfaction, they will book the procedure.

When booking, similar to paying the first night when making a hotel reservation, the usual approach is to pay half of the quoted procedure price to reserve the appointment slot; the second half is then usually paid the day of the procedure, before having it done. For cancellation or no-shows, there should be a very clear and precise written policy that is signed when the appointment is made. Commonly, a 24-to 48-hour cancellation is required to receive a refund. Anything less than 24 hours, unless an emergency, is problematic for the office. Some offices, as a gesture of goodwill, will apply all or a portion of the forfeited deposit to the next appointment if scheduled at the time of cancellation. Good judgment is necessary to manage these last minute no-shows and cancellations.

For some minor procedures such as toxins and fillers, where there is a variable in the final price, a deposit of $100 is common to book the appointment. This can be requested by the front office scheduling desk at the time that the appointment is made to facilitate patient convenience.

Assessment

For the actual procedure on any specific patient, it is clearly the responsibility of the treating provider to determine to the appropriateness of the patient and the requested procedure. This may consist of the actual physical evaluation, a mental status evaluation, comorbidities and overall health status, and any other complicating factors. Remembering the acronym ICG/RBE for informed consent given and risks and benefits explained for the particular patient is an excellent way to approach the assessment.

Some patients are clearly not good candidates for their desired procedures. Although this alone is not cause to withhold or deny cosmetic treatment, it should always be explored with the patient. Some, by virtue of age, health, medication, risk tolerance, timeline, or budget, may