The most important aspect of an initial consultation is the evaluation of the patient's problem in combination with an overall evaluation of the patient's face.

In the initial consultation, it is crucial to ascertain what is unattractive to the patient and then educate them about the different options available to correct the perceived imperfection. Every surgeon has a different technique which enables him or her to gather this information from the patient. Here is a step-by-step explanation of my initial consultation.

THE PATIENT'S PERSPECTIVE

After a thorough history, I hand a mirror to the patient and ask: "What is bothering you?" The patient can look in the mirror and show me exactly what they are unhappy about or which areas they would like to change. It is very important to gather this information directly from the patient! While I consider myself to have a good aesthetic eye, occasionally what is bothering the patient is not what I consider to be the most significant aspect of the person's face. For example, I have one elderly woman with significant lines around her eyes and bags underneath, but it was the fine lines on her upper lip that bothered her most. The shaded glasses she wore on a regular basis covered the eye area and she was not bothered by their appearance.

THE AGING FACE

Next, it is important for the patient to understand how the face and skin age. A detailed explanation of this in front of the mirror enables a patient to understand what is happening to their particular face, and place their concerns in an overall picture of the aging process.

Skin Changes

Several things happen to skin as people age. Much of this is determined by how much sun the individual has had in the past. Those with more sun exposure tend to develop earlier skin changes than those without. This is why the use of a topical antioxidant and a broad-spectrum sunscreen on a daily basis is crucial to those who want to slow down the aging process. What changes can be seen in the skin? First, skin begins to lose its luminosity. It begins to appear dull, with less light reflecting from the surface. Brown spots begin to appear and broken blood vessels can form, particularly on the nose, cheeks, neck and chest. (Compare skin from a never-exposed area such as a breast or buttock to get a clear picture of what changes have truly occurred.) Then lines begin to develop. Some lines, such as those across the forehead, “crow’s feet” on the sides of the eyes and the lines between the eyebrows (“squint lines”) – are exacerbated by motion in these areas. Lines above the upper lip tend to be worsened by smoking, current or past. Crepiness under the eyes is exacerbated by sun.

So what can we do to help these problems? The Fraxel laser can help repair aging, sun-damaged skin. This unique laser will renew your skin as it gradually becomes smoother, tighter and fresher. The fine lines will soften and uneven coloring and brown spots will noticeably fade. Broken blood vessels are best treated by the Photoderm/Photofacial/IPL laser, which has a speedy recovery but may leave small amounts of scabbing or bruising for a few days. Skin showing signs of sun damage and pre-cancerous lesions as well as skin with acne can be treated with the Photoderm Laser with Levulan Kerastick. This treatment is the same as the standard Photoderm Laser treatment, however, a special solution is applied to the skin prior to treatment. This product will help break down any actinic keratoses and pre-cancerous lesions as well as help with acne.
There are also skin “resurfacing” methods such the Erbium and CO2 which are both more aggressive forms of treatment for aging skin.

Motion lines are best treated by botulinum toxin (Botox), a chemical that blocks the connection between the muscle and the nerve, decreasing the offending motion and therefore the lines. At a minimum, a customized skin care regimen at home can help decrease fine lines, dullness, brown spots and larger pores. Antioxidants and sunscreens can be utilized to help prevent further sun damage.

The Sagging Face

Eventually, gravity will begin to affect the face. Eyebrows begin to drift downward and extra skin and fat become evident on upper eyelids. Below the eyes, fat can begin to bulge, creating “bags” under the eyes and a tired appearance. The face and cheeks can also droop, creating deeper nasolabial folds (the line between the side of the nose and corner of the mouth) or jowling along the jawline. The neck can become loose, develop bands or get a pocket of fat underneath. In these cases, skin and soft tissue below it need to be repositioned to create a more youthful appearance. The Contour Threadlift and the Composite Threadlift procedures are great ways to treat these symptoms. Depending on the needs of the patient the doctor will determine which lift is best. Both procedures are “incision free” and usually take less than two hours to perform. Neck liposuction is also be a fairly simple procedure that can offer tremendous improvement give a patient back her youthful, crisp jawline. Yet another option for those who want to improve jowling, tighten up the neck area and/or elevate the eyebrows, is the Thermage treatment. This treatment produces gradual new collagen growth to lift and tighten the skin with no down time at all. For some patients Botox injections can also help tighten the neck.

The Sinking Face

If you ever look at a caricature of an old witch, the woman is not sagging, skin is sunken and hollowed out. This is because the face loses fat as it ages. Sometimes around age 35 weight disappears quickly on the face than in other more desirable areas such as buttocks and hips. Many women need to maintain a higher percentage of body fat to keep a more youthful facial appearance. Nasolabial folds are created by a combination of sagging and sinking, although at times one process may contribute to a greater extent than the other. Cheekbones become more prominent, sometimes with an angular sense to them, and the chin can take on a more pointy appearance. Also those wonderful lips begin to lose fullness. These types of problems need "filler substances". Collagen, dermologen (human derived collagen), autologen (one's own collagen) and fat are all injectable substances that can correct these defects. Other products such as collagen, Restylane & Sculptra are available. One's own fat is also an excellent filler.

MAKING A PLAN

The next step is to determine which procedure is ideal for the patient. Occasionally a patient will ask for laser resurfacing, when really what she has are deep nasolabial folds and sunken cheeks. By explaining the aging process in the mirror, the patient can understand why laser resurfacing won't correct the problem she is concerned about, but something like fat injections will. Make sure the procedure can fix the problem. Also, occasionally a young patient will come in asking for laser resurfacing when all she needs is some good skin care and maybe some peels. Understanding the spectrum of what can be done will always help the patient make a wise decision. While I always listen to the specific complaints of each patient, I will occasionally offer suggestions as to other areas I feel will balance the face if I truly believe this will make a significant difference to her outcome. For example, the woman with significant bags under her eyes decided to undergo full-face laser resurfacing to remove some of the lines around her eyes, but did not opt to have the excess fat removed.

CREATING A BEAUTIFUL BODY

Most people have at least one area of their body they would like to change! Whether they were born with a “trouble spot” or if the body changed from pregnancy, weight loss or simply from the aging process – they want to improve themselves. The traditional modalities for improving the body, such as liposuction, are commonly known. However, there are also many other forms of treatment for body imperfections.

THE PATIENT’S PERSPECTIVE

Similarly to the facial consultation, I ask the patient what is bothering them. And again, it is important to hear directly from them what they would like to change. Sometimes a patient may be unhappy with the size of her hips or thighs and want the volume to be reduced while others may not be as concerned with the size as they are with the contour from one body part to the next or the crepy texture of the skin. Others may not have any concerns with body size but more so with the veins on her legs, brown spots on her neck and chest or the aged appearance of her hands.

MAKING A PLAN

Once it has been determined what it is that bothers the patient we can come up with a treatment plan. If it is the size of the body we can discuss liposuction as a means to reducing the volume in that area. Liposuction is also a great tool for contouring the body. If the abdomen has some excess fat with crepy, loose skin the Thermage treatment may be an excellent non-surgical approach to tightening that area. Broken blood vessels on the legs can be treated by either the Photoderm laser or by Sclerotherapy. It is also very common for patients to complain of blotchy, aged, sun damaged skin on the neck and chest. They want to even out the skin tone and improve the texture of the skin. The Fraxel laser can significantly improve these conditions with no down time involved. It is said that the hands show a woman’s age even more-so than the face! This is why many women find them to be an are of concern! Lipotransfer is a great procedure to help plump up the hands and minimize the appearance of veins while at the same time getting rid of that troublesome pocket of fat you cant seem to lose! Photoderm and Fraxel can also help with the texture of the skin and age spots.

A FINAL WORD

Lastly, the patient should be well informed. The best decisions are always made with the most amount of knowledge available. Make sure to discuss all options with the doctor, understand what you can truly expect as far as results and what is involved, and feel good about what you are going to do.

Karyn Grossman, MD is a board certified dermatologist specializing in cosmetic dermatology in Santa Monica, CA and Manhattan, NY areas. Areas of expertise include the Contour Threadlift being called the "60 minute non-surgical facelift" or the "no scar facelift", lipotransfer, liposuction, laser resurfacing, face and dermal fillers, chemical peels and other non-surgical treatments.