Dr Raj Acquilla shares his concept for successful patient consultations and presents a case study using multiple treatment sessions
This article will take you through a journey of how to assess your patients’ multiple needs and detail the importance of taking into consideration the mood and health perception of your patients, and the fourth dimension; expression and communication with other people.This is ultimately what we’re trying to optimise at the highest level to improve our patients’ lives.
Discover your patient
To generate higher levels of satisfaction, the first conversation with our patients should be about finding out who they are. This includes not only their age, but what they do for a job, what their relationship status is, and what they are hoping to achieve in life. How we inject our patients should relate to them personally, so during the consultation it is really important to get to know them.
For example, do they want to look innocent, or do they want to have a more edgy/ dangerous side to them? Greater structure generates higher degrees of impact, which I believe in some individuals may potentially influence a higher level of perceived power, danger and dominance.1,2 It can be a big mistake to make someone look more dangerous and edgy if it does not fit with their role in life and work. A primary school teacher, for example, may be better suited to an innocent and cute look to relate to her young students, whereas a company CEO might want a look that suggests power and firmness.
Taking this approach during the consultation is highly effective; for the first time you are making aesthetic medicine about life, not beauty. For example, when patients come in saying they want 1ml in their lips, having typically seen something on social media that makes them believe they need this volume in this particular area, being confident in explaining why this isn’t suitable and how you can offer a better result, personalised to them, will make you stand out from the crowd. This will help you build a loyal database of patients who respect your unique approach.
Of course, we have a responsibility both clinically and ethically to make sure these impressionable men and women are guided in the right direction. We have to educate and guide our patients within the consultation to what is truly achievable. In my clinic I have a very clear policy when it comes to injectables; I will always take a bespoke full face approach. This creates somewhat of a filtering system in that individuals who enquire and are simply price hunting for a single syringe or treatment area will not book themselves in for a consultation, or I will politely say that I am not the practitioner for them.
However, if people come to us and they are able to get past the questions around cost into a quality discussion, it means every consultation is an opportunity for us to educate the patient. This is particularly relevant for young patients to ensure we set a positive impression of medical aesthetics moving forward. We need to give quality and uncompromising excellence through effective assessment, rather than our focus being on making money.
Four parameters of assessment
When assessing patients, we need to utilise a logical and objective approach to identify what they are seeking, along with what you believe they need to achieve this, according to your clinical judgement and aesthetic eye. We can then find the solutions to make them the best version of themselves. Some of the symptoms that we want to work on are to try and correct emotional deficiencies that we perceive in the face, but also any health-related parameters like the appearance of stress or tiredness. It is my view that it’s our responsibility to identify all these factors in the patient’s face during the consultation.
We look at the face in totality, dealing with four aspects of correction: mood, health, anger and sagging, while also considering how best to beautify the patient’s face, which is largely based on the relationship of light and shade.
So, the confluence of light and shade, the unification of facial compartments, and also making our female patient look feminine and the male patient look masculine (if that is their desire, of course) by adhering to simple guidance with geometry of angles, ratios and proportions. This will be discussed in more detail in my next article to be published in the Aesthetics journal.
In my experience, the way to achieve the best results is to influence facial muscles, which impact facial expression, through myomodulation of depressor muscles. The concept of myomodulation has been discussed on p.23.3
Different expressions are caused by different muscles. Signs of happiness, for example, are not apparent just from the mouth through a smile, they also come from the eyes. As we age, we start to see negative facial vectors,4,5 which generally make patients look sad, moody, tired and can influence increased perception of stress and meanness.
When assessing a patient’s face you need to know not just which muscles impact dynamism in the face and therefore facial expression, but, most importantly, where the origin of the muscle is and where the insertion point lies. When we inject patients, we inhibit the hyperdynamism of the depressor muscle using myomodulation and therefore promote the paradoxical activity of the elevators.3,6
During the consultation it is important to educate the patient on how we have achieved the result to elevate nerves. This is not just important in any consultation to ensure the patient understands the treatment, but to also re-enforce that you are an expert within the field.
Working through the symptoms of mood and health disturbance systematically, we can then find the solutions and link that with an injection strategy or a treatment plan, which is associated with specific products, depths, quantities and mechanism of action. Through a careful strategy involving projection and uniting facial compartments, we can generate great results with a low volume of product.
Objective aesthetic scores
I use my own scoring system to help manage patient expectations and communicate my treatment plan to the patient. I firstly ask the patient to give themselves an aesthetic score out of 10. I then perform my own assessment, identifying the number of injection points I believe they require to get them to a 10, which is the best version of themselves. Of course, the number of injection points vary from patient to patient.
I aim to derive an objective aesthetic score for the patient by removing 0.1 for every correction point that they require. Therefore, I calculate my own aesthetic score by subtracting the number of injection points required for optimum aesthetic outcomes (0.1 for every correction point) from 10, exemplified below. This generates very clear end points if we use the right products, the right technique, the right depth and the right amounts, but we need to have the treatment plan from the assessment to be able to achieve thi.
Case study: 40-year-old woman
For this 40-year-old patient I identified several factors that needed addressing, such as hollows in the forehead, temple, cheek, tear trough and mid-cheek groove, a loss of definition in the mandible and a loss of projection of the chin and labial mental crease. She had soft tissue deficit of the nasolabial fold and crease, as well as skin textural issues (Figure 1). As detailed above, I aim to remove a score of 0.1 for every correction point. I identified 19 points in total that would need addressing, so in my assessment tool, we deduct 1.9 from 10 giving an aesthetic score of 8.1. I would say that 19 is actually quite a high number for someone of this age; usually for young, beautiful patients there may only be four points, and with those older there could be around 24, but again it’s very bespoke to each individual patient. In concept, I can then take her from 8.1 to 10 by executing the 19 points (Figure 2). However, if the patient needs 19 points to get to a 10 then that’s going to be expensive because it takes a lot of product and is going to involve a lot of injections. It’s not realistic to do all of that in one treatment session, so we explain in the consultation that we are going to break it down over several sessions according to structure, soft tissue correction, and then into textural considerations and refinement. If agreed, the next part of the consultation is to talk the patient through the technical strategy, outlined below.
For my treatment approach, I recommend that practitioners inject the products with the highest molecular weight for deep structural improvements first, then follow through your range in descending order to the more superficial areas.
Note that this patient was treated live at an international conference in one treatment session, however optimally, each session should be spaced one month apart as this amount of time allows for good tissue integration and also helps with patient finances.
Session 1 – structural
First of all, I aimed to treat the underlining support structures, which will involve deep injections down to bone with a needle. In my opinion, you need to use a product with a high G-prime and lift capacity. For this patient, I used Juvéderm Voluma in the temple and the cheekbone. Then, Juvéderm Volux was used for the angle of the jaw, pre jowl sulcus, the lateral labiomental crease and the chin.
Session 2 – contouring
The next stage is to achieve contouring, which will involve injections into subcutaneous fat. The product of choice here needs to be softer, so I chose Juvéderm Volift to address the nasolabial fold and labiomental crease.
Session 3 – refinement and texturising This session looks to improve skin texture and refine the results previously achieved. For this patient, I injected to the bone in the forehead, in the tear trough, the lateral lid cheek junction and also in the lip using Juvéderm Volbella. I then moved to texturising using very small quantities of Juvéderm Volite in the subcutaneous tissue for the perioral lines, the lower cheek and also those fine, feathery lines that we see in the chin.
Summary
The type of changes seen in this case study are usually life-changing for the patients who previously could not imagine results like these could be achieved with injections alone. A good consultation is the key to optimising your practice for longevity so that you have life-long partnerships with your patients, rather than a ‘revolving door’ relationship where a patient comes in, has a commoditised treatment and walks straight out, because ultimately they can get it cheaper down the road.
Full facial harmony and balance which makes our patients look and feel healthier, rested, fresh, happier and more beautiful means they will always keep coming back.
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