Aesthetic Procedures Introduction

Rebecca Small, MD

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Minimally invasive procedures have become the primary treatment modalities for facial rejuvenation and enhancement. Traditional treatment options have been limited to surgical interventions, such as facelifts to redrape and lift skin, which give a tighter appearance. However, there has been a shift away from invasive one-time procedures which may radically alter appearance, towards procedures that can enhance appearance in a more natural, subtle way. These procedures are performed in an ongoing capacity to promote and maintain a healthy youthful appearance. Minimally invasive aesthetic treatments today are aimed at reducing the signs of photoaging by relaxing overactive facial muscles with botulinum toxin; filling wrinkles and redefining facial contours with dermal fillers, and improving epidermal hyperpigmentation and vascularities with lasers and intense pulsed light treatments. Statistics published by the American Society for Facial Plastic and Reconstructive Surgery show that of the 11.7 million aesthetic procedures performed in the United States in 2007, 82% were nonsurgical, and the most common procedures performed were botulinum toxin, dermal fillers, laser hair removal, microdermabrasion, and intense pulsed light treatments. 
The advances in minimally invasive aesthetic treatments have opened up the aesthetics field to primary care professionals (PCPs), including physicians and nurses in family medicine, obstetrics, internal medicine, and emergency medicine. The skills that these providers have with office procedures and strong doctor-patient relationships make them particularly well suited to provide aesthetic care. 
There are several challenges faced by the PCP in performing aesthetic treatments. Obtaining high-quality, evidence-based training has been a barrier; however, with more same-specialty mentors and the emergence of formal training in some primary care residency programs, proper training can be acquired. Selecting aesthetic products and technologies to incorporate into practice can be daunting due to the vast array of therapies available, and treatment options continue to increase as the field of aesthetics grows. 
The goal of the following chapters is to provide PCPs with an appreciation for the aesthetic considerations of the aging face and a basic approach to facial rejuvenation utilizing a core group of procedures, the essential medical aesthetic rejuvenation treatments (ARTs). These treatments are highly efficacious, requiring minimal recovery time, have a relatively low risk of side effects, high patient satisfaction, and can be performed safely in the outpatient setting. They form a foundation of aesthetic procedures for PCPs that can be successfully incorporated into primary care practice. In summary, the essential medical ARTs for PCPs include the following: 
  • Botulinum toxin A (Botox) treatment for

    • Frown lines

    • Crow’s feet

    • Horizontal forehead lines

  • Dermal filler treatment for

    • Nasolabial folds

    • Oral commissures

    • Lip enhancement

  • Laser and intense pulsed light treatment for

    • Permanent hair reduction

    • Photo rejuvenation of benign vascular and pigmented lesions

  • Rejuvenation skin care program with

    • Microdermabrasion

    • Chemical peels

    • Topical products

  • Sclerotherapy for small varicose veins

Facial Aging

Over time, the skin naturally thins and loses volume as dermal collagen, hyaluronic acid, and elastin diminish. This process of dermal atrophy is accelerated and compounded primarily by sun damage and other extrinsic factors such as smoking. Prematurely photoaged skin exhibits textural changes with wrinkles and roughness; dyschromia with mottled hyperpigmentation and lentigines; vascular ectasias with telangiectasias and cherry angiomas, and undergoes benign and malignant degenerative changes. Hyperdynamic facial musculature contributes to formation of visible lines and wrinkles in the upper one third of the face. Redistribution of facial fat, skin laxity, and biometric changes such as bone resorption, contribute to skin folds and contour changes in the lower two thirds of the face. Specifically, descent of the malar fat pads contributes to deepened nasolabial folds and oral commissures; regression of dentition and resorption of maxillary and mandibular bones accentuates vertical lip lines and the mental crease. 

Aesthetic Consultation

Aesthetic consultation is an important part of successfully performing aesthetic treatments. Medical history should be reviewed, including: past medical history, medications, allergies, and past cosmetic history (including results from previous treatments and side effects if any, surgeries, and satisfaction with outcomes). An aesthetic patient intake questionnaire is shown in the figure. Repeated dissatisfaction with past aesthetic treatments is a red flag and can be associated with unrealistic expectations or body dysmorphic disorder, both of which are contraindications to treatment. While discussing the patient’s concerns, a mirror should be held between the provider and the patient and the areas of concern simultaneously examined. The areas should be prioritized by the patient and the treatment options discussed, along with the number of treatments recommended, anticipated results and the cost. Asymmetries, such as uneven eyebrow height, should be pointed out to the patient, noted in the chart and photographed. An aesthetics consultation form is shown in the second figure. 
Figure 1 Courtesy of Monterey Bay Laser Aesthetics.
Figure 1 Courtesy of Monterey Bay Laser Aesthetics.
Figure 2 Courtesy of Monterey Bay Laser Aesthetics.
Figure 2 Courtesy of Monterey Bay Laser Aesthetics.
Photographs should be taken prior to treatment, midway through a treatment series, and posttreatment. The patient should be positioned fully upright, looking straight ahead. Photographs are taken of the full face and specific treatment areas in this position, at 90 degrees and 45 degrees. For injectable treatments, photographs should be taken at rest and with active facial movement of the treatment areas. Aesthetic photographic systems, such as Canfield, Profect, and BrighTex, provide standardized angles and lighting, which facilitate consistent photography. 
Patients receiving elective aesthetic procedures typically have high expectations of efficacy and low tolerance for side effects. Time should be taken to cover all aspects of the informed consent process, which consists of: (i) discussing the risks, benefits (with emphasis on realistic expectations), alternatives, and complications of the procedure; (ii) providing adequate opportunity for all questions to be asked and answered; (iii) educating the patient about the nature of the aesthetic issue and procedure details (iv) signing the consent form; and (v) documenting the informed consent process in the chart.