Keywords

Introduction

The term cosmetics is a neologism adopted from the English language – cosmetic dermatology – considering that the cosmetic word in Brazil is related to aesthetics, cosmetic’s use, or beautician’s activity. In fact it is an area of dermatology dedicated to study and intervene in “unaesthetic” dermatosis in which treatments are completely grounded on scientific basis.

Dermatology is a visual art; cutaneous signs have a significant role in dermatological diseases and also in cosmetic dermatology. Careful observation of details and learning how and what to see beyond increase our medical assessment of patient’s complaints, making us better doctors in the field of cosmetic dermatology. For dermatologists, especially the ones who deal with beauty, knowledge and the study of art should be of great value to improve patient’s evaluation in clinical practice. It’s important to remember that sociocultural relations should be maintained when thinking, proposing, indicating, and performing cosmetic dermatological treatments and aesthetic procedures that interfere with the lines of facial expression and the natural appearance of the cosmetic patient.

The Consultation

The dermatologist who chooses to work in this area must have a great deal of knowledge in general medicine and dermatology; in other words, consultation in cosmetic dermatology can be the first contact of the patient with this specialty; thus dermatologist’s role in the anamnesis is to observe at physical examination the presence of suspicious skin lesions of cancer, advanced photoaging, as well as cutaneous manifestations of systemic diseases.

The consultation in cosmetic dermatology can be different from a consultation in any other medical specialty, but it is similar in many aspects. The relationship between the physician and the patient has always been and still is the successful key for coherent procedures without “overdoing” and leading to satisfaction on both sides. In cosmetic dermatology we must go beyond prescribing interventions or treating unsightly conditions; we need to provide a good guidance on prevention and maintenance of skin health, particularly in relation to cleansing, hydrating, and sun protection.

The most important pillar for building a successful relationship between physician and patient is the way the physician can value patient’s complaints. Often a relatively insignificant complaint may be of great annoyance to the patient. Knowing how to value patient’s complaints is an exercise that we should practice everyday. Since often what the patient verbalizes as a desire is only waiting for our sensitivity to capture what was not verbalized, it challenges us on how much we are prepared technically to help him or not.

It is already extensively known that there are two types of self-image: (1) the self-image we have within our subconscious and the image of how we interact with the outside world and (2) the other image we believe that others should have about us (Odo and Chichierchio 1998). So, these complaints that are frequently considered insignificant may represent the overflow of a low self-esteem, of social phobias, or even a distortion of the self-image. The physician at that time has a duty to be able to show to the patient what technically in fact makes the difference in his or her face and look out for worthy solutions to patient’s complaints, thus enhancing their self-esteem through an objective and technically relevant analysis.

The fundamental item for the success of cosmetics interventions always will be a good clinical indication (Coimbra et al. 2014).

The Anamnesis

A complete and well-directed anamnesis will be the greatest instrument for achieving this individual globally and the proper way to try to understand patient’s expectations regarding the final outcome.

It would be of major importance to know patient’s previous diseases, always making notes of all drugs already used or in use, any allergies, previous surgeries, and family history, asking about other previous aesthetic treatments, and investigating about products used and whether it was temporary or a permanent product, as well as the degree of satisfaction for the patient. It is also important to learn about patient’s lifestyle, outdoor works, sun habits, sunscreen use, inquiring about the ability to be absent from work or his daily routine, as well as to know about resources the patient can dispose on beauty treatments. One should be careful about the fears and anxieties of major interventions. All these aspects must be thoroughly assessed before performing any minimally invasive procedure.

The Physical Examination

The patient’s physical health also needs to be evaluated in this first contact prior to the possible proposed intervention (Monteiro 2010). Various procedures exclusively of aesthetic nature should be contraindicated in patients with bleeding and autoimmune disorders. It is extremely important to evaluate patients with a multidisciplinary approach, specially during some specific treatments like chemotherapy, for example.

The mental health assessment at the first consultation is a delicate matter and needs to be carefully accessed by the examining physician. It is extremely important to distinguish which procedures are well indicated to different individuals in the initial assessment of the cosmetic patient. The compulsion for aesthetic interventions is a frequent situation that dermatologists should deal with extreme caution. In fact, the physician cannot surrender to the eternal dissatisfaction of the patient, thus intervening in the aging process constantly and many times in an exaggerated and unnecessary way. Besides that, the cause of the real problem is not being accessed.

Patient Record

Recording all the information concerning the patient must be included in its medical report; this is the document with legal value for both patient and physician. It must include a detailed anamnesis, physical examination, laboratory test results, and all procedures performed. Apart from that it is wise to write down about the degree of patient’s satisfaction. It is a must to take photographs and to register the name and the batch number of the products used, in addition to medical prescriptions performed at each visit, including post-procedure consultations. A well-written patient consent form is of legal support for the medical professional as well as a valuable information for the patient. It is necessary to describe everything that the patient was told about, all the possible side effects of the procedure to be performed, possible risks, and potential complications that can occur during the treatment as well as possible duration of each effect. Post-procedural care also needs to be included in the patient consent form to avoid complications. This term must be signed by the patient with two copies: one for the patient and another for the professional.

Photographic Documentation: Before and After

Dermatology is a visual art and cutaneous images have an important role in general and cosmetic dermatology. In this context, digital photography becomes an important tool in the clinical practice when dealing with cosmetic patients (Monteiro 2011).

A proper record is extremely important for both patients and physicians. The photograph should be considered far beyond its documentary nature. A well-executed photograph, technically perfect and visually refined, is able to reveal precious information from the patient. Therefore, the medical documentation must be technically perfect and accurate; important objects and their details must all be in focus and sharp. It must be standardized and reproducible, with a clear picture of what was seen, with professional quality. Only then it can be considered of legal value.

The correct and standardized lighting is essential in particular, when it comes to photos intended for comparisons of “before” and “after” some cosmetic intervention. There is no value in comparing photos taken with different incidences of light or varying degrees of exposure.

It is by using this apparatus that the doctor and the patient can compare the area treated before and after the cosmetic procedure was performed. It is advisable that patient be informed by the doctor of individual characteristics that go unnoticed, so that they would not become an issue after the procedure was already performed.

The photographic materia l must always maintain the same standard in order to be used as a comparison: the distance between the patient and the camera has to be the same as well as the background; same angles and lighting must be maintained (Miot et al. 2006). It is recommended whenever possible to use the same equipment for all photographs taken for comparison purposes. Therefore, the offices designed for cosmetic dermatology should always include a special space or room, whenever possible, intended for this purpose.

What and When to Photograph

We should always remember to photograph our patients, for interventions with expected specific results, aesthetic frequent procedures, all treatments with possible complications such as scars, uncover potentially malignant lesions, and difficult cases, and also remember to photograph patients with potentially dangerous psychological profile or unstable. Those patients could have a nonrealistic expectation.

Patient’s Expectation Versus Possible Results

The patient who seeks the physician to perform cosmetic procedures demands an objective positive result from the cosmetic intervention that is exposed previously during the first consultation. In order to achieve the patient’s expectations regarding the cosmetic treatment and the possible outcome, it is necessary that the signs of facial aging have been thoroughly explained by the physician and fully understood by the patient. So we have to be sure that the patient understands the possible outcome we can provide and contemplate a more harmonious result individually. Undoubtedly the greatest tool we have against the frustrations of our cosmetic patients is the full and complete understanding of the dimensions and geometry of the face. We must have in mind that it is important to treat our patients globally, for them to see as themselves being more beautiful and younger after the intervention. Even without taking into account the financial aspect, a frustrated expectation from the patient would also be a frustration to its physician.

The Aging Process

Nowadays there is a world trend to consider the contour of the face as being the most important part for the aging process . The main idea is that, treating the face contour, the patient has the impression to have a more youthful and well-cared face. There are specific characteristics of the aging process that are unchangeable; thus we can manage with minimally invasive procedures to improve the geometry of the face but not to prevent the progression of the aging process. The great responsible for our aging is not the gravity but the absorption of our fat compartments, we shrivel up, and so the main face ends up with a “melted appearance” (Coimbra et al. 2014).

There are four main pillars of the cosmetic treatment that cosmetic dermatology can act in order to treat the aging process:

  1. 1.

    Skin treatment

  2. 2.

    Treatment of the muscles

  3. 3.

    Procedures to give bone support

  4. 4.

    Restoration of fat compartments

The main point that patient must understand when seeking for treatment for the aging process is that we cannot stop the natural evolution but we can treat and prevent this continuous process.

A good distinction between the light and the shadow zones of the face is the key for the best technique we can apply to mislead the aging process (Coleman and Grover 2006). All the concave structures provide a shadow zone in the aging face. So we look for interventions to let the face of the woman convex from the upper third to the lower third of the face. Yet in men, it is recommended to keep the straight lines and thus provide more aesthetically proportional faces to comply male beauty standards.

When we will propose a cosmetic intervention in the face of the patient, it is important to divide the face into three thirds: the forehead being the upper third, malar and zygomatic regions being the middle third, and chin and jaw regions being the lower third. The first action to be taken place is the intervention to give bone support and improve sustentation and laxity of the face, before thinking to erase any superficial groove.

With the advent of the idea of volumizing, nowadays interventions can last longer than in the past. The modern hyaluronic acids are designed to act exactly in restructuring face sustentation. They are lasting for longer periods of time, thus providing more aesthetically relevant and satisfactory results than just the old ones which were designed to fill the visible grooves without treating the cause of the aging appearance of the face.

Conclusion

In this special area within the dermatology, the cosmetics, our eyes cannot merely have a technical look. Our perception should not only be guided by science, though we must also have the ability of an artistic look (Shapiro and Rucker 2003). In addition to the scientific expertise, the physician must have the ability to artistically evaluate the patient and to evaluate which of those wrinkles belongs to patient’s self-image and what in fact can be treated without erasing the mirror of the emotions that the skin reflects.

Take-Home Messages

  • A complete and well-directed anamnesis is the best instrument to achieve all the information necessary to understand the patient globally.

  • Careful observation of details and learning how and what to see beyond increase our medical assessment of patient’s complaints and expectations.

  • It would be of major importance to know patient’s previous history (drugs used, any allergies, previous surgeries, family history, previous aesthetic treatment, degree of satisfaction).

  • It is important to learn about patient’s lifestyle: outdoor works, sun habits, sunscreen use, and ability to be absent from work and daily routine.

  • Dermatologists should know patient’s fears and anxieties about common interventions in cosmetic dermatology before performing any minimally invasive procedure.

  • Photography is an important tool in the clinical practice when dealing with cosmetic patients. A proper documentation of before and after procedures is extremely important for both patients and physicians.

Cross-References