Getting the Max — For the Minimum

Cosmetic and aesthetic physicians of all specialty backgrounds, including especially dermatologists, are learning from their patients that the “new” desired approach to cosmetic enhancement is through minimally invasive procedures. Also known as “no down time” or “lunch time” procedures, this disparate group of treatments are connected by one common thread; they typically do not require any type of prolonged healing time. Perhaps better described as “minimal down time” rather than as “no down time,” the list of treatments and programs includes such items as alpha hydroxy acid peels, microdermabrasion, non-ablative laser, intense pulsed light (IPL), Thermage, Botox, Cosmoplast, Hylaform, Restylane, and Sculptra, and more. Additionally, numerous new products are on the horizon to include other fillers and injectables, different types of lasers and next generation tissue tightening techniques. Just how does an aesthetic practice incorporate these techniques? Incorporating all of these different techniques into one easily communicated package that’s understandable to the inquiring prospective patient is often a major challenge for the cosmetic dermatology practice. I’ve divided this article into two parts; the first prepares the practice for aesthetic success by following three basic steps: education, communication and attention. The second part describes a potential step-by-step product and procedure program that meets the needs of the majority of aesthetic patients who desire a non-surgical total facial restoration approach that minimizes “downtime.” Part 1 of the overall plan In the first of the three parts, I recommend that the physician spend the time to become familiar with the basic features and benefits of each of the types of procedures. Once this has been achieved, then communicate the essential information to the office staff, so that they may become comfortable discussing these treatments to the prospective patients. The more information that you share with your patients in a clear, concise and consistent manner, the greater the chances that your patients will make informed decisions. You must support your verbal communication with written materials, which are preferably unique to each practice. These materials then can be read and re-read by the patient at her own pace. Although corporate and proprietary brochures are certainly helpful, they can be enhanced with a simple pamphlet or handout that describes the products and procedures used within your practice. In essence, the practice brochure serves as the unifying piece of information to materially support the verbal communication presented in your office. It also can be an effective sales tool by stimulating a call to action by the reader. After educating yourself and your patients, I’d next recommend that your practice designate a specific individual as the cosmetic patient coordinator to communicate your services to patients. This person is sometimes referred to as the patient “cosmetic concierge.” This staff member meets and greets the interested patients, educates them on what options are available within the practice, outlines a potential treatment program based on the assessment of the dermatologist, and tracks their progress in terms of follow-up scheduling, payment collection, post-treatment satisfaction analysis, etc. Ideally, this person does not bill the patient for services. Why is this necessary? Most dermatology practices are quite busy, and general disease-based dermatology visits are labor intensive for the entire staff. Frequently, the office has a perceived hectic pace, which isn’t conducive to spending increased time with the cosmetic patient, answering questions, following up with telephone messages, and in general, meeting the increased demands of desire dermatology. The natural triage that occurs within the office regarding disease vs. desire patients is one in which disease usually takes precedence. This is not a formula for aesthetic practice success, as the expectations of aesthetic patients are typically much grater than those of non-aesthetic patients. Failing to meet these expectations can, and probably will, result in suboptimal performance for your developing cosmetic practice. The third component of your initial plan is to be aware of your surroundings and the messages they communicate. Pay attention to the physical surroundings inside and outside of your office; the décor, music, signage, seating, ambiance, etc. — all communicate a “meta-message” to your potential aesthetic patient. If you haven’t been to an aesthetic plastic surgeon’s office in the past few years, visit one. You may be surprised. Their meta-message is all about paying good money to look good and feel good. Chances are, they also have a skincare facility of some type located within the office — where, most likely, nurse-estheticians (usually RNs) perform many of the same procedures that dermatologists offer. Many plastic surgeons’ offices are redecorated professionally on an annual basis. When was the last time your office was refreshed? Do you offer your aesthetic patients fresh coffee, tea or mineral water? Are fresh fruits and flowers placed in the common waiting areas? Are the latest issues of fashion and beauty magazines available? Do you have proper staffing ratios to give extra attention to the needs of the aesthetic patient? Is the overall atmosphere one of quiet and calm professionalism, or is it hectic, chaotic, and rushed because you’re behind schedule (again)? I once visited a level-three (equal mix of disease and desire dermatology) practice in the Southeast where there was a transformation performed every Tuesday evening. At the end of 2 days of regular disease dermatology, the office was literally transformed from a nice, albeit rather typical, suburban practice into a cosmetic center of excellence for the next 2 days. The waiting room was rearranged from the typical “bus station seating” into circular conversation group areas. The registration desk area was freshened with two vases of fresh flowers, and the skin disease posters were removed from the walls and replaced by floral prints. A coffee/juice/water station was set up near the entry on a small garden cart, the carpet was vacuumed and an area rug placed, and the patient information brochures were changed to those pertaining to cosmetic procedures. Common reading materials were exchanged for beauty magazines, along with reprints from professional journals on cosmetic topics written by the attending dermatologist. In the space of less than several hours, and for a few dollars, the entire complexion of the practice was freshened to promote aesthetic practice. Part 2, the products and procedures For many years, our plastic surgery colleagues (and surgical dermatologists) have divided the face into distinct units from which the changes of aging are defined. There are many different approaches used, depending in part upon which level of anatomy you are assessing, such as the bones, muscles, soft tissues, or skin. Dermatologists have traditionally used the skin as the organ of assessment, describing changes of aging by virtue of pigmentary and textural alterations to include dyschromia, crinkles, wrinkles, sagging, keratoses, telangiectasias, etc. What dermatologists have not typically done is to describe subsurface alterations except as they pertain to the skin surface. The entire evolving concept of non-surgical total facial restoration is based on not just the changes inherent in aging on the skin surface, but also the subsurface alterations which occur. Because of advances in products, procedures, treatments and technology, many, if not most, of the structural alterations of the aging face are amenable to minimally invasive techniques available to aesthetic dermatologists today. One assessment approach is to divide the aging face into three regions, loosely defined as the upper, mid and lower face. These areas, plus the surface of the skin, constitute the four major areas of intervention for non-surgical total facial restoration. I’ll propose a general approach to the assessment and treatment of the aging face utilizing these four general, yet discrete, areas of description. 1.The upper face. This area consists of the forehead and anterior hairline down to the eyebrows and temples laterally. This may also include the upper (and lower) eyelids. The general aging tendency in this region is one of inferior progression, with a lowering of the eyebrows relative to the superior orbital rim, a heaviness in the upper eyelids; frequently bi-temporal concavity due to fat loss with associated “hollow” eye rings accentuating the tear troughs; recession of the anterior hairline in men, and horizontal lines across the mid forehead with vertical furrowing in the glabella and lateral canthal regions. Here, the anti-aging approach is in part a smoothing of the surface lines (corrugations, furrows) with attention to elevation and lateral repositioning of the medial brow, elevation of the lateral brow, filling of the temporal depressions and eye rings, restoration of the anterior hairline to frame the face, and restoration of the platform of the upper eyelid. Botox is in many ways the definitive treatment for the upper face. With the exception of action on the hairline and temporal depressions, Botox can smooth and soften the lines created by the frontalis, obicularis and corrugator complex. It can elevate and re-position the brow, and help to redefine the upper lid platform. Mini and micrograft hair restoration can expertly re-establish the anterior hairline resulting in a more youthful appearance, especially in men. Sculptra can correct the temporal depressions and hollow eye rings, and if necessary, subconjunctival blepharoplasty addresses the infraorbital fat pads. 2. The mid face. Many individuals lose the buccal fat pads along with a diffuse facial fat loss, collectively known as facial lipoatrophy. This leads to loose sagging skin of the cheeks and jaw line, deepening of the nasolabial folds, drooping of the corners of the mouth (marionette lines) and fullness of the lateral chin. The corrective approach is to restore lost volume of the mid face, thus lifting the skin sagging onto the lower face and in the process restoring normal contours to the cheeks, jaw line, nasolabial folds, and corners of the mouth and chin. Until recently, volume restoration of the mid face was principally done by either surgical implants, usually of silastic, or through fat transfer. With the recent approval of Sculptra, poly-L-lactic acid (New-fill in Europe), injection therapy to restore lost volume is now possible. Through a series of three to five injections at 4- to 6-week intervals, Sculptra is thought to promote neo-collagenesis, resulting in long lasting (up to 2 years) corrections. 3. The lower face. This area could also be termed the perioral region, where aging can be defined by wrinkles and atrophy of the lips, with surface creases along the naso-labial folds and at the junction of the inferior obicularis oris and mentalis. Together with creases at the corners of the mouth, the aging mouth is of paramount concern to many aesthetic clients. Correction consists of restoring lost volume to the lips and lifting out of surface creases circumferentially around the mouth. Elevation of the corners of the mouth can create not only a more youthful appearance, but one of less anger or frustration as well. In this area, filling agents such as hyaluronic acids (Hylaform, Restylane) and collagen (Cosmoplast) are ideal. Not only do they restore lost volume, they actually can be used to enhance pre-aging proportions, such as lip enhancement. Additionally, these products can correct surface wrinkles and crinkles. 4. The surface of the skin. After the three facial units are assessed and a treatment plan is put into place for volume correction and wrinkle reduction, the surface of the skin needs to be addressed. Usually, there will be some degree of surface photodamage ranging from a few areas of pigmentation and fine lines to total dyschromia/actinic bronzing with severe wrinkling. The treatment choices are obvious and traditional, including skin peels, which are usually very light in the concept of minimal down time. Microdermabrasion can serve as a viable alternative, as can other options, especially retinoids. Non-ablative lasers, IPL (with or without 5-aminolevulinic acid [Levulan], and Thermage can all play an important role in “global” repair of the skin surface and repair of laxity. Maintaining Results Finally, maintenance of results is critical to patient satisfaction. This is achieved in principally two ways. 1. Daily skincare regimen. Help establish a system of daily skin care that includes the mandatory use of sunscreen with other products based on desire, experience and budget. 2. Follow-up visits. Our aesthetic facility will contact patients on a regular basis at predetermined intervals to request follow-up photographs. During these visits, pre-treatment photographs are reviewed, and likely serve as a reminder as to how successful the program really was. Prior to these procedures, a careful assessment of the overall skin health is necessary. Are there any pre-cancerous or cancerous lesions present? Does excessive skin laxity and redundancy obviate the need for non surgical intervention and would a more traditional face-lifting procedure be more appropriate? Is the patient aware of the timeline nature of the procedures and the associated costs? An emerging opportunity Non-surgical total facial restoration is an emerging treatment paradigm, and it’s sure to quickly evolve with each new product or treatment introduced. The important concept is not so much which specific procedures you perform, rather it is being aware of the greater concept and embracing this rapidly developing cosmetic arena as a growth area for aesthetic dermatology practice. Dr. Werschler is an Associate Clinical Professor of Medicine and Dermatology at the University of Washington, and section chief of dermatology at Sacred Heart Medical Center, Spokane, WA.

Cosmetic and aesthetic physicians of all specialty backgrounds, including especially dermatologists, are learning from their patients that the “new” desired approach to cosmetic enhancement is through minimally invasive procedures. Also known as “no down time” or “lunch time” procedures, this disparate group of treatments are connected by one common thread; they typically do not require any type of prolonged healing time. Perhaps better described as “minimal down time” rather than as “no down time,” the list of treatments and programs includes such items as alpha hydroxy acid peels, microdermabrasion, non-ablative laser, intense pulsed light (IPL), Thermage, Botox, Cosmoplast, Hylaform, Restylane, and Sculptra, and more. Additionally, numerous new products are on the horizon to include other fillers and injectables, different types of lasers and next generation tissue tightening techniques. Just how does an aesthetic practice incorporate these techniques? Incorporating all of these different techniques into one easily communicated package that’s understandable to the inquiring prospective patient is often a major challenge for the cosmetic dermatology practice. I’ve divided this article into two parts; the first prepares the practice for aesthetic success by following three basic steps: education, communication and attention. The second part describes a potential step-by-step product and procedure program that meets the needs of the majority of aesthetic patients who desire a non-surgical total facial restoration approach that minimizes “downtime.” Part 1 of the overall plan In the first of the three parts, I recommend that the physician spend the time to become familiar with the basic features and benefits of each of the types of procedures. Once this has been achieved, then communicate the essential information to the office staff, so that they may become comfortable discussing these treatments to the prospective patients. The more information that you share with your patients in a clear, concise and consistent manner, the greater the chances that your patients will make informed decisions. You must support your verbal communication with written materials, which are preferably unique to each practice. These materials then can be read and re-read by the patient at her own pace. Although corporate and proprietary brochures are certainly helpful, they can be enhanced with a simple pamphlet or handout that describes the products and procedures used within your practice. In essence, the practice brochure serves as the unifying piece of information to materially support the verbal communication presented in your office. It also can be an effective sales tool by stimulating a call to action by the reader. After educating yourself and your patients, I’d next recommend that your practice designate a specific individual as the cosmetic patient coordinator to communicate your services to patients. This person is sometimes referred to as the patient “cosmetic concierge.” This staff member meets and greets the interested patients, educates them on what options are available within the practice, outlines a potential treatment program based on the assessment of the dermatologist, and tracks their progress in terms of follow-up scheduling, payment collection, post-treatment satisfaction analysis, etc. Ideally, this person does not bill the patient for services. Why is this necessary? Most dermatology practices are quite busy, and general disease-based dermatology visits are labor intensive for the entire staff. Frequently, the office has a perceived hectic pace, which isn’t conducive to spending increased time with the cosmetic patient, answering questions, following up with telephone messages, and in general, meeting the increased demands of desire dermatology. The natural triage that occurs within the office regarding disease vs. desire patients is one in which disease usually takes precedence. This is not a formula for aesthetic practice success, as the expectations of aesthetic patients are typically much grater than those of non-aesthetic patients. Failing to meet these expectations can, and probably will, result in suboptimal performance for your developing cosmetic practice. The third component of your initial plan is to be aware of your surroundings and the messages they communicate. Pay attention to the physical surroundings inside and outside of your office; the décor, music, signage, seating, ambiance, etc. — all communicate a “meta-message” to your potential aesthetic patient. If you haven’t been to an aesthetic plastic surgeon’s office in the past few years, visit one. You may be surprised. Their meta-message is all about paying good money to look good and feel good. Chances are, they also have a skincare facility of some type located within the office — where, most likely, nurse-estheticians (usually RNs) perform many of the same procedures that dermatologists offer. Many plastic surgeons’ offices are redecorated professionally on an annual basis. When was the last time your office was refreshed? Do you offer your aesthetic patients fresh coffee, tea or mineral water? Are fresh fruits and flowers placed in the common waiting areas? Are the latest issues of fashion and beauty magazines available? Do you have proper staffing ratios to give extra attention to the needs of the aesthetic patient? Is the overall atmosphere one of quiet and calm professionalism, or is it hectic, chaotic, and rushed because you’re behind schedule (again)? I once visited a level-three (equal mix of disease and desire dermatology) practice in the Southeast where there was a transformation performed every Tuesday evening. At the end of 2 days of regular disease dermatology, the office was literally transformed from a nice, albeit rather typical, suburban practice into a cosmetic center of excellence for the next 2 days. The waiting room was rearranged from the typical “bus station seating” into circular conversation group areas. The registration desk area was freshened with two vases of fresh flowers, and the skin disease posters were removed from the walls and replaced by floral prints. A coffee/juice/water station was set up near the entry on a small garden cart, the carpet was vacuumed and an area rug placed, and the patient information brochures were changed to those pertaining to cosmetic procedures. Common reading materials were exchanged for beauty magazines, along with reprints from professional journals on cosmetic topics written by the attending dermatologist. In the space of less than several hours, and for a few dollars, the entire complexion of the practice was freshened to promote aesthetic practice. Part 2, the products and procedures For many years, our plastic surgery colleagues (and surgical dermatologists) have divided the face into distinct units from which the changes of aging are defined. There are many different approaches used, depending in part upon which level of anatomy you are assessing, such as the bones, muscles, soft tissues, or skin. Dermatologists have traditionally used the skin as the organ of assessment, describing changes of aging by virtue of pigmentary and textural alterations to include dyschromia, crinkles, wrinkles, sagging, keratoses, telangiectasias, etc. What dermatologists have not typically done is to describe subsurface alterations except as they pertain to the skin surface. The entire evolving concept of non-surgical total facial restoration is based on not just the changes inherent in aging on the skin surface, but also the subsurface alterations which occur. Because of advances in products, procedures, treatments and technology, many, if not most, of the structural alterations of the aging face are amenable to minimally invasive techniques available to aesthetic dermatologists today. One assessment approach is to divide the aging face into three regions, loosely defined as the upper, mid and lower face. These areas, plus the surface of the skin, constitute the four major areas of intervention for non-surgical total facial restoration. I’ll propose a general approach to the assessment and treatment of the aging face utilizing these four general, yet discrete, areas of description. 1.The upper face. This area consists of the forehead and anterior hairline down to the eyebrows and temples laterally. This may also include the upper (and lower) eyelids. The general aging tendency in this region is one of inferior progression, with a lowering of the eyebrows relative to the superior orbital rim, a heaviness in the upper eyelids; frequently bi-temporal concavity due to fat loss with associated “hollow” eye rings accentuating the tear troughs; recession of the anterior hairline in men, and horizontal lines across the mid forehead with vertical furrowing in the glabella and lateral canthal regions. Here, the anti-aging approach is in part a smoothing of the surface lines (corrugations, furrows) with attention to elevation and lateral repositioning of the medial brow, elevation of the lateral brow, filling of the temporal depressions and eye rings, restoration of the anterior hairline to frame the face, and restoration of the platform of the upper eyelid. Botox is in many ways the definitive treatment for the upper face. With the exception of action on the hairline and temporal depressions, Botox can smooth and soften the lines created by the frontalis, obicularis and corrugator complex. It can elevate and re-position the brow, and help to redefine the upper lid platform. Mini and micrograft hair restoration can expertly re-establish the anterior hairline resulting in a more youthful appearance, especially in men. Sculptra can correct the temporal depressions and hollow eye rings, and if necessary, subconjunctival blepharoplasty addresses the infraorbital fat pads. 2. The mid face. Many individuals lose the buccal fat pads along with a diffuse facial fat loss, collectively known as facial lipoatrophy. This leads to loose sagging skin of the cheeks and jaw line, deepening of the nasolabial folds, drooping of the corners of the mouth (marionette lines) and fullness of the lateral chin. The corrective approach is to restore lost volume of the mid face, thus lifting the skin sagging onto the lower face and in the process restoring normal contours to the cheeks, jaw line, nasolabial folds, and corners of the mouth and chin. Until recently, volume restoration of the mid face was principally done by either surgical implants, usually of silastic, or through fat transfer. With the recent approval of Sculptra, poly-L-lactic acid (New-fill in Europe), injection therapy to restore lost volume is now possible. Through a series of three to five injections at 4- to 6-week intervals, Sculptra is thought to promote neo-collagenesis, resulting in long lasting (up to 2 years) corrections. 3. The lower face. This area could also be termed the perioral region, where aging can be defined by wrinkles and atrophy of the lips, with surface creases along the naso-labial folds and at the junction of the inferior obicularis oris and mentalis. Together with creases at the corners of the mouth, the aging mouth is of paramount concern to many aesthetic clients. Correction consists of restoring lost volume to the lips and lifting out of surface creases circumferentially around the mouth. Elevation of the corners of the mouth can create not only a more youthful appearance, but one of less anger or frustration as well. In this area, filling agents such as hyaluronic acids (Hylaform, Restylane) and collagen (Cosmoplast) are ideal. Not only do they restore lost volume, they actually can be used to enhance pre-aging proportions, such as lip enhancement. Additionally, these products can correct surface wrinkles and crinkles. 4. The surface of the skin. After the three facial units are assessed and a treatment plan is put into place for volume correction and wrinkle reduction, the surface of the skin needs to be addressed. Usually, there will be some degree of surface photodamage ranging from a few areas of pigmentation and fine lines to total dyschromia/actinic bronzing with severe wrinkling. The treatment choices are obvious and traditional, including skin peels, which are usually very light in the concept of minimal down time. Microdermabrasion can serve as a viable alternative, as can other options, especially retinoids. Non-ablative lasers, IPL (with or without 5-aminolevulinic acid [Levulan], and Thermage can all play an important role in “global” repair of the skin surface and repair of laxity. Maintaining Results Finally, maintenance of results is critical to patient satisfaction. This is achieved in principally two ways. 1. Daily skincare regimen. Help establish a system of daily skin care that includes the mandatory use of sunscreen with other products based on desire, experience and budget. 2. Follow-up visits. Our aesthetic facility will contact patients on a regular basis at predetermined intervals to request follow-up photographs. During these visits, pre-treatment photographs are reviewed, and likely serve as a reminder as to how successful the program really was. Prior to these procedures, a careful assessment of the overall skin health is necessary. Are there any pre-cancerous or cancerous lesions present? Does excessive skin laxity and redundancy obviate the need for non surgical intervention and would a more traditional face-lifting procedure be more appropriate? Is the patient aware of the timeline nature of the procedures and the associated costs? An emerging opportunity Non-surgical total facial restoration is an emerging treatment paradigm, and it’s sure to quickly evolve with each new product or treatment introduced. The important concept is not so much which specific procedures you perform, rather it is being aware of the greater concept and embracing this rapidly developing cosmetic arena as a growth area for aesthetic dermatology practice. Dr. Werschler is an Associate Clinical Professor of Medicine and Dermatology at the University of Washington, and section chief of dermatology at Sacred Heart Medical Center, Spokane, WA.

Cosmetic and aesthetic physicians of all specialty backgrounds, including especially dermatologists, are learning from their patients that the “new” desired approach to cosmetic enhancement is through minimally invasive procedures. Also known as “no down time” or “lunch time” procedures, this disparate group of treatments are connected by one common thread; they typically do not require any type of prolonged healing time. Perhaps better described as “minimal down time” rather than as “no down time,” the list of treatments and programs includes such items as alpha hydroxy acid peels, microdermabrasion, non-ablative laser, intense pulsed light (IPL), Thermage, Botox, Cosmoplast, Hylaform, Restylane, and Sculptra, and more. Additionally, numerous new products are on the horizon to include other fillers and injectables, different types of lasers and next generation tissue tightening techniques. Just how does an aesthetic practice incorporate these techniques? Incorporating all of these different techniques into one easily communicated package that’s understandable to the inquiring prospective patient is often a major challenge for the cosmetic dermatology practice. I’ve divided this article into two parts; the first prepares the practice for aesthetic success by following three basic steps: education, communication and attention. The second part describes a potential step-by-step product and procedure program that meets the needs of the majority of aesthetic patients who desire a non-surgical total facial restoration approach that minimizes “downtime.” Part 1 of the overall plan In the first of the three parts, I recommend that the physician spend the time to become familiar with the basic features and benefits of each of the types of procedures. Once this has been achieved, then communicate the essential information to the office staff, so that they may become comfortable discussing these treatments to the prospective patients. The more information that you share with your patients in a clear, concise and consistent manner, the greater the chances that your patients will make informed decisions. You must support your verbal communication with written materials, which are preferably unique to each practice. These materials then can be read and re-read by the patient at her own pace. Although corporate and proprietary brochures are certainly helpful, they can be enhanced with a simple pamphlet or handout that describes the products and procedures used within your practice. In essence, the practice brochure serves as the unifying piece of information to materially support the verbal communication presented in your office. It also can be an effective sales tool by stimulating a call to action by the reader. After educating yourself and your patients, I’d next recommend that your practice designate a specific individual as the cosmetic patient coordinator to communicate your services to patients. This person is sometimes referred to as the patient “cosmetic concierge.” This staff member meets and greets the interested patients, educates them on what options are available within the practice, outlines a potential treatment program based on the assessment of the dermatologist, and tracks their progress in terms of follow-up scheduling, payment collection, post-treatment satisfaction analysis, etc. Ideally, this person does not bill the patient for services. Why is this necessary? Most dermatology practices are quite busy, and general disease-based dermatology visits are labor intensive for the entire staff. Frequently, the office has a perceived hectic pace, which isn’t conducive to spending increased time with the cosmetic patient, answering questions, following up with telephone messages, and in general, meeting the increased demands of desire dermatology. The natural triage that occurs within the office regarding disease vs. desire patients is one in which disease usually takes precedence. This is not a formula for aesthetic practice success, as the expectations of aesthetic patients are typically much grater than those of non-aesthetic patients. Failing to meet these expectations can, and probably will, result in suboptimal performance for your developing cosmetic practice. The third component of your initial plan is to be aware of your surroundings and the messages they communicate. Pay attention to the physical surroundings inside and outside of your office; the décor, music, signage, seating, ambiance, etc. — all communicate a “meta-message” to your potential aesthetic patient. If you haven’t been to an aesthetic plastic surgeon’s office in the past few years, visit one. You may be surprised. Their meta-message is all about paying good money to look good and feel good. Chances are, they also have a skincare facility of some type located within the office — where, most likely, nurse-estheticians (usually RNs) perform many of the same procedures that dermatologists offer. Many plastic surgeons’ offices are redecorated professionally on an annual basis. When was the last time your office was refreshed? Do you offer your aesthetic patients fresh coffee, tea or mineral water? Are fresh fruits and flowers placed in the common waiting areas? Are the latest issues of fashion and beauty magazines available? Do you have proper staffing ratios to give extra attention to the needs of the aesthetic patient? Is the overall atmosphere one of quiet and calm professionalism, or is it hectic, chaotic, and rushed because you’re behind schedule (again)? I once visited a level-three (equal mix of disease and desire dermatology) practice in the Southeast where there was a transformation performed every Tuesday evening. At the end of 2 days of regular disease dermatology, the office was literally transformed from a nice, albeit rather typical, suburban practice into a cosmetic center of excellence for the next 2 days. The waiting room was rearranged from the typical “bus station seating” into circular conversation group areas. The registration desk area was freshened with two vases of fresh flowers, and the skin disease posters were removed from the walls and replaced by floral prints. A coffee/juice/water station was set up near the entry on a small garden cart, the carpet was vacuumed and an area rug placed, and the patient information brochures were changed to those pertaining to cosmetic procedures. Common reading materials were exchanged for beauty magazines, along with reprints from professional journals on cosmetic topics written by the attending dermatologist. In the space of less than several hours, and for a few dollars, the entire complexion of the practice was freshened to promote aesthetic practice. Part 2, the products and procedures For many years, our plastic surgery colleagues (and surgical dermatologists) have divided the face into distinct units from which the changes of aging are defined. There are many different approaches used, depending in part upon which level of anatomy you are assessing, such as the bones, muscles, soft tissues, or skin. Dermatologists have traditionally used the skin as the organ of assessment, describing changes of aging by virtue of pigmentary and textural alterations to include dyschromia, crinkles, wrinkles, sagging, keratoses, telangiectasias, etc. What dermatologists have not typically done is to describe subsurface alterations except as they pertain to the skin surface. The entire evolving concept of non-surgical total facial restoration is based on not just the changes inherent in aging on the skin surface, but also the subsurface alterations which occur. Because of advances in products, procedures, treatments and technology, many, if not most, of the structural alterations of the aging face are amenable to minimally invasive techniques available to aesthetic dermatologists today. One assessment approach is to divide the aging face into three regions, loosely defined as the upper, mid and lower face. These areas, plus the surface of the skin, constitute the four major areas of intervention for non-surgical total facial restoration. I’ll propose a general approach to the assessment and treatment of the aging face utilizing these four general, yet discrete, areas of description. 1.The upper face. This area consists of the forehead and anterior hairline down to the eyebrows and temples laterally. This may also include the upper (and lower) eyelids. The general aging tendency in this region is one of inferior progression, with a lowering of the eyebrows relative to the superior orbital rim, a heaviness in the upper eyelids; frequently bi-temporal concavity due to fat loss with associated “hollow” eye rings accentuating the tear troughs; recession of the anterior hairline in men, and horizontal lines across the mid forehead with vertical furrowing in the glabella and lateral canthal regions. Here, the anti-aging approach is in part a smoothing of the surface lines (corrugations, furrows) with attention to elevation and lateral repositioning of the medial brow, elevation of the lateral brow, filling of the temporal depressions and eye rings, restoration of the anterior hairline to frame the face, and restoration of the platform of the upper eyelid. Botox is in many ways the definitive treatment for the upper face. With the exception of action on the hairline and temporal depressions, Botox can smooth and soften the lines created by the frontalis, obicularis and corrugator complex. It can elevate and re-position the brow, and help to redefine the upper lid platform. Mini and micrograft hair restoration can expertly re-establish the anterior hairline resulting in a more youthful appearance, especially in men. Sculptra can correct the temporal depressions and hollow eye rings, and if necessary, subconjunctival blepharoplasty addresses the infraorbital fat pads. 2. The mid face. Many individuals lose the buccal fat pads along with a diffuse facial fat loss, collectively known as facial lipoatrophy. This leads to loose sagging skin of the cheeks and jaw line, deepening of the nasolabial folds, drooping of the corners of the mouth (marionette lines) and fullness of the lateral chin. The corrective approach is to restore lost volume of the mid face, thus lifting the skin sagging onto the lower face and in the process restoring normal contours to the cheeks, jaw line, nasolabial folds, and corners of the mouth and chin. Until recently, volume restoration of the mid face was principally done by either surgical implants, usually of silastic, or through fat transfer. With the recent approval of Sculptra, poly-L-lactic acid (New-fill in Europe), injection therapy to restore lost volume is now possible. Through a series of three to five injections at 4- to 6-week intervals, Sculptra is thought to promote neo-collagenesis, resulting in long lasting (up to 2 years) corrections. 3. The lower face. This area could also be termed the perioral region, where aging can be defined by wrinkles and atrophy of the lips, with surface creases along the naso-labial folds and at the junction of the inferior obicularis oris and mentalis. Together with creases at the corners of the mouth, the aging mouth is of paramount concern to many aesthetic clients. Correction consists of restoring lost volume to the lips and lifting out of surface creases circumferentially around the mouth. Elevation of the corners of the mouth can create not only a more youthful appearance, but one of less anger or frustration as well. In this area, filling agents such as hyaluronic acids (Hylaform, Restylane) and collagen (Cosmoplast) are ideal. Not only do they restore lost volume, they actually can be used to enhance pre-aging proportions, such as lip enhancement. Additionally, these products can correct surface wrinkles and crinkles. 4. The surface of the skin. After the three facial units are assessed and a treatment plan is put into place for volume correction and wrinkle reduction, the surface of the skin needs to be addressed. Usually, there will be some degree of surface photodamage ranging from a few areas of pigmentation and fine lines to total dyschromia/actinic bronzing with severe wrinkling. The treatment choices are obvious and traditional, including skin peels, which are usually very light in the concept of minimal down time. Microdermabrasion can serve as a viable alternative, as can other options, especially retinoids. Non-ablative lasers, IPL (with or without 5-aminolevulinic acid [Levulan], and Thermage can all play an important role in “global” repair of the skin surface and repair of laxity. Maintaining Results Finally, maintenance of results is critical to patient satisfaction. This is achieved in principally two ways. 1. Daily skincare regimen. Help establish a system of daily skin care that includes the mandatory use of sunscreen with other products based on desire, experience and budget. 2. Follow-up visits. Our aesthetic facility will contact patients on a regular basis at predetermined intervals to request follow-up photographs. During these visits, pre-treatment photographs are reviewed, and likely serve as a reminder as to how successful the program really was. Prior to these procedures, a careful assessment of the overall skin health is necessary. Are there any pre-cancerous or cancerous lesions present? Does excessive skin laxity and redundancy obviate the need for non surgical intervention and would a more traditional face-lifting procedure be more appropriate? Is the patient aware of the timeline nature of the procedures and the associated costs? An emerging opportunity Non-surgical total facial restoration is an emerging treatment paradigm, and it’s sure to quickly evolve with each new product or treatment introduced. The important concept is not so much which specific procedures you perform, rather it is being aware of the greater concept and embracing this rapidly developing cosmetic arena as a growth area for aesthetic dermatology practice. Dr. Werschler is an Associate Clinical Professor of Medicine and Dermatology at the University of Washington, and section chief of dermatology at Sacred Heart Medical Center, Spokane, WA.