The Cosmetic Surgical Practice
Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

The cosmetic surgical patient is usually found at a dermatology office seeking help with skin care and, in many instances, wishing to proceed further with cosmetic surgical procedures. The dermatology practice is fertile ground for discovering patients wishing cosmetic surgical correction of their skin and facial rejuvenation. The two practices can feed each other and easily can run side by side. There, though, are significant differences in the approach to the patient requesting cosmetic surgery and the patient seeking medical help for a skin disease or problem. The approach of the office to this patient will determine how successful the physician is in integrating his cosmetic surgical practice with a general dermatology practice. Certain aspects are as incompatible as oil in water and must be separated, either structurally or temporally.

The first aspect is the physician's understanding of the needs, desires and general psychology of the cosmetic surgical patient. This patient will window-shop in your office and many other offices, inspecting materials about procedures such as skin resurfacing for wrinkles, chemical peeling, liposuction, blepharoplasty, etc. He/She will have examined brochures and booklets from many practices prior to developing the courage to call for an appointment. Many of these patients are literally afraid of the phone call and might dial your number two or three times and hang up prior to finally connecting with an office staff to make the appointment. The office staff must be encouraging to make this appointment and have time available for this patient to respond promptly. Too many busy signals, a hurried and abrupt telephone operator, an appointment weeks away may discourse this reticent shopper from making the initial contact needed for the consultation. This is your office staff's first outreach to this patient and it must be done courteously, promptly and receptive to their needs. A "smiling voice" is the tone that will be embraced by this patient while the hurried, abrupt operator who gives the sneering impression that cosmetic surgery is not as important as the medical part of the practice will turn many cosmetic patients away.

The same pampering is needed from the personnel in the waiting room, the front desk, the consultation room, and thus throughout all aspects of pre-operative evaluation, operative session, post-operative care and follow up care. To accomplish this, many of the normal procedures, policies and relationship between staff and patients must be changed to meet the needs of the cosmetic patient.

There are unique requirements of the cosmetic surgical office and practice which can be broken down into the following categories:

1. Office structure
2. Operating room structure
3. Management of the telephone
4. Personnel
5. Marketing

The fast past of a general dermatology practice does not coincide with the time needed to satisfy questions, responses and pampering for the patient seeking cosmetic surgery. A waiting room packed with patients with skin diseases, bandages from cancer surgery, ulcers, etc., are not the setting for patients seeking beauty. One must either schedule these patients at different times or structurally separate a different waiting area for the patients seeking cosmetic surgery. In that case, a smaller waiting room with less turn-over and the physical ambiance emphasizing composition, form, beauty, precision and competence should be displayed. This should include artwork, soft creative music, pamphlets concerning cosmetic procedures, reading material, and even pre and post-operative photographs. Coffee table books of artwork should be available as well as a reception secretary with a smile on her face, knowledgeable of the procedures and encouraging questions. The hectic pace of a general dermatology practice with telephones ringing, charts flying and little eye contact between staff and clients are not the ambiance of a cosmetic surgical practice.

A separate room should be set aside for consultations that is different from a typical treatment room. It should have more comfortable seating for the patient and special tools needed to display the patient's needs. This could include a three-way mirror, a projector for slides, an easel to draw and sketch profiles as well as illustrate procedures for a full understanding of the procedure. The physician should be seated on an equal level with the client of patient, encouraging a frank discussion that would include the patient's wishes and desires from the procedure, the nature of the procedure and the ability of the surgery to fulfill the patient's requests. The consultation should be uninterrupted to cement a firm relationship between physician and patient.

The operating room facility must have the appearance of excellence. It is best to have a pre-operative area, a fully equipped AAAHC approved operating facility, and a separate recovery area. It should be spotless in appearance with new, fully functional equipment and a staff ready and eager to carry out the necessary procedures with a smile. Little details such as a dirty 4 x 4 on the floor, instruments left on the floor, surgical staff not fully gloved and gowned, can be used as an excuse by the perceptive patient on why a procedure did not meet his or her needs or a reason for a side effect or complication. None of these reasons should be available in the physical facility itself.

Once the patient has made an appointment for a consultation and arrives at the office, a prompt response is made by the entire staff. The patient is brought back to the consultation room by nursing personnel who are thoroughly familiar with the consultation procedure. A "patient advocate" can be used to initiate the consultation and give the patient an opportunity to express her needs. Beginning the session with statements such as "what brought you in to see us?" or "if you could have anything in particular changed, what would it be?" Then, the advocate must be a good listener and allow the patient to express herself fully concerning what the changes are he/she wants, what those changes would mean to him/her, what his/her appearance means now, and the effect he/she feels it would have on him/her later. A sensitive listener can readily assess a level-headed, realistic patient who would be easy to work with during surgery or those with particular pathologic problems in which a red flag should alert one to the individual who should not have surgery; those who are unrealistic in their needs and demands and would not be a good candidate for surgery. As the patient advocate answers questions, these must be consistent with the physician's response. Initially, these can be "scriptive" but as the interviewer spends more time with the physician during his consultations, the consultation nurse will sound like the physician over a period of time and carry out the same messages. This, then, is the ideal person to have for interviews.

Three conditions for the physician to continue a productive consultation would include:

1. The patient's wish list is surgically possible and realistic.
2. A medical evaluation and emotional screening evaluation are within normal limits
and consistent with the surgery proposed.
3. The financial obligations for the patient are realistic and accepted.

Only if these needs are met should the physician proceed on with a full interview. As the physician begins, he, again, should give the patient a chance to tell what he or she desires with a question "what brought you in to see us?" Moving into particular details, the physician should then hold a mirror in front of the patient and ask particularly what the patient would like changed. The patient, then, can show you areas that bother him/her. For example, in acne scars, there may be one or two particular lesions that bother the patient most and those lesions, in fact, may be too deep for resurfacing or dermabrasion and need surgical correction or soft tissue augmentation. The physician should be sure to understand what particular items bother the patient and not spend the consultation evaluating the perfect face or form and showing the patient how to achieve this. The patient may not be interested in any of these things at all, but in one particular item she wishes corrected.

In the final analysis, the physician and patient should meet a common goal by understanding his or her needs and plugging this into the corrective procedure or procedures to fulfill those needs. Only then should the physician feel that the deal is closed and the procedure can be scheduled. At that point, the physician should turn the consultation over to the patient advocate or scheduling nurse for the final arrangements, which would include:

1. Financial arrangements
2. Medical evaluation and bloodwork
3. Consents for surgery, reviewed and signed.
4. Pre-operative photography
5. Scheduling
6. Pre and post-operative instructions and prepared kits for
post-operative care

Marketing the cosmetic practice involves both an external outreach, letting the general public know of the cosmetic practice, and an internal marketing approach, educating patients of the cosmetic portion of the practice. Both of these can be accomplished in a professional demeanor consistent with the medical practice. One must always remember that a cosmetic surgeon is not selling a product as the lady in the white coat at the cosmetic counter in your local department store, but rather making the practice and the community aware of the professional cosmetic services you offer. The difference between gaudy advertising and professional education can have a major impact on the perception of your practice in the general community. One should never compromise on professionalism in accepting advertisements, writing articles and speaking. Look, not only at the content, but the style, the graphics and where the ad is being placed. Many times, associated ads can influence acceptance of your practice's announcement or ad in cosmetic surgery.

Marketing a practice with a long shopping list of procedures is an impossibility. The goal should be to take one procedure at a time as a campaign and repeatedly show the marketing audience your practice's association with that procedure over and over again for acceptance. This form of campaign works well over a period of time. It can be done externally through public form lectures on a particular subject with newspaper announcements, press releases concerning new procedures to both newspapers, magazines, radio and television, advertisements tactfully placed in newspapers, local journals, radio and even television, and the physicians presence on talk shows, local news announcements and lecturing to civic groups and professional societies.

Internally, the judicious placement of pamphlets concerning procedures with before and after pictures in waiting rooms, treatment rooms, and even on racks in hallways can educate patients on cosmetic procedures available. In many instances, a busy dermatology practice can be the very best marketable environment for the physician. The best advertisement still remains the satisfied patient who will tell friends and colleagues of how pleased they were concerning their surgical procedure. A letter to these patients thanking them for their referral and trust in you as a cosmetic surgeon will continue to bring you many more referrals from those satisfied patients.

Thus, the needs of a cosmetic practice are different from those of a general dermatology practice. The physician must make the decision on how much investment he wishes to place of time, office structure, and personnel into a cosmetic practice to fulfill his goals.