Dr Manav Bawa shares a recommended protocol for assessing patients and providing aftercare to optimise their safety and results
A lot of my patients come to me seeking full-face rejuvenation treatments. This is a great approach to provide the overall lifting and revolumising that can really boost a patient’s confidence. However, treatment approaches like this can’t be seen as a quick fix.
Extensive pre- and post-treatment care is integral to make sure patients feel happy and comfortable while in clinic, as well as confident with their decision to continue with treatment. Patients should be safe and informed throughout their treatment process.
In my patient consultations, I use the MD Codes approach for assessment, which considers the patient’s emotional attributes.1 Developed by world-renowned aesthetic practitioner Dr Mauricio de Maio, the strategy aims to improve patient satisfaction by asking the patient to identify three out of the following eight emotional attributes that most closely align with how they feel before treatment. These are ‘I want to look’:
This is a great way to see what patients are seeking from their treatment because it isn’t overly complicated. I start to plan what areas I could treat to help with these expectations, while always being mindful of budget.
I then explore the possibility that patients may suffer from mental health conditions like body dysmorphic disorder (BDD) – an integral aspect of the consultation process in our specialty. I score the severity and impact from the patients’ opinions about themselves and then review how my professional opinion compares. I don’t use a particular questionnaire, instead I seek to clarify the severity and impact of their concerns through a variety of questions tailored to our conversation.
One option practitioners could use is five questions recommended by the National Institute for Health and Care Excellence (NICE), which entails asking patients the following:2
If I determine that they are not at risk, I move forward with my assessment. If, however, I believe they are at risk, I do not treat them and take time to explain that they may be suffering from BDD. I’ll detail what this is and highlight that treatment won’t necessarily make them feel better. I’ll then refer or signpost them back to their GP or a psychologist who could help. The most important thing is to ensure they understand the situation and get the necessary help they need instead of seeking treatment elsewhere.
A medical assessment is also crucial. I ask my patients if they have any known drug allergies, bee sting allergies, past medical or medicines history or social history that would have an impact on treatment.3 It’s also helpful to ascertain whether or not they have had aesthetic treatments before as this can affect their expectations.
I take front and profile photographs of each patient to document their results, and use anatomical diagrams to explain my assessment and suggested treatment plan. Using a structured approach, I look at the face as a whole, considering their facial shape, before breaking it down into the facial thirds – upper, middle and lower face. I then look at how concerns in each of these sections may impact each other, before examining concerns in certain areas. It’s also important to assess the face in animation, so I ask the patient to make a number of different facial expressions.
Finally, I review the patient’s skin quality so we can consider an action plan for improvement. Before starting my assessment, I’ll tell the patient exactly what I’m going to do, explaining that this will ensure I have a thorough understanding of their unique features and allow me to create a suitable and personalised treatment plan.
I’m proud that this case was the Winner of The Healthxchange Award for Best Non-Surgical Result at The Aesthetics Awards 2023.
My 63-year-old patient Karen was in need of a confidence boost after years of avoiding social events and feeling down about her ageing appearance, especially due to under-eye and temple hollowing, as well as jowling around her chin and jawline. In accordance with the MD Codes assessment, she wanted to look less saggy, less tired and younger.
After assessing her face myself, I noted she had both static and dynamic wrinkles in the upper face, temple volume loss and SOOF volume loss. There was also volume loss in her mid-face around the medial and lateral cheek areas, while nasolabial lines were noticeable. In the lower face, Karen had marionette lines, jowling, a labial mental crease and a loss of jawline definition. Her skin was dry and had lost its elasticity.
I decided to take a combination approach with botulinum toxin and dermal fillers. I used a combination of Juvéderm Voluma, Volift and Volux to treat the aforementioned facial areas to add volume and provide lift. After thorough consultation, the patient was happy to address everything in one session, so 8ml of dermal filler was used in the whole face to achieve the result. Finally, Botox was administered to the glabellar, frontalis and orbicularis oculi muscles to refresh the upper face.
Side effects and complications were avoided by adopting a strict aseptic technique. After treatment, we followed my standard post-procedure process. Two days post-treatment, Karen shared that she had felt safe and comfortable during treatment and was very happy with the outcome. I advised her that the results were expected to last 18-30 months.10 This treatment took place around 18 months ago and the results still look good. The patient is delighted, and her confidence has significantly improved.
I treated this 61-year-old male patient who had never had treatments before, but came to me concerned about his perceived tired and aged appearance affecting his confidence. This patient also cited wanting to look less saggy and younger.
I identified several factors that needed addressing, including temple hollowing, static forehead rhytids, the glabellar region and around the eyes. He had volume loss in his lateral and medial cheeks, leading to nasolabial lines and vertical lines on each cheek. He suffered with tear trough deformities and a labial mental crease. His skin was dehydrated with textural issues.
I created a bespoke treatment plan with six sessions administering 2-4ml of Juvéderm Vycross dermal filler per session every four weeks, as well as Botox at regular intervals. I spread the treatments out in this regard as I wanted to ensure he could get accustomed to his rejuvenated appearance through gradual enhancement. In terms of the procedures, I started with wrinkle relaxation and general mid-face restructuring, followed by temple rejuvenation and contouring in more superficial layers, finishing with improving the texture of the skin.
After all the sessions concluded, I made sure the patient understood all the required aftercare and potential complications, and emailed my full advice to him to ensure he was informed. I explained he would benefit from these results for 18-24 months.11 The patient did not have any side effects or complications and was really pleased with the results. He appreciated how natural and ‘well’ he looked, and his confidence has improved.
Our patient coordinator phones each patient 48 hours after their consultation to ensure they have understood everything and give them the opportunity to ask any further questions. More in-depth information on the procedure and a pre-care sheet is then sent over, which includes instructions to not wear makeup to the appointment, as well as detailing the products’ mechanisms of action, risks and our aftercare. When patients arrive at my clinic for treatment, they are reconsulted to solidify their aims and expectations. I talk through the risks and expected outcomes again, before obtaining written consent. All consent and other data is stored securely on our digital patient management system Pabau.
Patients’ hair is tied back when it’s time for treatment, and a head band applied. The face is thoroughly cleaned, first with a face wipe to ensure no makeup or sunscreen is present, before then using Clinisept+ to twice cleanse the skin. Finally, I mark my injection sites and use an alcohol wipe to each area just prior to every injection.
As with all aesthetic treatments, having protocols in place to prevent and manage adverse events is essential. In the case of dermal fillers, my complication prevention strategies include:5-7
If a complication was to occur, I’d ensure I adopt a compassionate and supportive approach. Active listening is essential to ensure we understand the impact of the adverse event on the patient, as is working with them to achieve the best outcome. Face-to-face review is essential, while explaining what has happened in a way they will understand will make a huge difference. Of course, if I was at fault, I would be honest and apologise to the patient while finding the best management solution. I follow both the Aesthetic Complications Expert (ACE) Group World and the Complications in Medical Aesthetic Collaborative (CMAC) protocols for complication prevention and management.7,8
After I finish injecting, I clean the face thoroughly and take time to ensure the patient feels okay. The ‘after’ photographs are then taken for the patients’ medical records (two weeks after treatment for toxin patients and one month for filler). These photos allow patients to see the difference for themselves, while giving us important medical records and marketing material if the patient allows. I advise them to follow the widely accepted parameters of avoiding alcohol, saunas and exercise for 24 hours to reduce the risk of swelling. To prevent product displacement, I also recommend they avoid massaging the treated areas for two weeks.
Next, I like to give patients a tinted SPF – I choose the Obagi Sun Shield Warm – to hide evidence of treatment and protect skin from photodamage and infection. Finally, I thoroughly document the treatment notes – including text and picture annotations of treatment doses and areas, product expiry dates and LOT numbers.
Follow-up appointments are booked, and I provide our contact number, including an emergency WhatsApp number, which is monitored by our patient coordinator, if necessary. I explain that if they have any concerns, they could get in touch at any time, even if it was just for some reassurance that everything is as it should be. In particular, I highlight that if they notice any changes in skin colour or are experiencing severe pain then they must contact us immediately.9 The aftercare instructions are also emailed out to each patient.
Two days later, our patient coordinator calls the patient to check their experience of treatment at our clinic was positive, and that they are happy with the results so far. I typically review patients at six-month intervals to repeat treatment a little at a time if necessary.
Performing a full-face rejuvenation comes with challenges – technically, you have to be confident in your treatment approach and understand how products can be used synergistically to achieve the best outcome for the patient. Following strategies such as the MD Codes comes with benefits, but having an artistic eye to enable you to tailor treatment is essential.
By being mindful of patients’ comfort, safety and satisfaction from the minute they step into the clinic door to our last follow-up appointment, we can do our utmost to provide them with the experience and outcome they deserve.
Receiving the Healthxchange Award for Best Non-Surgical Result 2023 was a great honour, showcasing my work to potential patients. I’m grateful to the judges for selecting me as the winner after reviewing all the entries.
If you’re considering entering The Aesthetics Awards 2024, I’d urge you to go for it! Taking part each year encourages me and my team reassess our practice and look for ways to continually improve and enhance our patient experience. Being a Finalist, and of course a Winner, has also given us great marketing opportunities and helps us stand out from the crowd.
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