Ideals in Aesthetic Medicine
This article is aimed at both Aesthetic Medical Professionals as well as Patients who may be interested in aesthetic medicine. I hope you find it interesting or at least not boring. Please feel free to give feedback here!
Introduction: (The Problem)
Over the last few years I have been invited to speak to doctors around the world on a variety of topics, but the most common subject I speak about is how to get the best results from your treatments. Initially I was surprised when I was asked to give these lectures, presentations and demonstrations because I assumed that everyone had a similar approach to my own and thought all our results would be fairly consistent and similar. However as time went on and I gave more and more of these sessions, and answered all the questions put to me by the audience, it became clear that the bulk of the doctors I was talking to all seemed to have the same basic problem with their treatments. All doctors had great techniques, and all had a very deep understanding of facial anatomy. Some had great understanding of patient expectations and psychology, and some were considerably more experienced than me, having performed two or three times as many treatments than I have. What I slowly figured out that they didn’t have, was an understanding of the concepts of aesthetics and beauty, and many didn’t have an understanding of the properties of the different devices and drugs that we use. They all were very knowledgeable in specific areas, but almost everyone had a few small gaps in the overall picture, so couldn’t put all the concepts together in an effective treatment plan.
How I Learned to Play The Guitar:
I started to learn the guitar in my teens. I taught myself to play stairway to heaven and under the bridge. I did this by getting the tablature and watching the bands play on a VCR over and over and over again. I can still play them and I’m really good at it. But unfortunately until recently I couldn’t really play anything else. I impressed all my friends and family by playing some amazing introductions but had to put the guitar away quickly before any one asked me to hammer out paradise city or ride the lightening!
Learning any new skill, whether it’s playing the guitar or aesthetic rejuvenation or scuba diving, just pick your favourite hobby, will require a fundamental grasp of a large number of basic concepts from which you can then progress your understanding onto the next level. Then you grasp all of the next level concepts which allow the next level of expertise to make sense. You won’t get differentiation unless you get calculus, and you won’t get calculus unless you get quadratic equations, and you won’t get quadratic equations unless you get algebra. You can’t understand supersymmetry unless you understand three dimensional coordinate geometry, and you won’t get that unless you get pythagorus equations, etc. etc. Your teachers at school were right and that is why you spend so much time in primary school memorising your multiplication tables. Aesthetic medicine is no different, yet we usually start off by teaching people how to inject toxins and fillers first, then expect them to learn all the rest for themselves later. Imagine if a child goes to it’s parent and say’s “Right, it’s time for me to learn to ride a bike” and the parent goes “Brilliant, first I’ll teach you how to pull a wheelie, and then we can start doing some stunts and I’ll get the unicycle out!” It’s obviously completely back to front.
p.s. I started taking guitar lessons a couple of years ago and unlearned everything I did before so I could start again from the basics. Unlearning stuff is much harder than learning it in the first place but now I can play anything you want to throw at me. My advice is to learn it all properly the first time around.
So now here we are. I’ve got to go and speak to a bunch of Doctors and Surgeons in the not too distant future, most of whom will have spent way more time in training than I have, will have passed more exams than me, have more letters after their names than me, written more papers than me, treated more patients and just generally are quite exceptionally intimidating. Someone has told them that I am an “expert worth listening to” and I’ve got to deliver the goods. In between videos and after getting bored with the in-flight shopping guide on a recent long haul I made a list of the few things that I think I could tell people that, in my humble opinion, may just make a difference to their practice. I start with the paint by numbers approach, which simply means getting good at something by following a set series of instructions over and over again until you have mastered said task. It’s great if you work in an assembly line and just make chairs, but you fall down when your boss asks you to make a bed. Our patients don’t all want big lips and flat foreheads so we need to change the way we approach the patients starting right at the beginning, Figure out the wrong bits of what we have mastered, and relearn. etc.etc. you get the idea.
How Not To Make Monkeys or Ducks (Thanks to Dr Heidi Waldorf for this gem!)
It’s not a paint by numbers approach! This should be obvious really. It’s medicine and medicine is complex, everyone is different. You can’t apply a simple pattern or the same treatment plan to every single patient because it just won’t work!
When I started training in aesthetic medicine in 2005 I attended a two day course and was shown how to use a form of botulinum toxin to treat three separate indications, frown lines, horizontal forehead lines and crows feet in one day. On the second day I was taught how to use a dermal filler to smooth out nasolabial lines and plump an upper lip. For the botulinum toxin treatments we had a series of landmarks on the face from which we would draw specific dots and inject in those areas. It went something like this. First inject 4 units perpendicular to the skin at a depth of 2 mm at a point 1cm above the eyebrow on the mid canthal line, next inject 4 units 1cm above the eyebrow at the mid pupillary line, next draw a line connecting the medial canthal to the medial head of the eyebrow on both sides and inject 4 units at the point at which the lines intersect. These instructions continued for all three areas of treatment and by and large got the same result in every patient. Now this approach actually only works in one specific sort of patient. Because not only does everyone have slightly different anatomy, different people have different expectations from treatment and will require a modification of approach to achieve their goals. The same goes for the lip treatments but on a much larger scale. Lips are incredibly complex and really difficult to treat well, and so so easy to treat badly. Learning just one technique based on the fashion at the time (larger upper lips) means that eventually everyone we treat ends up looking like a trout (duck lips / fish lips / chose your own favourite description here) And with nasolabial folds if we keep treating the nasolabial folds in the same way we eradicate the natural contour between the cheek and the upper lip. We’ve won because we’ve removed the crease, but we’ve lost big time because we’ve made our patients look like monkeys!
Oddly enough even though the above seems plainly obvious, almost all training in aesthetic medicine begins with this simple paint by numbers approach, and many of the larger companies who provide training in their products continue this tradition, even to the point of developing their own specific treatment plans specific to their treatments (Inject our product here, here, here, here and here and hey presto… you’ve made this patient look amazing!) The advantages of training this way are plain. We can get a large number of people performing procedures who may not yet understand the underlying nuances of the treatments they are doing, and use a lot of brand x whilst they are at it. But just like the botulinum toxin issue it isn’t the correct treatment for everyone and will often lead to disappointment. They key is to figure out which parts of which treatments work best for individual patients and do that.
There is more to it, naturally! There is something I call the practitioner school effect. This is something that happens because patients often attend different practitioners through the course of their lives, and invariably will compare the whole process from one practitioner to another. When they have been happy with Dr Smith down the road for the last 5 years, but then come to you because Dr Smith is on holiday then you have a difficult task ahead to convince the patient that you are just as good (or better) than Dr Smith. They already know that everything that Dr Smith does works perfectly, so when you do a procedure differently, or assess the patient differently the patient is quietly thinking “Dr Smith didn’t do this, He did it differently. Dr Smith is better than this guy, It’s not going to look right” The patient is unfortunately pre-programmed to expect the treatment to be substandard and is much more likely to return dissatisfied regardless of the aesthetic outcome. Both Dr Smith and the other practitioner may be very talented and skilled aesthetic practitioners but they may both have learned there techniques from different people, and therefore their approach will be different.
Two of my good friends and colleagues, Dr John Quinn and Dr Gertrude Huss, were once both on stage at the same time, performing a live demonstration of facial rejuvenation using botulinum toxins and dermal fillers. Both patients where actually quite similar in their aesthetic requirements and both ended up with excellent outcomes that they were extremely satisfied with, but interestingly the two side by side demonstrations demonstrated markedly different approaches to assessment and markedly different techniques when it came to injecting the face. Neither approach was a standardised “paint by numbers” treatment plan, rather they were based on a thorough understanding of the patients requirements and expectations, coupled with the practitioners considerable experience in a number of different techniques. In my discussions with the audience later on some of them felt a little confused by this, not sure which technique they should be using, having just seen two techniques where previously they were only ever shown one way of doing something. Later on I pointed them to Dr John Quinn’s interview for the conference video, where he sums it up succinctly “Just goes to show, there are many ways to skin a cat!”
My first piece of advice to any medical professional planning on a career in aesthetic medicine, or hoping to learn and develop their practice would be then not to concentrate on any one technique, not to focus on any one product, or focus too much on what one “expert” says. What we should all do when we start, and then continue to do as we develop is to get into the habit of finding out as many different ways of doing things as we can. My practice has developed over the years by reading about techniques, observing world class injectors and speaking to them about the reasons they chose to do things the way they do. I’ve seen implants injected in ways I would never have thought of doing myself with amazing outcomes and managed to incorporate many techniques into the way I perform procedures. No one person is correct or has all the right answers and no one person is simply “the best” so what we need to do is learn, understand, and become proficient in a wide variety of aesthetic medical procedures and take from it all the best bits that work for us to develop our own way of doing things.
When we teach in the Clinetix Training Academy, we don’t provide road maps, we teach applied anatomy and assessment, to give our students the knowledge required to develop specific and individual treatment plans. It’s a lot harder and takes more time, but it means that the doctors dentists and nurses we teach have the potential to progress to be exceptional aestheticians.
Successful aesthetic medical outcomes do not depend on learning a technical skill and repeating it over and over again. It depends on learning many technical skills, and being able to assess the specific requirements of the patient based on understanding of anatomy, product behaviour, assessment of the patient and consultation to determine their expectations. Once you get all that, pick up your guitar and be a rock star!
If you’ve got this far thanks for reading! Please feel free to feedback here, you can also use the link if you’d like to speak to anyone at Clinetix about our medical aesthetic rejuvenation treatments or our training courses.