Judy Akin Palmer, PhD, RN, CPSN, PHN
West Region Director, American Society of Plastic Surgery Nurses
Chair, Southern California Chapter American Society of Plastic Surgery Nurses
Newport Beach, California
Although practices vary from one office to another, the facial rejuvenation patient experience always begins when patients arrive at the office. Every staff member contributes to the patient experience, from the receptionist to the clinical staff, in making patients feel comfortable, helping them work through a treatment plan, and listening to their needs. For some patients, the plastic surgery nurse may perform all procedures, while for other patients, the nurse helps in prepare the patient for more extensive facial rejuvenation techniques and surgery. In all cases, the nurse provides the first and most thorough consultation to educate patients about the treatment process.
The Patient Interview
The patient interview is an important process that includes three phases: preparation, introduction, and interaction.
Preparation starts with the nurse, who needs to become familiar with each patient’s file before they sit down for the interview. The nurse should have current knowledge about facial rejuvenation products and procedures and have the most recent brochures at hand. The initial patient packet should contain the general health and skin health forms for patients to complete. These forms should be filled out in the waiting room prior to the consultation. Later, it is extremely helpful to go through the general health and skin health forms with patients, as there may be things they don’t understand or information they fail to provide that could affect their treatment outcome.
It is important for the nurse to appear friendly, and focus on each patient, regardless of what else is going on in the office. Introduce yourself and your role in the practice with an attitude that is confident and helps to elicit trust. Provide patients with contact information so they immediately know who to call if questions or concerns arise later. Set aside a place that is uncluttered and quiet where patients can talk with you privately. Above all, strive to make the initial experience calm and relaxing, as in that kind of atmosphere you are likely to gather more information from patients and they will feel more confident of the information being received in return.
At all times during the consultation, it is important to speak slowly, clearly, and concisely, while giving patients information they can understand and remember. You want to maintain a relaxed and confident manner to engage patients in sharing information that might otherwise be withheld. The information you learn here will help you design a treatment plan with each patient that meets his/her specific needs. It is important to find out what products and procedures patients are interested in and what their current level of understanding is about them, and then build on the existing knowledge.
Take a Complete History
As with any consultation, the more information you gather, the better. Make sure to have patients fill out the questionnaires and ask them about any incomplete or missing information. In addition to asking questions about their medical history regarding allergies, cold sores, pregnancy or breastfeeding, you should also inquire about previous treatment experiences, including inflammation or infection at a previous treatment site, and whether patients have undergone previous laser treatments or chemical peels.
After a general health assessment, perform an analysis of the condition of the skin. Document facial moles, lines, and scars, and discuss these with patients to make sure they are aware of them.
The aging process is certainly hard on the skin, which becomes thinner and drier, and naturally less supple over the years.2 Photoaging compounds the aging process as a result of long-term sun exposure, which can manifest in loss of translucency and elasticity, a sallow coloring, and the development of rhytids, lentigines, keratoses, and enlarged capillaries. Two scales provide very effective ways to document skin condition relative to aging and sun damage. These are the Fizpatrick Scale of Sun-Reactive Skin Types (Table 1), which classifies skin types according to skin pigmentation and known reaction to ultraviolet rays, and the Glogau photoaging scale, which provides an assessment of wrinkling and discoloration (Table 2).3-5 [DR. PALMER: COULD YOU ADD A SENTENCE OR TWO DESCRIBING HOW YOU USE THESE SCALES? FOR INSTANCE, HOW DO THE FINDINGS AFFECT THE OUTCOME OF PROCEDURES—EG, WILL PEOPLE WITH LIGHT SKIN BE AT RISK FOR MINIMAL ALTERATION IN PIGMENTATION, WHILE THOSE WITH DARKER SKIN BE AT GREATER RISK AS A RESULT OF UNDERGOING PROCEDURES? ALSO, CAN PEOPLE WITH HIGHER GLOGAU SCORES EXPECT GREATER BENEFITS THAN THOSE WITH LOWER SCORES?]
Table 1. Fitzpatrick Scale of Sun-Reactive Skin Types3,4
- Type Sun Reaction
- Type I Always burns, never tans, skin is extremely sun-sensitive
- Type II Usually burns easily, tans only minimally, skin is very sun-sensitive
- Type III Sometimes burns, but tans gradually to a light brown color, skin is sun- sensitive
- Type IV Burns a little, always tans to a moderate brown color, skin is minimally sun-sensitive
- Type V Rarely burns and tans easily and well, skin is not sun-sensitive
- Type VI Never burns, skin is deeply pigments and is sun-insensitive
Table 2. Glogau Scale of Photodamage5
|Skin Type†††||Age in Years†||Findings|
|I (mild)††||20s-30s†||Early photoaging. No wrinkling, discoloration, or keratoses.|
|II (moderate)†||30s-40s†||Early to moderate photoaging. Skin wrinkles with facial movements. Patient has fine lines near the eyes and mouth and no visible keratoses.|
|III (advanced)†||50 and over||Advanced photoaging. Patient has visible wrinkles all the time (even when the face is at rest), as well as noticeable discolorations and keratoses.|
|IV (severe)†||60 and over||Severe photoaging. Patient has visible wrinkles all over the skin, and skin may be a yellow or gray skin color, with multiple actinic keratoses and prior skin cancer|
Document Facial Asymmetry
No face is perfect, and slight asymmetries are common to us all. Sometimes patients may only notice an existing asymmetry after they have had a procedure done, at which point it is cause for dissatisfaction. It’s much better to help them see these irregularities beforehand, so they will be realistic about the results of their procedure and you can open a discussion of potential corrections for the problem as well.
To document facial asymmetry, have patients hold a mirror about 1 foot from the face and point out and document any asymmetries you find. Take photos to clearly note them.
The final discussion in the consultation involves preparing patients on what to expect after the procedure. With injectable fillers, the concept of full correction is one that is usually only achieved over multiple visits with use of several syringes of product. Some patients come in and want to try one syringe in one area, and then are disappointed to find that it is not enough to make the change they were seeking. You might explain that the first injectable treatment sets the ground work and more product may be needed closer to the surface to further correct the defect and achieve their goals. For full correction, they may need a touch up in 2-4 weeks. Suggest that it is a good idea to book that appointment before they leave the office today. Some practices apply a cost reduction to the next syringe if it is scheduled within 4-6 weeks.
Table 3 highlights the types of products that are used in different regions of the face. Make sure patients understand what products are best suited to their needs and how many syringes they will likely need to achieve a full correction.
Table 3. Injectable Treatments by Facial Region
|Region||Description||Usually Treated with|
|Upper third||Brow to glabella||Botulinum toxin type A (Botox CosmeticÆ)|
|Midface region||Glabella to nasal base (where nasal septum and upper lip meet)||Fillers with or without Botox Æ|
|Lower third||Nasal height to chin||Fillers with or without BotoxÆ|
Explain Basic Post-Injection Instructions
Patients also need to be told in advance about the accommodations they should make in the days and weeks after their procedure and the reactions they might experience, which they may want to consider when scheduling their appointment (Table 4).
Table 4. Post-Injection Instructions
- Avoid excessive facial expressions/strenuous exercise for 4 hours after your treatment
- Do not rub/massage the area for 24 hours
- Redness/swelling may last for 1-2 days
- Temporary bruising may require make-up to cover
- Avoid extreme heat or cold for 2 weeks
- Take only acetaminophen for discomfort.
- A follow-up treatment 2-4 weeks after the initial treatment may be necessary to optimize the results
Closing the Consultation
After making sure patients understand everything they have been told, and giving them the opportunity to ask questions, you will want to finish with a discussion of consent forms. Detailed consent forms for each product used will need to be signed before any procedure can begin. Patients should read the brochures you have provided on each product and then the consent form for that product, which will detail any risks involved. When patients returns for the procedure, review the consent forms with them again.
Before you close the consultation, conduct a final review of the paperwork, and then bring patients to the plastic surgeon so a treatment plan can be devised.
1. Vedamurthy M. Standard guidelines for the use of dermal fillers. Indian J Dermatol Venereol Lefrol. 2008;74:S23-S27.
Available at: http://www.ncbi.nlm.nih.gov/sites/entrez?
2. Holck DE, Ng JD. Facial skin rejuvenation. Curr Opin Ophthalmol. 2003;14:246-252.
Available at: http://www.ncbi.nlm.nih.gov/pubmed/14502051?
3. Shoshani D, Markovitz E, Monstrey SJ, et al. The modified Fitzpatrick wrinkle scale: A clinical validated measurement tool for nasolabial wrinkle severity assessment. Dermatol Surg. 2008;34 (Suppl 1):S85-91.
Available at: http://www.ncbi.nlm.nih.gov/pubmed/18547187?
4. Fitzpatrick TB. The validity and practicality of sun-reactive skin types I through VI. Arch Dermatol. 1988;124:869-871.
Available at: http://www.ncbi.nlm.nih.gov/sites/entrez?
5. Glogau RG. Aesthetic and anatomic analysis of the aging skin. Semin Cutan Med Surg. 1996;15:134-138. Available at†: http://www.ncbi.nlm.nih.gov/pubmed/8948530?