Clinical Practise in Aesthetic Dermatology

• Consultation

  Essential to establish a relationship between the patient and doctor, should be done in a comfortable setting
• Differences between Aesthetic Consultation and Classic Medical Consultation

  • Patient condition: Well vs diseases / suffering
  • Motivation
  • Expectations
  • Elective vs medical purpose
  • Financial consideration
• Medical Consultation

  Patient seeking for diagnosis and treatment for their health / skin problems
• Aesthetic Consultation

  Patient seeking for an improvement to their general appearance
• Initial consultation cannot be rushed, allow patient to ask questions freely, educate patient by giving adequate information
• Aesthetic treatments are elective, not for medical purpose
• Obtain informed consent before treatment, proper documentations, medical photography
• Initiating The Session

  1. Greet patient by name

  2. Introduce yourself

  3. Demonstrate interest and respect for patient's comfort

  4. Identify reasons for consultation
• History Taking

  • Patient biodata
  • Chief complaints
  • History of presenting complains
  • Past aesthetic history
  • Review of systems: Skin disease, autoimmune, infectious disease, neuromuscular disease (myasthenia gravis)
  • Past medical history
  • Past surgical history
  • Drug history: Vitamin deficiency (C, A, zinc), Aspirin
  • Allergy history: Topical products, anaesthetic products, aesthetic products
  • Social history: Smoker, alcohol, outdoor sun exposure, diet, exercise, occupation, pregnancy & breastfeeding, hobby, friends circle, lifestyle
  • Family history
  • Psychiatric history
• 7 Key Questions for Skin Lesions

  • When?
  • Where?
  • Does it itch or hurt?
  • Spread?
  • Change?
  • Triggering factors?
  • Previous treatment?
• Physical Examination

  • Examine target organs directly - skin, nails, hairs, mucous membrane
  • Appearance of the patient - Well, uncomfortable, toxic looking
  • Vital signs - BP, PR, temperature
• Physical Examination - Aesthetic Aspect

  Generally, 2 groups of patients: 1) Those who point out one particular feature they dislike, 2) Those who are dissatisfied with overall appearance
• Main tool for physical examination in aesthetic aspect is the Mirror
• Visual Assessment

  • Skin complexion & texture
  • Structural features: Soft tissue volume, Bony proportions, Symmetry, Dynamic facial expression
  • Views: Full frontal, 45 degree left and right side, Lateral left and right side
• Visual Assessment

  • Fitzpatrick skin type
  • Glogau classification of photoaging
  • Wrinkles evaluation
  • Any skin conditions and surface findings
  • Any skin rashes, active infection, inflammation
• Fitzpatrick Skin Type

  Fitzpatrick I, II, III generally tolerate aggressive treatments, lower risk of hyper- or hypo- pigmentations. Fitzpatrick IV, V, VI have greater risk of hyper- or hypo- pigmentations, suitable for more conservative treatments.
• Glogau Classification of Photoaging

  Classifies photoaging into 4 types based on degree of wrinkling, pigmentary changes, telangiectasia, and actinic keratoses
• Wrinkle Evaluation

  • Puckering of skin around the mouth
  • UV damage - degeneration of elastic fibers, forming folds
  • Dynamic wrinkles from facial expression
  • Lines caused by subcutaneous tissue atrophy
  • Lines caused by gravity
  • Sleeping lines
• Skin Conditions & Surface Findings

  • Redness - rash, inflammation, vascular
  • Pigmentary changes - epidermal, dermal, nevus
  • Bluish discoloration - reduced Hb or O2 levels (lung disorders)
  • Yellowish discoloration - liver disease, carotenoid
  • Dry skin
  • Moist, clammy skin
  • Oily skin
• Skin Lesions

  • Type of lesion
  • Colour
  • Shape
  • Margination
  • Surface features
  • Areas involved
  • Consistency
• Skin Lesions

  • Distribution of rash
  • Morphology
  • Symmetrical or asymmetrical
  • Flexural or extensor aspect
  • Dermatomal
  • Acral
  • Photoexposed sites
  • Other body sites: Scalp, nails, hair, oral mucosa, skin folds
• Other Skin Findings

  • Telangiectasia
  • Petechiae
  • Purpura
  • Ecchymosis
  • Specific dermatological signs: Auspitz's sign, Darier's sign, Nikolsky sign, Dermatographism, Koebner phenomenon
• Other Body Sites

  • Scalp
  • Nails and web-spaces
  • Hairs
  • Oral mucosa
  • Skin folds
• Tools for Bedside Skin Examination

  • Ruler
  • Torch light
  • Magnification with hand lens
  • Wood's lamp
  • Diascopy
  • Dermoscopy
• Manual Examination

  • Palpation: on targeted structure, at rest, upon movement
  • Skin "Snap Test": Elasticity / laxity / hydration, Speed of skin to snap back to original state after being grasped for few seconds
  • Palpation: Surface texture, skin turgor, thickness, Volume assessment, Wrinkle assessment, Palpation during procedure
• Investigation in Dermatology

  • Skin swab
  • Skin scraping
  • Blister fluid aspiration
  • Skin biopsy
• Investigation in Aesthetics

  • No specific investigations listed
• Treatment Plan

  • Single or multiple treatments
  • Patient seeking for short term or long-lasting results
  • Downtime tolerance
  • Potential risk that patient can accept
  • Patient's financial consideration
• Final Decision: Patient's wishes (provided no contraindication, understood all available options, risks vs benefits), Doctor's proposed treatment plan based on professional assessment, Once agreeable - Consent Form - Proceed for treatment
• Elasticity / laxity / hydration

  Speed of skin to snap back to original state after being grasped for few seconds
• Palpation

  • Surface texture, skin turgor, thickness: dry, coarse, oily
  • Volume assessment
  • Wrinkle assessment
  • Palpation during procedure
• Assess

  • Bony landmark
  • Needle position and orientation to ensure accurate injection
  • Injected amount
• Informed Consent

  Process in which a patient learns and understands the purpose, benefits, and potential risks of an aesthetic procedure and then voluntary and thoughtfully agrees to receive the recommended procedure
• Informed Consent

  • Verbal and written
  • Treatment options - pros & cons of each option
  • FDA approved or off label uses
  • Potential associated adverse events or complications
  • Realistic expectations
  • Downtime, compliance to post treatment care
  • Expected duration of the clinical outcome
  • Long term strategy
  • Financial implications
• Consent

  • Voluntary acquiescence by a person to the proposal of another
  • Permission for something to happen or agreement to do something
  • Good medical practice – It's the law!
• Types of consent

  • Implied
  • Expressed
  • Informed
  • Valid
  • Verbal
  • Non-verbal
• Implied Consent

  A form of consent which is not expressly granted by a person, but rather inferred from a person's actions, and the facts and circumstances of a particular situation (or, in some cases, by a person's silence or inaction)
• Expressed Consent

  May be in oral, non-verbal or written form and is clearly and unmistakably stated
• Informed Consent

  Can be said to have been given based upon a clear appreciation and understanding of the facts, implications, and future consequences of an action. In order to give informed consent, the person concerned must have adequate reasoning capacity and be in possession of all relevant facts at the time consent is given.
• Valid Consent

  Can be defined as the voluntary agreement by an individual to a proposed procedure, given after appropriate and reliable information about the procedure, including the potential risks and benefits, has been conveyed to the individual.