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Treat cosmetic derm patient as a whole


New Orleans — When performing cosmetic procedures, take a big-picture approach, and consider what's best for the patient overall. Rather than executing a single procedure here or there, it is up to the dermatologist to take responsibility for doing what is best to improve the patient's total appearance, says Ellen C. Gendler, M.D., who shared her ideas and experiences in cosmetic dermatology at the 63rd Annual Meeting of the American Academy of Dermatology (AAD) here.

"It is not just about selling your product or procedure to a patient. It is about taking care of a cosmetic unit ... about attacking a patient's cosmetic issues from many different perspectives and understanding what can really be accomplished," suggests Dr. Gendler, associate professor, department of dermatology, New York University Medical Center.

Aggregate view Having an aggregate view of the patient's treatment plan is one thing, but executing such a plan is another. Achieving a patient's overall improved appearance may require procedures outside of one's expertise.

"Learn relevant procedures; learn them well. Understand your own limitations and know when to refer."

Also, she says, know when to rein in a patient's unrealistic expectations of what a cosmetic procedure can do. She stresses the importance of giving patients an upfront, realistic explanation of what the results will be. Be ready to address their doubts or their insistence that their request for a certain cosmetic procedure be honored.

"Just because a patient asks about a procedure does not mean you have to do it," she says.

In some cases, "nobody could deliver what a patient wants," she adds. "Dermatologists need to be prepared to give that kind of news."

Upfront honesty also is needed when patients present with multiple cosmetic problems that they want resolved quickly.

"Either you short them by addressing all of their problems at once, or deal appropriately with one or two issues and then set up other appointments. Set limits of what you can take care of in a single visit."

For your consideration Dr. Gendler's approach to cosmetic dermatology may or may not jibe with other dermatologists' methodologies. However, she believes the techniques she uses and the decisions she makes in her practice are perhaps new ideas worth considering.

For instance, she usually will not perform cosmetic rejuvenation procedures on patients who do not limit sun exposure. Before any rejuvenation procedure she finds it very important to question patients about their sun exposure habits, especially during winter months when darker, tanned skin usually is not so prevalent. Potential patients who do not protect themselves from the sun's damaging rays are not good candidates for cosmetic procedures, and Dr. Gendler typically turns them away.

"I am strict about it. If someone does not avoid the sun, it is a total waste of my time to consider doing this because they will never adhere to a regimen and will never show improvement because they will reverse everything I am trying to accomplish. You end up with a dissatisfied patient," she explains.

"I like to choose motivated patients who are also patient. They are realistic and can stick to the regimen," she says.

She also is choosy about which new technologies or pharmaceutical agents she incorporates into her practice. Dr. Gendler's "wait and see" approach seems to run counter to the majority.

"Being the first one on the block to try the latest laser or the latest anything is usually a prescription for dissatisfaction and maybe disaster," she says.

Rather, she prefers to wait for scientific evidence that supports a new modality's claim of safety and efficacy. Dr. Gendler says she was one of the later physicians to start using botulinum toxin (Botox) because she waited for evidence. She became convinced of its value after consulting with experts across the country and assessing patient satisfaction results.

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