- Email: [email protected]
Establishing a cosmetic surgery practice: an algorithm to management of the cosmetic surgery patient in your practice
Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 253–260
Establishing a cosmetic surgery practice: an algorithm to management of the cosmetic surgery patient in your practice Scott L. Bolding, DDS, MS* Department of Oral and Maxillofacial Surgery, Private Practice, Fayetteville, AR 72701, USA
Oral and maxillofacial surgery has celebrated a significant history with many advancements over the years. Although many believe that cosmetic surgery is a relatively new facet of the specialty of oral and maxillofacial surgery, a careful review of the history of oral and maxillofacial surgery reveals that facial aesthetic surgery has been involved since the beginning of our specialty. The art of oral and maxillofacial surgery began in dental school. We learned the beginning of facial aesthetics and harmony in our dental training. During our surgical residency we also had to understand the aesthetic balances of the face to participate in areas such as trauma reconstruction, orthognathic surgery, and dentoalveolar surgery. Cosmetic handling of the tissues of the head and neck regions are a natural part of our surgical history, and cosmetic surgery should be considered as an essential part of our specialty. Recently, oral and maxillofacial surgeons have begun to provide more cosmetic facial surgical procedures in their practices. Incorporating cosmetic surgery into one’s surgical discipline requires that the surgeon not only understand the surgical principals but also make proper decisions regarding his or her approach to the cosmetic surgical need of each patient. As with any surgical procedure, application in its appropriate form requires an intimate understanding of risks and benefits involved. Training in the discipline of cosmetic surgery is essential.
Training As an oral and maxillofacial surgeon in the United States, the American Dental Association mandates your training requirements. A minimum number of requirements must be qualified for one to become an oral and maxillofacial surgeon. As you finish your residency program, you soon learn that your education is only beginning. Many of the residency programs currently offer extensive training in facial cosmetic surgery. However, other programs only provide a light exposure to the area of facial cosmetic surgery. If this is the case, additional training must be obtained before electing to offer cosmetic surgery within your practice. This is not unique to oral and maxillofacial surgery, because many surgical disciplines vary in the amount of cosmetic surgery to which residents are exposed. Currently many fellowships are available after completion of an oral and maxillofacial residency program. Some of these programs provide extensive training only in head and neck cosmetic surgery, whereas others also offer training in full body cosmetic procedures. The training programs are typically 1- to 2-year post-residency fellowships. The key to obtaining proper training is to ensure that one has complete exposure, not only to the surgical techniques * 2926 West Huntsville Avenue, Springdale, AR 72762. E-mail address: [email protected] 1061-3315/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.cxom.2004.04.004
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S.L. Bolding / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 253–260
but also to the work-up and follow-up of patients. It is difficult for anyone to learn cosmetic surgery or any surgical technique during a weekend course. I recommend that all surgeons who want to become masters in the art of cosmetic surgery spend many hours studying and reading. One-on-one fellowship-type training with surgical mentors also is a good idea so that you have a good understanding of the surgical procedures that you will provide for your patients. Each training program must be evaluated carefully, because each surgeon has different approaches to types of training. Each surgeon’s personality varies, and certain individuals with different talents may require more training or may require less training than others. I recommend that you take the advice of your mentor in determining whether you are ready to proceed on your own. If you are not ready to proceed on your own with a particular technique, I recommend seeking out additional experience in either a fellowship format or spending time in a cosmetic surgeon’s office or hospital setting before initiating these cosmetic surgical procedures on your own. After several years in practice, some of my own personal observations have been that one must continually practice a particular procedure to be competent in offering that procedure to patients. In the area of cosmetic surgery, there is much finesse and understanding of the facial anatomy and surgical planes that must be continually thought through as one proceeds with a surgical technique. If an individual surgeon has limited knowledge or experience in this area and then proceeds with a surgical technique on a fairly infrequent basis, this could lead to a less desirable result. As with anything we do in life—such as riding a bicycle, flying an airplane, swinging a golf club, or hitting a tennis ball—we must practice those procedures frequently to be fully competent. As surgeons, we must understand that for us to offer cosmetic surgical procedures to our patients or any particular technique within our discipline, we must offer it on a fairly frequent basis or ask for help from another colleague. I believe it shows a much better sign of maturity to ask for help than try to proceed with a large ego and potentially have an unfavorable outcome. I believe that training is essential, but facial cosmetic surgery must be performed on a routine basis to offer this to your patients.
Office setting A cosmetic surgery patient is different than a medically ill patient who comes to your office for a cure for a disease or for evaluation of a tumor. A cosmetic surgery patient seeks your assistance to help improve his or her quality of life and not quantity of life. A cosmetic surgery patient seeks your assistance purely on an elective basis. Often a cosmetic surgery patient believes a surgical technique will improve his or her appearance and seeks advice from you for this particular procedure. To offer cosmetic surgery within your practice, your facility must be designed so that it provides a statement as to your attention to detail. I believe if you are going to offer cosmetic surgery to your patients, you must have a well-designed and aesthetically pleasing office setting to attract the type of patients who would seek cosmetic surgery (Fig. 1A, B). Many surgeons have tried to offer cosmetic surgery to their community, but because they had an older office that was poorly lit with unpleasant surroundings, many patients did not seek that particular surgeon. The appearance of an office may reflect a disdainful taste to the patient regardless of the surgeon’s ability in a particular area of cosmetic surgery. An anesthetically pleasing and non-sterile setting is important in the area of cosmetic surgery, as with any other areas of oral and maxillofacial surgery. The waiting room and reception area must greet each patient with an inviting personal touch. The environment should be quiet and private so that each patient is treated in a discreet manner and confidentiality is maintained for each patient. The waiting room should be designed so that each patient has a sense of privacy. Postoperative patients especially should have a separate waiting area or separate entrance so that their identity can remain discreet. Few cosmetic surgery patients want other patients to see their results until the healing has been completed. Office design is important in regard to maintaining the confidentiality of patients.
S.L. Bolding / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 253–260
255
Fig. 1. Operating room. (A) Surgical procedure performed by Scott Bolding with assistants, Tara Hammarstrom, Dennis Champagne, and Julie Hodkin. (B) Anesthesia administered by anesthesiologist, Dr. Bill Beck.
The consultation room for the cosmetic surgery patient should be non-threatening (Fig. 2). Many surgeons try to perform cosmetic surgical evaluations in an examination chair or in a procedure room, which is sometimes threatening to a patient. I recommend that all cosmetic surgery consultations be performed in a nice, non-threatening setting with several mirrors available to discuss the particular areas of concern for the patient. The consultation room should be well lit and offer many educational materials regarding a particular technique. I also recommend having a series of before-and-after photographs of patients. Consents must be obtained from a patient if he or she is going to be used to demonstrate to other patients. We
Fig. 2. Consultation room.
256
S.L. Bolding / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 253–260
have found that before the consultation, taking initial photographs of the patient to discuss during the consultation is helpful in seeing the affected areas that are of a concern to the patient. Video imaging also can be used to simulate facial changes that may be possible with certain particular surgical techniques. Three-dimensional images are currently available on the Internet that may improve imaging capability. During the consultation, it is important that the surgeon listen to a patient regarding the desires that the patient has about treatment. It is essential that the cosmetic facial surgeon be aware of all underlying imbalances or deformities that may create the overall unaesthetic appearance to the patient. Sometimes it is wiser to spend more time informing the patient of the underlying problems associated with a particular need than to explain the overall treatments. As oral and maxillofacial surgeons, it is essential that we understand the underlying deformities that may create facial imbalances. As a cosmetic surgeon, it is your responsibility to determine if a surgical procedure will benefit a patient to improve the overall facial appearance. Often a patient does not understand the particular procedure that may be required to gain the aesthetic result that is desired. For example, a patient who wishes to have his or her nose decreased in size actually may have an underdeveloped maxilla or mandible that creates the illusion of an enlarged nose. The training of an oral and maxillofacial surgeon is important in evaluating the overall facial structures that are out of balance. Although a patient may desire a cosmetic surgical procedure, a totally different procedure may be required to gain results. Often it is better to inform and not offer a surgical option until a patient completely understands the problem. This is an area of critical decision making for the cosmetic facial surgeon. The surgeon must learn that in case presentation and treatment planning, a standard cookbook formula cannot be followed. Once the underlying problems have been identified, the surgical procedures that are to be performed should be discussed in detail with the patient. At this consultation, I recommend that all potential risks and complications associated with a particular procedure be discussed with the patient so that they can be discussed entirely in a non-threatening setting. Once the treatment plan has been outlined for the patient and options have been discussed, the patient should be directed to the scheduling or financial coordinator to discuss the particulars of where the surgical procedure will be performed. Financial responsibilities for the procedure should be discussed clearly and settled before surgery. Before fully discharging the patient from the office, a presurgical appointment should be made for the patient and all preoperative photographs should be taken before scheduling the patient for the surgery.
Photography To perform cosmetic surgery, accurate photography is essential. A standardized photography technique should be used for each cosmetic surgical patient. I recommend that a patient have full facial photographs: anterior-posterior with repose and smiling, a three-fourths oblique with the eyes facing toward the camera, and right and left lateral profiles. The face should fill the frame of the camera in a vertical fashion. I also recommend a close-up view of the eyes with eyebrows raised and relaxed with upper gaze and lower gaze of the eye. A frontal photograph of the nose, three fourths right and left of the nose, and a lateral profile of the nose also are obtained (Fig. 3). When offering skin rejuvenation procedures, close-up photographs of the area of concern (eg, periorbital rhytids, periocular rhytids, submental jowling) should be taken at a certain distance with the distance marked. Follow-up procedures after the surgical technique could be standardized and allow you to observe your results. Throughout the literature, we see preoperative photographs at different sizes and ranges than the postoperative photographs. We also see different light settings for the preoperative and postoperative procedures. I believe if cosmetic surgery is to be performed adequately and a surgeon truly evaluates the results, then standardization in the photographic technique should be achieved. Currently there are many options regarding photographic systems. The traditional methods of photographs using paper pictures or regular photographs or slides soon could become less standard. Most surgeons who obtain many photographs during the day have found that digital photography fits well into their practice. A high-quality digital camera with a lens that could be
S.L. Bolding / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 253–260
Fig. 3. Series of photographs.
257
Fig. 3 (continued )
S.L. Bolding / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 253–260
259
used for full-body, full-facial, and close-up photographs should be considered. Many ring flash and medical flashing devices can be attached to the camera to provide adequate lighting. Background lighting also can be provided with modern photographic background flashes and umbrellas. Shadows in the background distort the overall quality of the picture and do not enhance the features being observed. Various backlight flashing devices help eliminate shadowing behind the patient. Shadow boxes or indirect posterior lighting can aid in eliminating these shadows. In the office setting, your photographs should be well lit and be taken in a certain area within your office. Attention to detail within the photography area shows a level of commitment to monitoring the follow-up results of your patients. The photography area does not have to be large, but it should have adequate spacing to get the full complement of photographs needed for a particular patient. Various digital cameras and systems are currently available. In addition to digital cameras, it is important to have a carefully planned storage media for digital photographs. Many of the cameras currently available can take photographs in a low-, medium-, and high-resolution setting. The high-resolution setting for photographs is good but requires a large amount of hard disk storage space on a system to store the photographs. Many surgeons take photographs, store them on a CD, and place the CD or storage media device in the patient’s chart. Many patients’ records are stored on electronic medical record systems or Web-based charting systems, such as RxDDS. These electronic medical storage system servers should be backed up continually with optical drive or tape drive to ensure privacy and security of patients’ digital images. Many companies also offer off-site back-up servers for a fee. The Web-based medical storage systems currently available have the advantage of not only backing up the images within your office but also backing up images in multiple sites and allowing them to be obtained easily from anywhere Web access is available. These sites and systems must comply with the current confidential laws. The sizes of the images on a server can vary from less than 1 megabyte to as many as 10 to 12 megabytes. The only advantage of the large image file is that a large photograph or poster can be printed. A standard size for digital photographs is generally 2 megabytes or less. Anything larger than 2 megabytes represents a higher quality image, but it may not be clinically necessary for standard review. The size of the image dictates the quality of the image if it is expected to be in a larger format. Most digital cameras store their images on a compact flash or Smart Media card that is transferred to the computer system with a compact flash adapter or Smart Media card adapter. The images are downloaded into the computer system and routed through the network either to the Web-based storage media or within the image server in the office. Some practice management systems also have the ability to store images within the practice management software. There are several types of formats for the images. Most images are stored in a jpeg or tiff format. Use of photography in a cosmetic surgeon’s office is essential. It is paramount that the surgeon and staff understand the entire photographic sequencing that must be performed for each patient and how the images are stored and handled within the practice.
Preoperative visit At the preoperative visit the surgeon explains to the patient the procedures involved with the surgery. In this setting the patient is prepared for surgery. It is essential that each procedure be discussed in detail so that all confusion is eliminated before the day of surgery. Each procedure should be described and all risks and potential complications should be discussed again. It is recommended that informed consents be signed, a preoperative history and physical be performed, and the appropriate preoperative laboratory test results be obtained at this visit. Postoperative care instructions also should be reviewed with the patient and the family, if available. In our practice, we provide postoperative instructions and a postoperative care kit for the patient, which consist of appropriate items necessary for wound management after the surgical procedure. Proper diet and nutritional concerns for the patient during postoperative healing are discussed; a list of proper nutritional supplements is provided.
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S.L. Bolding / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 253–260
Questions regarding issues such as postoperative exercise, return to work, how long swelling can last, how much discomfort or pain is expected, resumption of driving, and assistance for the patient should be addressed in detail. At this preoperative visit the patient gains more confidence in the surgical team. The preoperative visit also should be conducted in a non-threatening setting, and adequate time should be given to the patient so that he or she does not feel rushed or hurried. Any records or photographs that have not been obtained in a prior visit should be obtained at this visit. Any concerns the patient has should be addressed and discussed during the visit. All prescriptions and preoperative soaps or medications are given to the patient at this visit.
Day of surgery On the day of the surgery, it is essential that the surgical team be prepared for the patient before the patient’s arrival. All supplies and instruments should be carefully thought out, planned, and readied for the patient in the operatory setting, before the patient arrives. Planning is essential for any surgical technique. The operative team should discuss the way in which the patient is brought into the operative theater and how the patient is to be handled. The patient’s method of anesthesia should be discussed thoroughly with the anesthesiologist along with the means of intubation, securing the tube, head positioning, and table positioning. With cosmetic surgery patients, it is important that the surgical team discuss the way the skin should be prepared and the proper drapes applied during the surgical procedure. Proper lighting, preoperative photograph access, and outlined treatment plan should be determined before the patient enters the room. As in all procedures, once the surgical procedure has been performed, it is important that the family be informed of the patient’s current status and how the surgical procedure went. Postoperative visits should have been established, but the patient’s family also should be informed about the patient’s postoperative appointments.
Postoperative visits Once the surgical procedure has been completed, I recommend that the surgeon contact the patient either the evening of the surgery or the next day, if possible, to assess the patient’s overall condition. This contact provides the surgeon with a better picture of the patient’s progression and instills confidence in the patient that the surgeon is in touch with his or her needs. The postoperative setting is just as important as the preoperative visits. Surgeons often rush through postoperative visits once the surgery has been completed. A patient’s memory of a procedure is determined not by preoperative visits but by the postoperative care they receive from the surgeon. Each cosmetic procedure requires different visits at different time intervals. The most important part of the postoperative visit is assessing the overall progression of healing and assuring the patient that the postoperative results are normal. Even well-informed patients before surgery often have questions regarding postoperative swelling, bruising, or results. If suture removal is required, the sutures should be removed at an appropriate time interval to avoid suture damage to skin tissues.
Summary As oral and maxillofacial surgeons, we have the skills to provide this service at an exceptional level. Each of us must obtain the proper training and continually update our knowledge in this area so that we can continue to advance the specialty of oral and maxillofacial surgery. Our forefathers in the specialty paved the way for us, and that is why we have privilege to practice our specialty. Providing cosmetic surgery in your practice can be rewarding.
Establishing a cosmetic surgery practice: an algorithm to management of the cosmetic surgery patient in your practice Scott L. Bolding, DDS, MS* Department of Oral and Maxillofacial Surgery, Private Practice, Fayetteville, AR 72701, USA
Oral and maxillofacial surgery has celebrated a significant history with many advancements over the years. Although many believe that cosmetic surgery is a relatively new facet of the specialty of oral and maxillofacial surgery, a careful review of the history of oral and maxillofacial surgery reveals that facial aesthetic surgery has been involved since the beginning of our specialty. The art of oral and maxillofacial surgery began in dental school. We learned the beginning of facial aesthetics and harmony in our dental training. During our surgical residency we also had to understand the aesthetic balances of the face to participate in areas such as trauma reconstruction, orthognathic surgery, and dentoalveolar surgery. Cosmetic handling of the tissues of the head and neck regions are a natural part of our surgical history, and cosmetic surgery should be considered as an essential part of our specialty. Recently, oral and maxillofacial surgeons have begun to provide more cosmetic facial surgical procedures in their practices. Incorporating cosmetic surgery into one’s surgical discipline requires that the surgeon not only understand the surgical principals but also make proper decisions regarding his or her approach to the cosmetic surgical need of each patient. As with any surgical procedure, application in its appropriate form requires an intimate understanding of risks and benefits involved. Training in the discipline of cosmetic surgery is essential.
Training As an oral and maxillofacial surgeon in the United States, the American Dental Association mandates your training requirements. A minimum number of requirements must be qualified for one to become an oral and maxillofacial surgeon. As you finish your residency program, you soon learn that your education is only beginning. Many of the residency programs currently offer extensive training in facial cosmetic surgery. However, other programs only provide a light exposure to the area of facial cosmetic surgery. If this is the case, additional training must be obtained before electing to offer cosmetic surgery within your practice. This is not unique to oral and maxillofacial surgery, because many surgical disciplines vary in the amount of cosmetic surgery to which residents are exposed. Currently many fellowships are available after completion of an oral and maxillofacial residency program. Some of these programs provide extensive training only in head and neck cosmetic surgery, whereas others also offer training in full body cosmetic procedures. The training programs are typically 1- to 2-year post-residency fellowships. The key to obtaining proper training is to ensure that one has complete exposure, not only to the surgical techniques * 2926 West Huntsville Avenue, Springdale, AR 72762. E-mail address: [email protected] 1061-3315/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.cxom.2004.04.004
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S.L. Bolding / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 253–260
but also to the work-up and follow-up of patients. It is difficult for anyone to learn cosmetic surgery or any surgical technique during a weekend course. I recommend that all surgeons who want to become masters in the art of cosmetic surgery spend many hours studying and reading. One-on-one fellowship-type training with surgical mentors also is a good idea so that you have a good understanding of the surgical procedures that you will provide for your patients. Each training program must be evaluated carefully, because each surgeon has different approaches to types of training. Each surgeon’s personality varies, and certain individuals with different talents may require more training or may require less training than others. I recommend that you take the advice of your mentor in determining whether you are ready to proceed on your own. If you are not ready to proceed on your own with a particular technique, I recommend seeking out additional experience in either a fellowship format or spending time in a cosmetic surgeon’s office or hospital setting before initiating these cosmetic surgical procedures on your own. After several years in practice, some of my own personal observations have been that one must continually practice a particular procedure to be competent in offering that procedure to patients. In the area of cosmetic surgery, there is much finesse and understanding of the facial anatomy and surgical planes that must be continually thought through as one proceeds with a surgical technique. If an individual surgeon has limited knowledge or experience in this area and then proceeds with a surgical technique on a fairly infrequent basis, this could lead to a less desirable result. As with anything we do in life—such as riding a bicycle, flying an airplane, swinging a golf club, or hitting a tennis ball—we must practice those procedures frequently to be fully competent. As surgeons, we must understand that for us to offer cosmetic surgical procedures to our patients or any particular technique within our discipline, we must offer it on a fairly frequent basis or ask for help from another colleague. I believe it shows a much better sign of maturity to ask for help than try to proceed with a large ego and potentially have an unfavorable outcome. I believe that training is essential, but facial cosmetic surgery must be performed on a routine basis to offer this to your patients.
Office setting A cosmetic surgery patient is different than a medically ill patient who comes to your office for a cure for a disease or for evaluation of a tumor. A cosmetic surgery patient seeks your assistance to help improve his or her quality of life and not quantity of life. A cosmetic surgery patient seeks your assistance purely on an elective basis. Often a cosmetic surgery patient believes a surgical technique will improve his or her appearance and seeks advice from you for this particular procedure. To offer cosmetic surgery within your practice, your facility must be designed so that it provides a statement as to your attention to detail. I believe if you are going to offer cosmetic surgery to your patients, you must have a well-designed and aesthetically pleasing office setting to attract the type of patients who would seek cosmetic surgery (Fig. 1A, B). Many surgeons have tried to offer cosmetic surgery to their community, but because they had an older office that was poorly lit with unpleasant surroundings, many patients did not seek that particular surgeon. The appearance of an office may reflect a disdainful taste to the patient regardless of the surgeon’s ability in a particular area of cosmetic surgery. An anesthetically pleasing and non-sterile setting is important in the area of cosmetic surgery, as with any other areas of oral and maxillofacial surgery. The waiting room and reception area must greet each patient with an inviting personal touch. The environment should be quiet and private so that each patient is treated in a discreet manner and confidentiality is maintained for each patient. The waiting room should be designed so that each patient has a sense of privacy. Postoperative patients especially should have a separate waiting area or separate entrance so that their identity can remain discreet. Few cosmetic surgery patients want other patients to see their results until the healing has been completed. Office design is important in regard to maintaining the confidentiality of patients.
S.L. Bolding / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 253–260
255
Fig. 1. Operating room. (A) Surgical procedure performed by Scott Bolding with assistants, Tara Hammarstrom, Dennis Champagne, and Julie Hodkin. (B) Anesthesia administered by anesthesiologist, Dr. Bill Beck.
The consultation room for the cosmetic surgery patient should be non-threatening (Fig. 2). Many surgeons try to perform cosmetic surgical evaluations in an examination chair or in a procedure room, which is sometimes threatening to a patient. I recommend that all cosmetic surgery consultations be performed in a nice, non-threatening setting with several mirrors available to discuss the particular areas of concern for the patient. The consultation room should be well lit and offer many educational materials regarding a particular technique. I also recommend having a series of before-and-after photographs of patients. Consents must be obtained from a patient if he or she is going to be used to demonstrate to other patients. We
Fig. 2. Consultation room.
256
S.L. Bolding / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 253–260
have found that before the consultation, taking initial photographs of the patient to discuss during the consultation is helpful in seeing the affected areas that are of a concern to the patient. Video imaging also can be used to simulate facial changes that may be possible with certain particular surgical techniques. Three-dimensional images are currently available on the Internet that may improve imaging capability. During the consultation, it is important that the surgeon listen to a patient regarding the desires that the patient has about treatment. It is essential that the cosmetic facial surgeon be aware of all underlying imbalances or deformities that may create the overall unaesthetic appearance to the patient. Sometimes it is wiser to spend more time informing the patient of the underlying problems associated with a particular need than to explain the overall treatments. As oral and maxillofacial surgeons, it is essential that we understand the underlying deformities that may create facial imbalances. As a cosmetic surgeon, it is your responsibility to determine if a surgical procedure will benefit a patient to improve the overall facial appearance. Often a patient does not understand the particular procedure that may be required to gain the aesthetic result that is desired. For example, a patient who wishes to have his or her nose decreased in size actually may have an underdeveloped maxilla or mandible that creates the illusion of an enlarged nose. The training of an oral and maxillofacial surgeon is important in evaluating the overall facial structures that are out of balance. Although a patient may desire a cosmetic surgical procedure, a totally different procedure may be required to gain results. Often it is better to inform and not offer a surgical option until a patient completely understands the problem. This is an area of critical decision making for the cosmetic facial surgeon. The surgeon must learn that in case presentation and treatment planning, a standard cookbook formula cannot be followed. Once the underlying problems have been identified, the surgical procedures that are to be performed should be discussed in detail with the patient. At this consultation, I recommend that all potential risks and complications associated with a particular procedure be discussed with the patient so that they can be discussed entirely in a non-threatening setting. Once the treatment plan has been outlined for the patient and options have been discussed, the patient should be directed to the scheduling or financial coordinator to discuss the particulars of where the surgical procedure will be performed. Financial responsibilities for the procedure should be discussed clearly and settled before surgery. Before fully discharging the patient from the office, a presurgical appointment should be made for the patient and all preoperative photographs should be taken before scheduling the patient for the surgery.
Photography To perform cosmetic surgery, accurate photography is essential. A standardized photography technique should be used for each cosmetic surgical patient. I recommend that a patient have full facial photographs: anterior-posterior with repose and smiling, a three-fourths oblique with the eyes facing toward the camera, and right and left lateral profiles. The face should fill the frame of the camera in a vertical fashion. I also recommend a close-up view of the eyes with eyebrows raised and relaxed with upper gaze and lower gaze of the eye. A frontal photograph of the nose, three fourths right and left of the nose, and a lateral profile of the nose also are obtained (Fig. 3). When offering skin rejuvenation procedures, close-up photographs of the area of concern (eg, periorbital rhytids, periocular rhytids, submental jowling) should be taken at a certain distance with the distance marked. Follow-up procedures after the surgical technique could be standardized and allow you to observe your results. Throughout the literature, we see preoperative photographs at different sizes and ranges than the postoperative photographs. We also see different light settings for the preoperative and postoperative procedures. I believe if cosmetic surgery is to be performed adequately and a surgeon truly evaluates the results, then standardization in the photographic technique should be achieved. Currently there are many options regarding photographic systems. The traditional methods of photographs using paper pictures or regular photographs or slides soon could become less standard. Most surgeons who obtain many photographs during the day have found that digital photography fits well into their practice. A high-quality digital camera with a lens that could be
S.L. Bolding / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 253–260
Fig. 3. Series of photographs.
257
Fig. 3 (continued )
S.L. Bolding / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 253–260
259
used for full-body, full-facial, and close-up photographs should be considered. Many ring flash and medical flashing devices can be attached to the camera to provide adequate lighting. Background lighting also can be provided with modern photographic background flashes and umbrellas. Shadows in the background distort the overall quality of the picture and do not enhance the features being observed. Various backlight flashing devices help eliminate shadowing behind the patient. Shadow boxes or indirect posterior lighting can aid in eliminating these shadows. In the office setting, your photographs should be well lit and be taken in a certain area within your office. Attention to detail within the photography area shows a level of commitment to monitoring the follow-up results of your patients. The photography area does not have to be large, but it should have adequate spacing to get the full complement of photographs needed for a particular patient. Various digital cameras and systems are currently available. In addition to digital cameras, it is important to have a carefully planned storage media for digital photographs. Many of the cameras currently available can take photographs in a low-, medium-, and high-resolution setting. The high-resolution setting for photographs is good but requires a large amount of hard disk storage space on a system to store the photographs. Many surgeons take photographs, store them on a CD, and place the CD or storage media device in the patient’s chart. Many patients’ records are stored on electronic medical record systems or Web-based charting systems, such as RxDDS. These electronic medical storage system servers should be backed up continually with optical drive or tape drive to ensure privacy and security of patients’ digital images. Many companies also offer off-site back-up servers for a fee. The Web-based medical storage systems currently available have the advantage of not only backing up the images within your office but also backing up images in multiple sites and allowing them to be obtained easily from anywhere Web access is available. These sites and systems must comply with the current confidential laws. The sizes of the images on a server can vary from less than 1 megabyte to as many as 10 to 12 megabytes. The only advantage of the large image file is that a large photograph or poster can be printed. A standard size for digital photographs is generally 2 megabytes or less. Anything larger than 2 megabytes represents a higher quality image, but it may not be clinically necessary for standard review. The size of the image dictates the quality of the image if it is expected to be in a larger format. Most digital cameras store their images on a compact flash or Smart Media card that is transferred to the computer system with a compact flash adapter or Smart Media card adapter. The images are downloaded into the computer system and routed through the network either to the Web-based storage media or within the image server in the office. Some practice management systems also have the ability to store images within the practice management software. There are several types of formats for the images. Most images are stored in a jpeg or tiff format. Use of photography in a cosmetic surgeon’s office is essential. It is paramount that the surgeon and staff understand the entire photographic sequencing that must be performed for each patient and how the images are stored and handled within the practice.
Preoperative visit At the preoperative visit the surgeon explains to the patient the procedures involved with the surgery. In this setting the patient is prepared for surgery. It is essential that each procedure be discussed in detail so that all confusion is eliminated before the day of surgery. Each procedure should be described and all risks and potential complications should be discussed again. It is recommended that informed consents be signed, a preoperative history and physical be performed, and the appropriate preoperative laboratory test results be obtained at this visit. Postoperative care instructions also should be reviewed with the patient and the family, if available. In our practice, we provide postoperative instructions and a postoperative care kit for the patient, which consist of appropriate items necessary for wound management after the surgical procedure. Proper diet and nutritional concerns for the patient during postoperative healing are discussed; a list of proper nutritional supplements is provided.
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S.L. Bolding / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 253–260
Questions regarding issues such as postoperative exercise, return to work, how long swelling can last, how much discomfort or pain is expected, resumption of driving, and assistance for the patient should be addressed in detail. At this preoperative visit the patient gains more confidence in the surgical team. The preoperative visit also should be conducted in a non-threatening setting, and adequate time should be given to the patient so that he or she does not feel rushed or hurried. Any records or photographs that have not been obtained in a prior visit should be obtained at this visit. Any concerns the patient has should be addressed and discussed during the visit. All prescriptions and preoperative soaps or medications are given to the patient at this visit.
Day of surgery On the day of the surgery, it is essential that the surgical team be prepared for the patient before the patient’s arrival. All supplies and instruments should be carefully thought out, planned, and readied for the patient in the operatory setting, before the patient arrives. Planning is essential for any surgical technique. The operative team should discuss the way in which the patient is brought into the operative theater and how the patient is to be handled. The patient’s method of anesthesia should be discussed thoroughly with the anesthesiologist along with the means of intubation, securing the tube, head positioning, and table positioning. With cosmetic surgery patients, it is important that the surgical team discuss the way the skin should be prepared and the proper drapes applied during the surgical procedure. Proper lighting, preoperative photograph access, and outlined treatment plan should be determined before the patient enters the room. As in all procedures, once the surgical procedure has been performed, it is important that the family be informed of the patient’s current status and how the surgical procedure went. Postoperative visits should have been established, but the patient’s family also should be informed about the patient’s postoperative appointments.
Postoperative visits Once the surgical procedure has been completed, I recommend that the surgeon contact the patient either the evening of the surgery or the next day, if possible, to assess the patient’s overall condition. This contact provides the surgeon with a better picture of the patient’s progression and instills confidence in the patient that the surgeon is in touch with his or her needs. The postoperative setting is just as important as the preoperative visits. Surgeons often rush through postoperative visits once the surgery has been completed. A patient’s memory of a procedure is determined not by preoperative visits but by the postoperative care they receive from the surgeon. Each cosmetic procedure requires different visits at different time intervals. The most important part of the postoperative visit is assessing the overall progression of healing and assuring the patient that the postoperative results are normal. Even well-informed patients before surgery often have questions regarding postoperative swelling, bruising, or results. If suture removal is required, the sutures should be removed at an appropriate time interval to avoid suture damage to skin tissues.
Summary As oral and maxillofacial surgeons, we have the skills to provide this service at an exceptional level. Each of us must obtain the proper training and continually update our knowledge in this area so that we can continue to advance the specialty of oral and maxillofacial surgery. Our forefathers in the specialty paved the way for us, and that is why we have privilege to practice our specialty. Providing cosmetic surgery in your practice can be rewarding.