What should you do when the patient wants surgical results without surgery?

I am interested in Botox® and microdermabrasion,” said a middle-aged East Indian woman to me the other day during a consultation.

“What concerns do you have about your appearance?” I earnestly replied.

She then proceeded to grab her large jowls between her fingers, and pulling them outward, exclaimed, “I hate these things! Botox and microdermabrasion will take care of them, right?”

To this I answered, “I’m sorry, Ms Ramesh [not her real name]. The only way to effectively treat the loose skin and muscle of your jowls is by surgery, such as a facelift.”

To this she gave the all-too-familiar-to-plastic-surgeons “deer in the headlights” look and replied, “Facelift?! I am not interested in surgery. I see ads all the time that say that I can look 20 years younger without surgery using things like Botox, microdermabrasion, and anti-aging creams.” She then grabbed her jowls again and repeated, “Botox will tighten all this skin up, right?”

The increasing popularity of nonsurgical aesthetic treatments that are performed in physicians’ offices is both a blessing and a burden to most aesthetic plastic surgeons. Every day, prospective patients are bombarded with advertisements in the local and national media from the latest company to put out new nonsurgical technique designed to approximate a surgical result. From radiofrequency devices to skin creams to intense pulsed light to mesotherapy, the public is constantly inundated with the next substitute for the facelift.

Confusion Reigns

Unfortunately, we as physicians don’t do a good job of clarifying this for the public. This is exemplified by an ad in my local newspaper by a “board-certified physician” (actually an internist) whose cluttered ads hawk everything from lip fillers to fat injections to mesotherapy to threadlifts to laser treatments to sclerotherapy to microdermabrasion. With all of the services and claims publicized by physicians and companies, it’s no wonder that patients like Ms Ramesh get confused about which procedure can get them the results they want.

Although as plastic surgeons, we are accustomed to wielding a scalpel during our work, the use of nonsurgical modalities has become a necessary element in any well-rounded aesthetic plastic surgery practice. As with the case of Ms Ramesh, I have been astounded by the number of patients who consult with me who have facial-aging concerns but are not interested in having any type of surgery.

Sometimes I wonder why in the world they go to a surgeon if they don’t want surgery. The plethora of plastic surgeons’ ads that tout nonsurgical treatments (including my ads, I must admit) is the most likely cause.

Nevertheless, I have found that offering some of these nonsurgical treatments can be a very valuable adjunct to my practice, especially as a bridging tool to allow patients to become comfortable with me, my office, and plastic surgery in general. Often, patients will slowly graduate from less-invasive treatments (such as peels and medical-grade skin care) to more invasive treatments (such as facelifts and facial fat grafting) as they become more comfortable with plastic surgery in general.

A Useful Strategy

In addition, I have found that offering nonsurgical treatments can also help me avoid completely rejecting a prospective surgery patient whose psychological state is questionable. At this point in my young career, I turn down approximately 20% to 25% of the patients who come in for aesthetic surgery consultations. The majority of these patients are not good candidates because of unrealistic expectations of the result they can achieve or of the recovery associated with the surgery.

There are also the occasional patients whom I suspect of having psychological issues, but I don’t know for sure. Often, instead of completely turning them down for plastic surgery, I have referred them for less-invasive treatments, allowing me time to get to know them better. Within a few weeks, some patients turn out to be model citizens, whereas others eventually reveal their unstable side.

I recall one patient whom I saw for a facelift consultation and was a bit concerned about her affect. I subsequently flagged her chart for reconsideration in case she signed up for surgery, and proceeded to discuss skin care with her. She ended up purchasing a set of medical-grade skin products, including tretinoin and prescription-strength vitamin C.

Later that evening, she found the same group of products for sale by a irreputable company on the Internet for $100 less than she paid me. The next morning, she sent my office a fax demanding a refund of $100, or else she would never consider having surgery by me. Needless to say, I did not refund her the money and no longer had any desire to operate on her.

No Regrets

One of my mentors, Bradley Bengtson, MD, has always said, “You never regret a decision not to operate on someone.” I’ve found this dictum to be true, and I try to keep it in mind during consultations every day. It has probably saved me from many uncomfortable situations.

Whereas nonsurgical aesthetic treatments may not offer surgical results, I do believe that they are a very valuable adjunct to the well-rounded aesthetic plastic surgery practice—especially the growing practice. Not only do they add another dimension to the practice, but they also serve as a valuable tool for keeping patients coming back to the office. They continually remind the patient that surgery is an option and allow the surgeon to get to know his or her patients better. PSP

Anthony Youn, MD,is a plastic surgeon in private practice in Rochester Hills, Mich. He can be reached at (248) 650-1900 or [email protected] Megan Callahan is a freelance writer in Rochester, Mich.